A35 172PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
3 2 � �0 3� l?2
Da of I spection Sys em Inst llation Date Type ax Map Parcel #
?'r� �4� (� ►� —
Property Address
Instructions: Check yes or no for appropriate items and explain in space provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible,free of
infiltration and surface water diverted 7
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ? n
Inches of solids(pump/dose t k):�
Elapsed time readings ?
Counter readings ?
Drawdown rate: 'r p
❑ �
❑ � ❑
❑ �. ❑
REMARKS
-- 5 �c ��� vl�� ac�xs; d �e
. �
- ��oMMe�Q r ri se�s � S�jo�� '�`/t
� % ❑❑N — �l� � �K ac CCc.�,�k C�t���,►^
� � � �%�P � � T- o vt
►: .
■ �
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ?
Diversions/swales properly maintained ?
Vegetative cover maintained ?
Protected from traffic/unauthorized uses ?
Distribution devices in good condition ?
Field free of settled or low areas ?
/
/
/
/
/
/
/
/
(i
►'�
■
■
■
■
■
■
— i �r a ja�r�
PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑/V�
Pressure head properly adjusted ? ❑ / ❑ �1/�"
COMPLIANCE: �
Compliant
Non-compliant ❑
Needs Maintenance ❑
��- $G.�j�e ��
�°P � ✓���P
--�fo �s5u✓� n'�l�
—5P �� hol� 4cc�ss; 6�
.`
�
00
.�"'n,�ount paid � 6•
L?eceipt � '
'� �. r% 4 .6
H
O
�
�`� `�a���d
.�-' �, Q $ I
Improvements Permit. (Established/Recorded L.ot)
Im�ovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
_ Improvements Permi[ (Addition)
I -13�99
Date
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit foc New Well
_ Replace Existing We11
• 1. Permit re uested b:
owner/ rospective own�
Address: . '1 �
r• I irne-i
� ��
� •
�
�
�W �99- 8�09
Home Phone N:
¢ usiness Phone N� a�'ie. �119– ��'-77�� T`m
�., – n: „�, . 599-
7. Dimensions or Proposed Structure:
Width: �
Depth: `�U
8. Whac type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
. Name and addre�s of current owner: ' 9. Water supply t5•pe:
�,l, n /-�- � }�.rr�5 private tr`�. . public ❑ community ❑ spring ❑
3l9 �� Are any wells on adjoining property?Yes ❑ No (�.
�U G��5�� If so, identify location:
. Property Description: Lot size: _
. Tax Map#: � �
Parcei#: ..
Townshin:_ _ � od5
. Directions to property: State Road #& Road
Iames,�tc. _ _
�
0
10. 'Type of structurerracility: rrcpased: `�Existing: �
Type of dwelling:
House: � Mobile Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �— �
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No� If so, # of basement fixtures:
�6. Number of occupants or people to be served: �( J
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make appIication to the Pet'SOn COun�y Health Department for a site evaluation for the on-site
sewage disposal system 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� alterel o; the
in[ended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I undecstand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and alt fees paid forfeited.
or Authocized Agent
b
�-
\ ��,��
/ ,o,�
`�r
/ ,�� � � �.
,�
,� -
�- � �
�� � �' �`�
� �, ,.
�
J� �
,���\��i�F �`QG � ny�. o15S,�5�1G1L � �
, �c1 '' �(� �� " � �
�)��s �e �
� ~
_'`�l/ \�EP �%,���r
, �� �
�s
� � s,ti �XS
s� �
�`
� �� ��e ` ° T�
._, c � " �4
` �5��
r �
� / � �,�( � � '�'o
,1�,,�'���. � ' ti �'`r i`�� � `{r
(� '�, �. �� �_ � � \� �b , � �� ,, ..e
'� � ��� �`� � � � � � �.y '� � � �" ��-f �� \ �i
� a � �
. a � �
\ - . n, '`�
� �, � �.�� .p ` � �
v �
�` �c
:...�-^- , � � U �� !r . � � r <�
q a' c
Sk- �"� �',� P � 'L `�c
lo / " _ �� �c� � �\ " ��_
�+ i �_ � � .R �. �
z-- �`Qt � 'oC
�_
c ,, � �
� � � t�� G .. �
�� �i � � ' o, �� Q � \
� �� � �� � �� � ,
� � - � _�, 6 t �` �
� � •
P�� 0 9� o� ��.i �\ � � b
' C1� � �i 9 �� / m � �p �j .
