A28 184,��sniicatlon Daie:3_�i
�pnoant Paid: �=
��i �: u3l�Q
4�srson Cauntv Heaith Deoartment
�rnrironmentai Health Section
APPUCATION FOR SERVIC�S
�'ax �Aao #: A��
Parca! #: � �
IF THE INFORMATION IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS FALSIFiED. CiiAPIGED. OR THE S1TE IS
ALTERED. THEiV TiiE IAAPROVE�IAEiNT PERIwiT AND AUTHORIZATfON TO CONSTRUCT SiiALL BECOME IIdVAIlD.
1] Permit r+equesfied by: (Ownedager�Uprospective owner) �1�eRF � a
Home Phone: Address:
Business Phone: —1 � .
2) Name and address of cumerrt owner.?� I�?'�' GOU NTR�i
3) Property Descriptlon: Lot s�ze: ��� Townsni� L �� f�%L(,
Diredions to the praperty (Induding road names and numbers):
4) Propoaed Use and Structure Descriptton: answer each of the following questions:
a) Proposed,� 6dsting ❑
b) � Stidc Built �. Moduiar Q, ingle Wide 0, Double Wide,�' �
c) Number of Bedrooms: �, d) Number of occupants or people to be served: �_
_ e) Basemen� Yes �. No� (f yes. # of basement foctures: : . -- _ ... �: : _-_. _ _ .. . . _. . _ . .. _ .
fl Garbage Disposal: Yes O, No�{
g) Dimensions of Proposed Strudure: Width: ��Depth: ��
5) Water Supply Type: Private�'(new,�or�existing �), PubUc Q, Cammunity �. Spring ❑
. Are arry we!!s on adjoining property? Yes�; No ❑ If yes, lacation
6) Pleasa Indlcate Desired System . i ype: (systems can be ranked in order of ycur preferencs)
�Comrerrtiar�al _Modified Cornentlonai _ Attemative (nnovative
Other (specify):
CL�ARLY STAICE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF�ALL PROPOSED STRUCTUR�.
PLE�►SE ATTACH SURVEY PLAT OR SiTE PLAN TO TNIS APPLICATION
I hereby make application to the Persan County Heatth Departrnent for a site evaiva�on for the on-site sewage disposal system for
the above-described property. 1 agres that the cortterrts of this application are true and represent the maximum fac'sTities to be
piaced on the property. I understand if the site is aitered or the irrtended use changes, the permit shall become irnalid. 1 understand
that as appiicant, I am responsibie for identiiying and markir►g property lines, comers and making the siie accessibie for the
personnel of the Pesson Courrty Health Departrnerrt to condud their evaluations. I understand that I am responsible for notifying the
Health Department ifi ro cornains any wetlands as designated by the Amry Corps of Engineers.
� Zo�-v 1
owner ar Legal Representative � Date
PCHD� rev.10!'12199
�
� � ,��
Amount paid ����I � � " � d a�� ���
Receipt 0 �p� � g.,q
�
H
O
�
Impcovements Permit. (Established/Recorded Lot)
ments Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Imorovements Permit (Addition)
,/D -�7-9�
Date
Reinspection of Existing System (L'oan Closing)
Repair/Replace existing Sepcic System
�imit for New Well
lace Existing Well
1. Permit requested by: . �,` � �, � 7• Dimensions or Proposed Structure:
�tra.�..
Address:
W
�
z
f �/"�%y , a.�
ome Phone #: S�� - �9��
usiness Phone #:-S�% /�"�
Name
�� auaaa.
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve
address of current owner: 9. Water sup l�type:
� �;,�1� private public ❑ community ❑ spring ❑
,. Are any wells on adjoining propecty?Yes ❑ No �
, � �, ��s73 If so, identify location:
Description: Lot size:
. Tax Map#: Y'
Parcel#: `, J �
T_"'_..1..:..• /%��/� .CL'/� •
Directions to propercy: State Road #& Road
mes,�tc- _ . � i1 �li -r-
10. Type of stcucturelfacility: Proposed: DExisting
Type of dwelling:
House: obile Home: Q Business: ❑
Type of business:
Number of Empioyees: .
