A40 196Date:—
Owner: _
- � \,' �.. . .". \ . �\ �'. :. "i,�\ K ..
Person County Heaith Department
�ewage System Improvements P�r
� �. �s , � }�
Permit # z9 �''
– SR#
Subdivision Name: _
Lot Size: /• C� G
, Water Supply: Private:
Bedrooms: �
Basement
INFORMAT�O�Q' C'�'
REPAIR:
LY P Type of Dwelling:
� Public: ommunity:
Gazbage Disposal
Basement F' �
�B BY r . - Y
'ALUATION:
-------------------------
Size of Septic Tank: _�� gallops Size of Pump Tank:
Nitrification Line: _ �� � x 3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: �
-------------------------
Date Well Approved:
BY
Date S ge te
BY �
_ Well should be 100 ft� from any sewer system
_ s�� 3/_ 95l
- Sanitarian
�
�
.. - ���� � u-..,ATE OF COMPLETION ,�
Contractor. ��,VQ ,�.�,,�j l� W�
------------------------- �
b
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intende3 use change this pemut is subject to revocation.
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
NOT�: Make sketch of installation showing lot size and shape, location oi house, septic tanks, privies, water
su�,'plies, 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. -,,
I �l,J � `�!, ,�J.� / �`/rV`, '
I
, � • Person County Health Department
Well Permit
Date•(� _'�-`i � This Permit Void After 5 Years
Owner. �-Y�',i ��� —rr�, c e� � ve n.-, SR#
Subdivision Name: e t #_
Drilling Contractor: r « l ,
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution�
Total Depth: Ft. Yield: 2.� GPM Static Water Leve] FG
Watzr Bearing Zones: Depth ��Ft Ft�Ft.
Casing: Depth: From � to Ft. Diame r: Inches
TYPE: Steel Galvanized Steel�
If Steel, does ownet approve�No
Weigh� Thickness:- Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: , /
Grout: Type: Neat �and/Cement Concrete
Annnlar Space Width ��� Inches
Water in Annulaz Space: Yes No
Method: Pum d Pres�u�e Po�sed '�
Depth: From � �to CSJ FG
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes � No
4 x 4 slab Yes�—No
b
�
�
�
'd
z
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS �ORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH RE ULATIONS SET �
FORTH BY THE PERSON COUNTY H H PA ENT. R
' 1 � 9y�
Sig r C tr tor D te
, 9����
. tanan s S g e Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
�i �JTE: 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.
o�°° \(�v%� /� ��� �1� � �1��.
��AA/�n �asS-�l�y��'
'� C. 5' / 9 L.� e� ire zY=
`�y�/t�e.pane 730,� APPLICATION FOR:
�C , a
/'
. ( Improvement Permit ( ) Subdivision
1. Permit requested by/:
Address: R,'f' 3 r,�C (c
2. Name and address of current owner:
3.
4.
�. �
o^� / �
Date Received: 5-�-�r
z
( ) Other �
Home Phone( �"'���o �
Business Phone ��
Property Description: Lot size � d% ct,� . Dimensions:
Front Left Right Rear
�
Tax map No. �0 � Township: Wt,r Block No. Lot No.
5. Directions to property: State Road No. & Road Names, etc.
6. Psrmit requested for: New Installation �/ Repaired
Additional Renovation re-using present system
7. Number of occupants of people served
8. Dimensions of Proposed Structure: Width Depth
9. What type (if any) additions, expansions, or�replacement is an�icipated
to the structure or facility that this sewage disposal sys�em is intend
to serve?
10.
il.
Type of water supply: Well �/ yes no: If ao, name source of water
supply: Are there any wells on adjoining
property� If so, identify location.
�� � �
Type of structure or facility: Proposed Existing
Type of dwelling: Honse Mobile Hom� Business
Type of business Number of Employees_
Number of Bedrooms�� Number of automatic appliances
Basement Number of basement fixtures
12. Clearly stake all corners of the property snd the corners�of all proposed
structures.
I hereby make application to the Person County Health Department for
a site evaluation or existing system evaluation for the on-site sewage
disposal system for the above described property. I agree that the content
of this application are true and represent the maximum facilities to be
placed on the property. I understand that if any changes are made without
approval from the Person County Health Department, the permit will be void.
Any permit for a system is non-transferable without prior approval of the
Person County H�alth Department. Per 'ts a valid for 6 months from date
of issue.
1 �
H �
�
x
�
a
�
�
�
X
0
�
�
r
0
rr
�
OC
�
0
0
x
b
�
K
�
�-
rr
�
�
FACTORS - SITE EVALUATION
1. SLOPE (%)
2. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 in.
(Clayey soils) �
4. SOIL DEPTfi (in.)
S. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAIPIAGE/GROUNDWATER
(btternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
AREA 1
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
AREA 2
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
P5
U
S
AREA 3
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
AREA 4
8. OTfiER (specify) PS PS PS PS
' U U U u
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOMMENDATIONS/COMMENTS.
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill.areas, wells, water bodies, slope patterns, etc.)
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM
Name of System: proax, Cassandra
Address: 296 Everette Ave
Roxboro, NC Zip: 27574
County: PERSON
Report To: Person Co. Health Dept. ATTN:
325 South Morgan Street Ste C (336) 597-2371
Roxboro, NC 27573
Courier: 02-33-15
Collected By: B HOLT Date: 7/7/2009
Location of sampling point: Outside spigot
Remarks:
Source of Water: Well
Source of Sample:
Type of Sample: Raw
Type of Treatment: None
Type of Analysis Private
Time: 1:33:00 PM
Parameters Results Units Date Analyzed:
Alkalinity as CaCO3 9 mg/I 7/8/2009
Arsenic <0.005 mg/I 7/8/2009
Calcium 2A mg/I 7/8/2009
Chloride IC <5.0 mg/I 7/8/2009
Copper <0.05 mg/I 7/8/2009
Fluoride <0.20 mg/I 7/8/2009
Iron 0.57 mg/I 7/8/2009
Hardness as CaCO3 (Ca,Mg) 9 mg/I 7/8/2009
Magnesium 0.9 mg/I 7/8/2009
Manganese <0.03 mg/I 7/8/2009
Lead <0.005 mg/l 7/8/2009
pH 5.9 Std. units 7/8/2009
Zinc <0.05 mg/I 7/8/2009
Date Received: 7/8/2009
Today's Date: 7/28/2009
Report Date: 7/27/2009
Ref: 9369 Login Batch:
Reported By: U�''�\
I�
Sample Number: A691759
Explanations
Coliform Analysis: ,
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking putposes.
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 watec Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
l .3 mg/1
4 mg/1
No established lirruts
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/I
l0 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.� units
5.0 mg/1