7 � ;' b` / ` �o, � � r. �SyaU �
• J
, � 4 /a ,,, ��,.;
� ,o �8 �l�ti� , a�� � ��� �
�, ��'.^)�' �� m °�'.q'� 9 �6 ,, `��
b�' a, , m �: Z Z' t" c
� ^' �o �', � Z 6 �
� ���� �1 � ���
� � �.
. �F � .
� �,c ,��j�UN
��� S�pi�lihl
� �` � �n�,ti a�p0{N
�' `�$+r� Jd S��`�f�
; 11�
�`,
r�t
y� St 5 1 '
r► � � � �
� �s I " �, � �
� � I
I ly fV j
. � C. � I �� V n 0
^ O I O � V
� _y ( � � l.� (Q
V.7
U I -�ti
r � _ �'S �
� N
�•1 N a`" G� 9C� S` 5
�p S ,N�9L LC'-
�� �, i
,-- i.
� � � 4 ^ I � a'6�: i� -
� 1 ,` �• i I M.9P
�g ; �
� " � , �� r, �i
"+ I i l+i�-S
y ,Koti-
/ �
2 ', � I I ,
a� '. `� I�,!
�� � !�,
J �� o
_ � �,
�?
��
,.�� f
,�
�� -�
n � j�
� � �, �,,.
� � T' ` .. ,�• ,� �'';
� �� _ , ` .
r� �-.' . � . ,
I �� ' �
.� .
�'L���i
Tax Map #: _
Zoning _
Applicant:
Location:
Sub�ivlsion:
PERSON COUNTY ENVIRONMENTAL HEALTH
'ACH�D PLAN FOR SOIL Ai�EA AfV� SYSTEiVi i
Parcel # � 1 Z
Township ` "b d��a, �..
S�tior,:
Lot:
��prov�ment ?erm�r
A buildin� �,��rr�� ca���ot be issued with oniv an Improvem�nY rermit
!�c•:� � Repsir Additi�n _. Type of Structure�� Water Supoly ��,}�
s� ot Uccupants � # of Bedrooms 3 Other
Basement? _ Basement Fixtures?��,�pp
0
Projected Daily Iow:3�Z g.p.d. Permit Valid For. �e Years 0 No Expiration
Proposed Wastewater System Type _a� �.trnQ C�,n Ven1-�`Dn2,1
Pump Required? �Yes No
Proposed Repair : ` � ab;��
Permit Conditions:
� � �����/�l
Owner or Legal Representative Signature: Date: w
Authorized State Agent: � , Date: ' � S'
The issuance of this permit by the Health Depa�tment in no way guarantees the issuance of other permits. The permit
holder is responsiblE for checking with appropriate governing bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Building Permit)
Type of Wastewater System� — �, Wastewater Flow: �g.p.d.
Facility Type: �i'
Basement? Yes ❑ No
WastewaterSystem Requirements '�
New �Repair DExpa}► �ion ❑�_�pL/
Basement Fixtures? (�'Yes C�1'1VcY
Septic Tank Size: �_ gallons Pump Tank Size: � gallons
Total Trench Length: �� feet Maximum Trench Depth: � inches Aggregate Depth:L in.
