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A35 117Amoun t ,: Receipt H O , d paid ��6'� � � � l�6'�.. � ��o,°� �,6a, v- P �.e�e'� �0:��1 � �.-�-�q Date Reinspection of Existing System (Loan Closing) Permit for New Well _ Replace Existing Well Permit :eques:ed by: . ner/pros�ective owne:�'agent: dress: _ � U�n✓� �' . ��xrek� � rso� lOoVc� tirr ot-1 � � 7 �; � �-iome Phone `: 33i�- 5Q8 �`!�°+1 a usiness P�one 7: 3ab-5�,�1- z�z� n►�h4-o�1�� W � z Name anc� addre5s of:current owner: Property Description: Lo[ size: ��cre-- Tax Mag�: '�S�`i . it��tto - 30( ParceIn: q 35 - f.l 1 Townshio:_L'�nr�tnc��am . 5. Directions to propercy: State Road #& Road Names,gtc. K Number of occupants or N� Ie to be served: �Dimensions or Proposed Structure: Width: 30ff Depth: a'1 ff �What type (if any, additions, expansions, oc ceplacement is anticipated to the structure or facility that this sewa�e disposal system is intended to serve? /,.�.I h�J-t,,,.,.,.�, �-n P.�i SI-i nu I�cl i iGI� /1G � Water s pply t5 pe: private t...`�. public ❑ community ❑ spring Are any wells on adjoining property?Yes �No (� If so, identify loca[ion: �ND-l�' �dom hc(i�c�iriq 10. Type of stcucturelfacility: Proposed: �Existing: �` Type vf dwelling: House: ❑ Mobile Home: C7 Business: ❑ Tyge of business: Number of Employees: �� Number of bedrooms: � � Garbage Disposal? Yes ❑ No C� Basement? Yes ❑ No� If so, # of basement fixtures: CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make appIication to the PersOn COunty Health Department for a site evaluation foc the on-site sewage disposal syscem for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is� altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permi[ can be issued, I must present a survey pla[ of the propercy to the Health Dept. I undecstand tfiat in the event I have not delivered a survey plat of the propeccy to the Health Dept. within 60 DAYS aftec the date oF the evaluation of the si[e by the Health Dept., this application shali become void and all fees paid forfeiced. Signcc� Owner or Authorized Agent � � / � � j� d � Iy � 1 O � `•� b SR.i '` � � � \4�'" � � �� , 3, �'• 3 " �� ` � �' .� �a. m..�a�a� � _.,..._.�._�......m.�...� ...�..�,.�.�,.._R -._e . .....r_. _..__...._.w_..�...__..�..� � ,_ - � � '' ' �. B 2811 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. 3 r�.' Tax Map # �-� Parcel # � Owner/Contractor � Location/Address I2 Subdivision Name Township rl ; C',�.- _,r r�k D te - Lot# S.R.# SEWAGE SYSTEM SPECIFICATIONS � Repair Lot Area�_C�O� Size of Tank O � � SFD Mobile Home Size of Pump Tank ! Business � # of Bedrooms Nitrification Line `� � �s�� Max Depth Trenches � � � � a V Permits may be voided if site �Well and Septic out by a Comments: �, �� ( Date �f'�S��IG1 Well Permit Paid Individual Public Site Approve Well Head ppro� � Grouting ppro Comme ts: � Date .« � .; Installed or � Approved `� WELL SYSTEM SPECIFICATIONS Semi-Public Required Slab _ Replacement Air Vent /'' Required Well Log Well Ta� � Installed by Approved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for tnis permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l �� ,, — ,oz . ,lvf�� - - .� _� r'� i°L � � � w . :��' � � .. . • - �� W .4' C �� • � '� �.�. 0? 4� /, 49 . k, Ml•!£•Lb•�10•N D � � � � �� . G L� a 0 0 � � 0� � Q� � cD � � . �88' 181 I �6Z'S9 0 - � � - � .. . , 1 _�. ! � � � � . � �. - /�,� ti . . � /�/ .y : /V � .. . - . _ / .. . . , ..,- . � x ' _. ' ��.. . , . . • � /�. y � �.�a firi'�s't�.� � e t . � � ; r ' _ ��-/ � . � . _ " � � �� ' f , . .��. � C*� �� +� t�yC ' � � ,� • � �y�i-'h<ala� ,�n'� � . Z �,'iE,Fs"ty:- . .""` _ � - � _ �. -�� _, � ., . . a. q+`` f. `i'� �v Zx..7l � � �. � 'f "' � �`r�� ` 'M . i %� ;�� t�r �; t �'r ,*,, c�„w+,/,�R � . . : Y. �. ,rrs �,, r ;,�. � ' - ' I . ` ,.<: 'L � s ., t ?� .�'�""r��l�5�"�� t.. +• y ` : ` ., e,�,�,� -�r3� , � �. z. ,,,- „� <i � Y a s' f .'; r t r . � -�t+ il � y,� �.