A28 149The Dist�e� i�ealth Deportment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
��- Date � :'' :—.j' '� '
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Owner: },'�,�),' j ,. �: ,; �
Location: I
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Contractor: .t a�l r
Waier Supplp: Private �''l Public
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Sewage_Disposal-Facilities: No. bedrooms -�'�' Dishwasher, Disposal,
washing machine,�ther automatic appliances
.._------` � , n r ; i
' Size of tank: rj� �!.�!.,� `�r^4'� Nitrification line:� •
,, �
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 an3 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 DEPARTMENT
STAFF BEFORE ANY PORTION OF THE II�JST�ALLATION IS COV-
ERED AND PUT INTO USE. �( f %}
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Date approved: Signed i 4i��' l'".a''`'� �'�- �'�0 �
._,.' Sanitarian
Well:
Sewage Disposal: I Counter-
signed
BY� (Owner or his representative)
Cestificate of Completion �
Date Approved: ��r-� By' � )
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks,' privies, water
s lies te special problems existing on lot. Wr1te in measurements in order that installations may be located
a ep d����Vote location of water supplies on adjacent lots.
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Applicant: �s�,� c3.�
Location: L1�t �3 -a
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Subdivis�ion
Phas�e Sect�ion Lot �
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Improvement Permit
Permit Valid for '� Five Years No Ezpiration
Type of Facility: t�inc,�2 �i�� 1�. � Q.9�+� New ,/Addition _ Water Supply �nl�a�
# of Occupants �# of Bedrooms L�_ �cted Daily Flow �1�_ g.p.d.
Proposed Wastewater System: e. �..�..��....� O _ Type:
Proposed Repair: ��„� xe� l25 % �¢c�..�,•.►•. Type:
Permit Conditions:
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�p rn ur� eros,w,
Owner or Legal Representative
Authorized State Agent: �
Date: 3 ' �� � d �
Date: 3- / fo -OL�
The issuance of this pernrit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements aze 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 (�. �
Proposed �Wastewater System: C�n��- �� �Q Type � Wastewater Flow 480 g.p.d.
New ✓ � Repair Expansion _ Soil LTAR: . 2c-�T g.p.d./ ft 2
Type of Facility: � Basement _ Yes x No
Wastewater System Requirements �e � C��`k`�
�k,' \
Tank Size: Septic Tank: 125a gal Pump Tank: -" gal Grease Trap: — gal �
Drainfield: Total Area: 1'��-t5 sq ft Total Length sFsS ft Ma�mum Trench Depth�/-Zlo in
Trench Width _� ft Minimum Soil Cover: �_ in Minimum Trench Separation: � ft
Distribution: �C Distribution Bog
S ecifications• �
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Authorized State Agent:
Permit Expiration Date: _
Serial Distribution
0
Pressure Manifold
Date: .3 -1(0 -c�
The type of system permitted is �Conventional Accepted Alternative. I accept the specifications of the
permit. . l% �
Owner/Legal Representative: rL(l �� Dat� �� j%
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i'H!S SYSTE3�1 Hi4S BEEN lNST�►L.LED !N COMPLlANCE WIZH APPLlCABLE . NORTN
C'�4ROLIY�A GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND - ALL COND(TiONS OF ' THE lMPROVEMEIVT PERNIIT AND C�iVSTRUCTION
AUTI-IOR OM. � �
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� uthorized State Agent Date
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Tax Map #�?� Rarce! # 1�f 9 Sysiterri Type (Tabi� Va}
Ow�erlApplicant � � � Subdivision
Address/Location Sec/Phase Lot # '
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Ca aci 25a al. � Trench De th in:
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Sea{ant � c./ Trench S ac9n �
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• �-F'ank Outlet Seal �� Dams/Ste down� etc.
f Permanent Marker Pressure Laterals � � �
Purnp Tank � -- Hole S acing • ��
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Water Ti ht � From� Welts � � 5 �
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North Carolina State Labo�atory 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: Popp, Rita
Address: Blayloch Dairy Rd
Roxboro, NC
County: PERSON
Report To: Person Co. Health Dept.
325 South Morgan Street
Roxboro, NC 27523
Courier: 02-33-15
Collected By: CASEY SLAGLE
Location of sampling point: Well
Remarks:
Parameters
MA�t � n 200�
Zip:
Source of Water: Ground
Source of Sample:
Type of Sample: Raw
Type of Treatment: None
ATTN: Type of Analysis Private
(336) 597-2371
(-�a� -t �3
Date: 3114/2006 Time: 1�03:00 PM
Results :` Units
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Date Analyzed: `� � �ob�
�--��� �-, �,
Alkalinity as CaCO3 68 � ��� e .,' mg/I�� � � � ��3�15/2006 � �
Arsenic <0.001 �,� � �� " ' mg/I '—' 3�15/2006 " '
� � . - r-,
Calcium 16.8 � �` mg/1 �- 3 15/2006
Chloride IC 11 � ` -` mgll -' -;, 3 15/2006
Copper {0.05 mg/I 3/15/2006
Fluoride <0.20 mg/I 3/15/2006
Iron 0.07 mg/I 3/15/2006 �
Hardness as CaCO3 (Ca,Mg) 73 mg/I 3/15/200/�
Magnesium 7.5 mg/I 3115/2006
Manganese � ��� <OA3 � ' . �� r,ig/I � - � � 3/15/2006
..�a ��.�_ _._,.
Lead °, ; � <0 005 # :E �mg/I� � �: .� G i 3 3/'�5/2006
�
pH �� !� �w F ?, , 7.��; , � '� � r i �Std": urnt . � � �� ; ` �. �. 3/15/2006
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Zinc 0.07 my/1 3/15/2006
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Date Received: 3/15/2006 Report Date: 3/28/2006 Reported By: •
Today's Date: 3/28/2006 Ref: 3472 Login Batch 06030035^; Sample Number: AB39572
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 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 rega�ded as a complete report on the water supply.
Inorganic Analysis:
Recommended limits for drinking water. 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
1.3 mgll
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
.
0.30 mg/1
0.015 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
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAIYiPLEANALYSIS
Name of Owner or Tenant �'f� �w�
Address �c� ��.� �--1- d-z., � County �.�su�.
Collected By �
Date Collected� — ���— cXo Time Collected �� vS
Source: � Well p Spring ❑ Other
Location: ❑ House Tap
pNo Charge �Charge
J�Well Tap � Other
A2�-ly�i
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Total Coliform
FecaUE. Coli
Results
Present Absent
❑ C�
❑ L�'
Reported By �_s%�"' �h ��► ,mT
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