Maximum Soil Cover: l2 inches Trench Separation: � Feet on Center
Other:
�
� " �--l�--�5 - - ------
Permit Expiration Date:
Authorized Sta:� Agent: a �,,�, Date:'" 7-15 -r�
The type of system permitted ❑ does ❑ doe ot differ from the pe specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signature: � at . �'
PCHD, rev. 11/18/99
Application #:
Tax Map #:
Parcel #: 1 � Z
Person County Health Department
Environmental Health Section
SiTE SKETCH
�
; ��h v �C� n�� ��es
Applicant s Name Subdivision/Section/Lot#
�/- J 5-�0
Authorized ate gent Date
System compone�ts represent approzimate contours only. The contractor must fl'ag the system
nrior to be�innin� the installation to insure that proper �rade rs maintained _
0
5�'
� .�
C �-
�'
----- � � -�f'r 'i�Svv��_�'� ; n
� �
('� 1
` �— -' �' `-��- _ `
VJ
�a
�
a�
� ���:�sn
fh_eL'�-c'n`�'
--�� ~��� ��
� �9'
� \
j 83 .i � � � � _ I
, G�
Scale: ( ` �- It�' ` � -`
_ -� �„x� s�. n[� � � �—
�1 L�{'
� PCHD, rev.10/12J99
,t�e.r -40
�n'o r }-o
�yS�ern�
nK��lack
Person County Health Department
/� Environmental Health Section �
Tax Map #: I-f �s Parcel #: ,� � a
Zoning: Township: ���dQ (�-
Subdivision: Section: Lot:
A licant• ��em � C���d y 6aw�s
PP
Location•
�qeration Permit
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMtT AND CONSTRUCTION
AUTHO TION
� .- �.y-- o `
Authorized S ate Ag t Date
�
�
J���
N Em (t
-- �. S•
Tax Map #:
Parcel #•
PCHD, rev. 10/12/99
Person County Heafth Department
Environmental Heaith Section
Zoning: Township: ��S��Z
Subdivision: Section: Lot:
Applicant: ��m �' Ci n��r (�c,�(�'�
Location •
Operation Permit
1. LOCATION AND SEPARATfON DISTANCES
A) System meets .1950 setback requirements
B) Distance from system to any welis (0�,
C) Distance from septic tank to foundation '
D) Distance from system to property lines lo
2. SEPTIC TANK ✓
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls affle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture S rroocsr) 5 as-oa.P �)
D) Tank serial number 571314 Z� R t S S
E) Liquid capacity of tank l�OD gallons
3. SUPPLY LINE TO TR CHES
A) Grade (1/8 inch per foot minimum)
B) Material suppl�r�line is constructed from Z`` �I�L
C) Diameter oZ .,
D) Length 1a'8' �
E) Distance from tank to drainfield/distribution device a�_
4. DISTRIBUTION EVICE(S)
A) Type ' rib %�'a� i30k . -
B) Is Device water tight�
C) Distance from the distribution device(�the trenches 5 t� �S`
D) Is the device on a level foundation
E) Does the device perForm according to its de ' specifications �
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth o� 4 inches �
B) Trench width �_�inches � �
� C) Distance betwesn trenc�s
D) Number of trenches
E) Length(s) of trenches' � � 3��
F) Aggrega#e depth �_ in hes
G) Aggregate materiat and size '��.�7 �'�S �
H) Record septic tank outl levation � 1/4" er 10')
I) Trench grade � (_ p
J) Step downs /
a. Minimum of 2' of undisturbed eart /
b. Proper rise over step d�Nii
a Solid pipe used l
d. Elevations of step downs /(Record elevations and show on as built)
See "as built" plan an attached sheet.
�i
� PCHD, rev. 10/12/99
♦ PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: T / �� Parcel # � � �
Zoning
Tow�ship �� �lJ"a�v��
. . �
Applicant:
LocaUon:,
Subdivision:
Tvpe of Water SupplV:
Requirements:
Site Approved by �t
Grouting App ovesl by
Well Log 5
Well Tag '
Air Vent �-S
Hose Bib s 5
Concrete Slab <
Section: Lot-
Well Permit
Individual Community Pubiic
. ��-o�
�-d-`I� � a l
n
� f
��
• . . . - . : �.� • Cc►^.�
_
Date• 1 ' 2�'— � �
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
Application Date: �`� �� � Tax Map: � 3�
Amount Paid: CS � Parcel #: �
Receipt#: �i�;��.�
� R �� �-.._�--��. � ��I�� ��T
������
IG�da�-��,.-,.-T ���.m.11 ]Hi�.tn.11.t7�
Applicatioa for Services (Septic Systems and Wells)
1) Services Requested by:
Name: ��rr�e�-h�� � � � �,�,,, � b ��r �S
Address: 7! �� �aK C✓oJ� oacl
�a xhar /�! G -�1•�r7�
Phone # (home): �3G -�`��-�''�'� 9
(work/cell): .3 3 G - �0,3- � .p/'J
2)Name and address of current owner (if different than applicant):
Nacne: �A�.1
Address:
3) Property Description: Lot Size:
Address and/or direcrions to Property: 7 �� C'��
Lot #:
, .tv�_ �7S'7-
4) Proposed Use and Type of Structure: � 3� X� O
Residential Business/Type: Other �F}1'f�i'� F
Number of bedrooms C7 / Number of people served (seats/employees):
Basement: Yes No �/ (with plumbing: Yes � No �� �
Garbage disposal: Yes No _�
� Water Supply: ✓
Private Well e/ (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes t/ (please show location on site plan)
Note: A completed a�plieation must also include:
➢ A plal/site plan of the property that sliows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `�ot Prepar:�tion' form ver�ing that the property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. I understand
that if the infarmation provided is incorrect or if the sitc is subsequcntly altered, or if the intended usc changes,
all permits and approvals shall become invalid.