�.,[ t t'.�..... . . .��;> �� K�;� .T " y s.'i.. 2`- t , � .. . � � '� :t`..x�..: t_.. � �' I , . ,� . , � .. . �� l � �.. � �� ./ � �.J � V � � ��n�n�-onan�nra��a��.Il IHI��.Il��in Date: � /�/�� Name: �U�A� GA�B-� i-�-' Address: � � (� � , 1� Z75.'� Re: Bacteriological Test Results Dear Well Owner: Ta�c Map•,,�� Parc,el: !17 `�our wzli waier was sampled on �/�2�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results onlv. X' Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. "lotal coliform bacteria are naturally fnund in the soil. Fecal col;{or .m bact�ri� are asseciated :.�:th animnal and/or human waste. The presence of either total �r fecal coliform bacteria in wzli water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the water may not be safe for use. Young childrer., the elderly, and the individuals with compromised immune systems are especially vulnerable and ttieir physicians should be notified of the test results. A well t.ha! tests positive or total or ecal coliform bacteria sh�ul� be preperl•� C�ISlltfected ard retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, �lease contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� Environmental Health Specialist Persor. County H:,alth Departrr�nt (rev. 4/2U/16) Peeson Coanty Envirenmental Health, 325 S. Margan St., Suite C, P.oxboro, NC 2', 573, Phore: 336-579-179Q Fax 336-547-7805 c�c� �7f ��'- PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 �'3S�//7 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant l�l>2��'T Address 1 Zc�.�c��,�,��,�T'�c� , County Collected By d.�.��/ Date Collected ��/ �� Time Collected I L= ZS Source: �eil ❑ Spring ❑ Other Location: [�'House Tap ❑ Well Tap o Other _ ❑ No Charge harge `��-��Q,, � " ..............................................................................� *********************�***************************************�************** Total Coliform Fecal/E. Coli Resuits Present Jw ❑ Reported B Date Reported ��`7 ' � � Report Called �ES ❑ NO Called To •t� << � � : Absent ■ � � � J ! � �. � � �. � �� .! � V � � �na�n�o�an�nca�na��.Il ��,Il�Ila Date: ��/�//� Name: .� Tax 1V!ap:� Parcel: // 7 Address: , 7�� Re: Bacteriological Test Results rJ�ar Wel! Owner: Your well water was sampled on �/�/�, and tested for both total and fecal coliform bacteria. Your water saniple test results are noted below: No coliform bacteria were detecte�l in the sample. Your well water is safe ±o use for d:�inkin�, cooking, washing dishes, bathing and showering, based on the bacter�ofog#cel resr�lts only. x Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. 2'otal ccliform bacteria ar? natural!y found in tl:e soil. Fecal colrf�rn: bs�teria ar� associated w::h animnal and/or human waste. The, presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. I,J'coliform bacteria are pre.sent in yo�r water sample, the rvater may not be safe for us� Young childrer., the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested prior to rssumin�normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please conta.ct the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� Environmenta Health Specialist Person County Health Department (rev. 4/20/16) Pers�n County Environmer.tal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 :1 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant '��.� ��--�'�'{" � Address � Z�jy��- �s� ''�� County Collected By �� Date Coliected �� Time Collected ��'�- `�� i��`�, Source: o�ell o Spring ❑ Other Location: � House Ta o Well Tap ❑ Other P ❑ No Charge t�'Charge � ..............................................................................� **,�************************************************************************* Results Present Absent Total Coliform � o r Fecal/E. Coli ❑ � Reported By Date Reported l� '�' � � Report Calied 1�YES ❑ NO Calied To ,I�' 6V� /i�u..�.. � � �. la� ` �' � � � � �l