A35 147QI
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The District Health Department
Orange, Person, Caswell, Chatham, Lee Counties
r �
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Date �=E• � ' �
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� Owner: ��/ c .�.� l� �'' � Q rf
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pa. Location:
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Contractor: �- �-� ' � " -
Water Supplye Private — �� Public
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Sewage Disposal Facilities: No. beclroom� � Dishwasher, Disposal,
washing machine, other aut matic appliances
Size of tank: �:' ` �''� Nitrification line: � G G'�� 3
�G-�y ' ��- .;—
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEF'ARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
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Date approved:
. Well: -
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Signed , �
, " Sanitarian
Sewage Disposal: Counter-
" � signed
By� (Owner or his representative)
. r` . ^ . . �.l J�
Cer2ificate of Completion �
ti -� � � /j�►�;,-�7 '�`./ '�,�
�' Date Approved: � By: � /
° � Sanitarian
� _ (OVER)'
'- Location of weli and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
�
Application Date: a�d -�' a° r/ Tax Map: I� 3-�
Amount Paid: �OC� . 0 � � � � � ,� l� `� d Parcel #: �_
Receipt#: �c'5,2.2� ��
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1I-1..:ca.w�i��:.r.vzr.n.:�xa-nae>n-nd.cn.A. THIa�.cn.11.cG-.�Ev.
Application for Services
(Sentic Svstems and Wells)
d Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
G Mobile I3ome Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Services Requested
�onstruction Authorization
(Fee is dependent on the type of sys
0 Permit Revision
$75.00
❑ Repair of Esisring Septic System
No Charge
Important: If t/:e information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then the
Imnrovement Permit and the Autliorization to Construct shall become invalid.
1) Services Requested by:
Name: �t �.
Address: t3 1/� t�- H � �
`�(kil qi�Yd � 27 S%�
Phone # (home): �� - 5 9 � " ��`� �l
(work/cell): h0 4 -9�3f„
2) Name and address of current owner (if different than applicant):
Name: `
Address: �
3) Property Description: Lot Size: �_ Subdivision: Lot #:
Address and/or directions to Property:
D � M ee ' (
4) Proposed Use and Type of Structure:
Residential Business/Type: Other �r�r��ef F
Number of bedrooms �/ Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes _ No � Garbage disposal: Yes No _
Approximate size of building foundation: Length�_ Width �
,
5) Water Supply:% �., ,� -
Private Well ✓ (Proposed Existing _)
Community Well: Public Water System:
� Q Q �'� r� �� ,�-
Are there wells on the adjoining properties? No Yes (please show location on site plan)
Note: A cotnpleted application must also include:
➢ A plat/site plan of the property tlzat slzows properry dimensions and the size and location of all
proposed structures.
➢ A sig�:ed copy of tlie `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Si nature Owner/Le al Re resentative : l` Date: �`-o� v"��
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11/07 Person County Environxnental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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� TiiIS PLAT REFLECTS ON�Y
A�OVE GROUND FEATURES
FOURID ON SITE AT TWE
DATE OF THE SURVEY.
J6PIP� W. �Ui��F!
�NT�OL
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Applican�
Location:
T�x M�p : Fa�rcel �
Su�bdivision y
Ph�se Sect�ion Lot # . :
Permit Valid for V Five Years
Type of Facility: �
# of Occupants �_
Proposed Wastewater Sy
Proposed Repair: ��
Permit Conditions:
Owner or Legal
Authorized Statf
# of
Improvement Permit
No Expiration
New _ Addition Water Supply �.Q-1 I
s�� Projected Daily Flow _,71� g.p.d.
Type: �
Type: --�
Date:
Date: $`- 20 -�3i�
The issuance of this pemut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Propose Wastewater System: �2�� Type� Wastewater Flow �-�d g.p.d.
New � Repair Expansi n Soi13.T�t: • Z�S� g.p.d./ ft 2
Type of Facility: 3. �2�j ���:n �• Basement _ Yes No
Wastewater System Requirements
Tank Size: Septic Tank: ➢ DO D gal Pump Tank:'` gal Grease Trap: �----- gal
Drainfield: Total Area: �� sq ft Total Length �2� ft Maximum Trench Depth �� in
p, C,
Trench Width �� ft Minimum Soil Co er: _� in Minimum Trench Separation: � ft
Distribution: �Distribution Box V �erial Distribution Pressure Manifold
Specifications: ���ok a� S�Pri'al 0� � l� �'��-ox yN�tr,�-�iain 'c�tia( l�'��4�
1 ihn �.
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Authorized State Agent: �
Permit Expiration
te: �5 - 7_ /� -
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The type of system permitted is Conventional V Accepted
permit.
Owner/Legal Representative:
Date: �"- Z!� Ok
Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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Report To:
, �
P.O. Box 28047
North Carolina State Laboratorv ��f Pu�»c Health 306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
httq://slph.state. nc. us
lnorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
Courier # 02-33-15
StarLiMS ID: ES012610-0090001 Date Collected: 01/25/10
Inorganic ID: Date Received: 0'/26/10
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Name of System:
JASON WRENN
802 MCGHEES MILL RD
ROXBORO, NC 27574
Time Coilected: 11:00 AM
�ollected By: J Sm�t"
Well Permit #: � 3 S � �`��
GPS #:
Inorganic Chemical (Profile)
Analyte Result Allowable Limit Unit Qual�fier(s)
�
Total Alkalinity 0 mg/L � � �'�
Fluoride < 0.20 2.00 mg/L �.`�, l��
Chloride 10.00 500 mg/L `� � � ` `
�.' ��
Sulfate 12.00 250 mg/L �\ �,.� 1'
Arsenic < 0.005 0.010 mg/L -.�
Copper < 0.05 1.3 mg/L \\ `-'- �`
Lead 0.016 0.015 mg/L ���� `�
Manganese < 0.03 0.05 mg/L �
Zinc < 0.05 . 5.00 m� �l
Barium < 0.1 ,2.00 mg/L
Cadmium �� �.CO i 0.005 mgiL
Chromium 0.02 0.10 mg/L.
Silver < 0.05 � 0.10 IT�y/L
Selenium < 0.005 � C1.005 � mg/L
Iron 0.89 0.3� mg/L
pH 4.3 N/A
Calcium < 1.0 mg/L
Magnesium < 1.0 mg/L
Total Hardness < 7 mg/L
Report Date: 02/15/2010
Page 1 of 1
Reported By: �e�ie'%%leKcol
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria aze Present, the water is considered unsafe for drinking purposes.
Presence of E. coli (bacteria) generally indicates that the water has been contaminated
with fecal material. It must be remembered that a water analysis refers only to the
sample received and should not be regarded as a complete report on the water supply.
,\
Inorganic Analysis: �
Recommended limits for drinking water. Sample should not exceed levels liste� '-
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/I
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
0
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
,_`
0.30 .lig/1
�.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1