Signature (Owner/Legal Representative): Date : �QS�� �
�
�
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
� � � � �
`�, � � ,.
, � � ...�;
, � � � �� � � ����
�:�����:��.«��.�� ���.���.
�
�u�n���aa� f���E$IlOIIfl�I PVg��D��c� ��&Hfl� ���D���E�flc�dII`�5
Tax Map #:�,�
Approval Requested for:
Parcel#: �
obile Home Replacement
Building Addition (De�c1,e� Car���
� • • � - � /i �,. i
' � � - / / ,� , ' i
/
•i_ � i
��� - ii � ,/ i / i
Permit Located: �/ Yes No
Insta.11ation Date: �-,21� - D 1 Design flow: �(¢b (Dpd)
Current Contract with Certified Operator on file (if required):
Water Supply: V Well Public or Community
Wastewater system shows no visual evidence of failure on: 2'/��/� (date)
(Applicant's signature if site visit is not required)
Comments:
���flIl�a��������aa���� �����d��
�
� �'/�'��
Enviro ental Health Specialist Date
1 ? /15/OS
.�\, ly j ��� ��`��+� �.�1./ V ��-y
�_ v _~ ti/' \/ � � Y
1���u-�,�„,..,.,,��¢�.11 ]L"-3I��.11�
SITE S�TC�-I
Name � A il ��� ��we�, Ta� Ma.p #�"3,`� .Pa:tcel # �� Z
Subdivi ' � Section/Lot#
_ 2-/S ((
A tho�ized Sta.te Agent Date
System cnmponents r�present approximate�contours only. The contrnctor »aust, flag the syste»aprior to
beginning the instaTlation to ansure that prnpergmde i.r maintained
�� � � - - - ����.
� � � � � ,�.. ��`' � � � � � ��
•� ' � f `� �_ � ��' ���� .y� ••� �� . ��:
. . a i�=�- . �� _,
r�
� s
y •F
T' � �`r n
. �
. . . +�'. 6y � � ��T � �� + '� � "_
� € �i-.: '`� � a. x
, ,� " ,�,. y„s � ��, . .�ri_ . : .� r
�� . . � • � � i �'"4 .c
�" �'.
^ "A�? P,. " -w� �i` . � . � ( � �
� �� � � � �
���"` � _:,�, _ ,
� �a � � s. � �p � �„} ro.�,
�
�
�'
,
_ �'.
. �, a
r
�� �, � :
� � � ,
�++t 4` s v,��`� '"�` :, '
•$ ^�� � � �Y. Y
�� � : � � . ...�'�� � • � � � y
i �}� �
� : ':. _ �„ � `& ,_, ; �. ���� �
y, r
ti �. � ,nr �. ' iL.r� : , � . , .. ' �
� �, �: .�� � .. .. � . � � � .. � � � ...
5Y
.. �.�, ��� �'. ':.�. M'� ; � .. ���� ay`J'Rti �i ,gel � . �',a
�� y, ,_
. 'Ns �:•. ^ � Gv -�e �. . �,��'. v
��g �
�. F� r ,s`�' � .
� x
�, "�s . o..�. ,� " =°� d a'3 �
.. �' �� „� - �,., � � „�. . :
e � � ` � `� -� �
��_ � � : � �=° � -
. � d � r���
�aA 3 � � ; �:�; �;�; � ��, ���� �
� �s
� .
� , :
, . . , _:
�:
M:, � , � � �
.
'� ' r., . • ���� �
;.
�
_;o �
a ' C .$s �
>,
..: z ��..�.� . . .
.. .,. �� . -.
.. 'g 4i � , � � � ...� .
�.. � .� �` � , .
�I & � c �. � •1 { ��{�� �1 ; �e �
� ��-�" � �'"� � � � t�+��}j� E y J '���.: `� ` p�r- ,
_ � �� � `� , ' �t � � � �m . �'� � '��
� ��.
�a� � � � � � �' *"'�`'
_ � ,� -:.. �, �
r� '�" �,- 63 � � � .
4�:�.. .. ���.+a Prt �F r "i \4 ;���. . . . � �� � � �+. .
, � t �t� r, ��, �°��
�-'. ; � .
�. ,.
_;
�. �
> _ e . �,�, �, .._ �
� � ���
�
�, — _� � _ � � �� � ��"`���� � � �
, � � ,� �� � �' ^ � . ,�` '=� , / �'� 4� � � � ,,.. �i„ �`
� � � � ;� �° ` „�#` "��.._,_.-,.._... "Jr -� _ �' �' "� '� �
� � � � `� . .,,,, -""_".-- �``s4., � � �
m " �� �q � � �
� x, � �� �
I �� ,: �', �Ye � ¢ �` , �� �
� � � .,
' � W i '�.., '�`= " � F� � �� �'i' � %
z � � � 3 � ... � � �
'�� .s?.'�c� ��`�F -��. t . � � As. � `�RD �$ nmg,e '^ ,,:�"�. � 5�..
. � '�xi,°�� . rt , ' � F��it' ,�fp. rt ,� qq��p `' ad
���.` . . � -"�j.. �' � �. � .� . -.,., ,� ��1, � � >
, ,.; �
� .0 , _ .. w . ���� a "�
.; �'z�.., - ^�. »" �
�-
,�. w � s.
P .;,. ,. , �� - ' _. - � 3'r`
., _'
� ,
�,
��_ " � . . ..�•.,. , -�, . .�" ' r .
i ,� . .. a, �� � ' n� _ . ' .� .. �" `�" , .
'�. .
- �� �;< �_. � ��r.. ,. . � .,. - - r,5 a �... .
..g '
'� . . _ � .. g�. _ -., »��
A► .� � a
s� �'; .. ; h! � _. .. �" ' a �; �: . _ � � � - � �
��
I, �eA
y � . �"e, t W' ''ai.� ,-'.b .� ' , -. . . � . '�x� a.�' �'� � °�G'.,€
e
� _ . _ v .. . . - � .. �� ..�.4 . �., �.' �.� �
P�RSON COUNTY ENVIRONMENTAL H�ALTH
WELL LOG
� . �. • �'��r � ' � S � SR#
Date._._.-----�G�l� � f �1��
Owne;. — .
Lo�auon%Directions: ��� �E �
i�.�t �
Subdivision Namc: �ry �1�.� „�M _ T,r.� c _
Drilling Contractor: -�._nN�tt�C'i�ON
Discancc from Ncaresc Pr°perry Linc _
D�stancc from Sourc� of
Pollution � rj GPM Static Water Level F�
. � Toxal Depxh: FG Yield: _ . �t.
Zones: Depth FG -- Fi' F��` / Ynches
� Wacer Bearing to��..Ft. Diame � .
. - Casing: Depth: From
. �. � 'I'YPE: Steel � Galvaiuzed Steel .
� If �Steel, does owner approve: Y�s No
����5; � Height Above Ground: Inches
� �'Veight• '
� Drivc Shoe: Ycs N� - .
. Were Problems Encountercd in Setting thc Casing? Ycs_ No_____--_
. . - . ;. "ycs" giv,: rc�.�on: Sand/Cement_ Concrete
�.. Gmuc: Type: Neat, —" 1?_ Ynches
� � � Annular. Spac� Width,_._ • — ----No_�
� . Water iri ,Anriular Spacc: Yes_ �ourcd •�_ �.
� : � N:athod: Pumped-. -. Pressure,,._.._ -
� � . Uepth: From_ -� � � ��'
. . ga portland Cesr,ent____—„ Weight of 1 bag_......._....lbs.
. Materials Used: No. � - I2atio:� co �
� xf mixture (sar�d, grav�l; cuttings) - . �
TD Platcs: Ycs '� No � :
� �.. �t �tal, Yc�c ✓ _ NO_�..... . '
�--- .
T HEREBY CERTIFY THAT THE ABOVE YNFORMATION TS COR GULA ONS SET
THIS WELL WAS CONS'I'RUCrED IN ACCORD P RTMEN"!`RE
FGIZTl:3�' Tl•IE P�RSQ� �Q�Y HEALTH DE
, . .
• �'� � � �-19�=oa
Signarirc of Contract � Datc