Number of bedrooms:
Garbage Disposal? Yes ❑ I`io 0
Basement? Yes❑ Nofl If so, # of basement fixt
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF TT3E PROPERTY AI�ID THE CORI`IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOn COt1I1ty Health Depar th econtent of th s applic tf on ahe toi
sewage d�sposal system for the above described propecty. I agree that
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 Pecmit
iSsued, I must pcesent a sucvey plat of the property to the Health Dept. I understand that in� the even[ I ha�
delivered a survey plat of the pcoperty to the Health Dept. within 60 DAYS after the date of the evaluatio
the site by the Health Dept., this application shall become void and all fees paid forfeited.
�
Si�nc� Owner oc Authorized Agent
Application Date: a-'R -« Tax Map: ���
Amount Paid: Parcel #: �
Receipt#: �
, �i
�'--���� ).� ���� ��
� � �����
IG gn�-u a- Kn �. ��a,� �.�, ll ILHI ��.�. Il�.l�a
Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) 0 Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charse
/
Services Requested by:
Name: 1��►vi�� l�� .�, 1�'� iv�"
Address: � y,�, S�. i}-h J-�, II L n� .
l�-r°isr E�:�.� C- � > � �
Phone # (home): 3 3 � " Si`� ' `J ? ► %
(work/cell):
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:,,r t 4� � Gu, r�-� J-�
Lot #:
,� 75�
4) Proposed Use and Type of Structure: ,
Residential Business/Type: Other � C-� p�e.�.�
Number of bedrooms / Number of people served (seats/employees :
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No
5) Water 5upply:
Private Well (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A comnleted anplication must also include:
➢ A pladsite plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' 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 information provided is incorrect or if the site is subsequently�ltere , or if the i ended use changes, all
permits and approvals shall become invalid. ,, /j
Signature (Owner/Legal Representative): Date : � �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
c
l �
Application Date: , / �
Amount Paid: /1(�/fi'_
Receipt #:
�
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
� i SG.GO (if site visit required j
O 'Well Permit (l�tew/Replacement/Repair)
$3 00.00/$200.00/$75.00
~�� r Tax Map: ^
" ��J ���� �� Parcel#c
������
IE�.�ra-s an•a�a�,.,�,,,��na:�,.11 'IHt�ea�.11�,�n
�lication for Services
Services Reauested
0 Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
1) Applicant I ormation:
� Name: ' �SS � ' � 1
Address: � ' `' —
2) Name and address of current owner (if different than apglicant):
Name:
Address �
_
of Existin c System
ication o Char� CA $150.00 or $300.00
Phone (home): N �
(work/cell): —
Phnr.e:
3) Property Description: Lot Size: Subdivision: �n �. Lot #: 3
Address and/or directions to Property: �, � �., , � �+
❑ yes "�no
�1-yes � no
❑ yes no
❑ yes no
❑ yes �o
Does the site contain any jurisdictional wetlands? �
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other public agency?
Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
�Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Ex�zr.sion of Existing System If expansion: Currznt r;�r►be* of bedrooms:
�cpair to :l•lalfunct�oning System Will there be a basement? 0 yes L7 no With plumbing fixtures? ❑ yes O no
❑Non-Residential
Type of business:
Mzx:m4rn number of employees:
Total Square footage of Building:
i�aximum numb�; o: seats:
5) Water Sup�ly: ❑ New well �xisting Wel) ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? O yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other �Any
I certi that e informa '
� r , o' e si is
Signatu (Owne�
* Supporting docun
above is complete and correct. I also understand that if the information provided is
y alter , or the intended use changes, all permits and approvals shall be invalid.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�-f..i71.`�"i�"Q1��'i'11'IrY11 t�i�.71.�„�4.� �'�<�.�'��
����d��a� A���timn�/ I�o�i�e �offie �e�lac��ae�ts
TaX Map #:����� 1'arcel#: ( �
Approva.l Requested for: Mobile Home Replacement
� � Building Addition
Applicant Name: (
Address: c� �
� -� "iZ
Phone #'s: � � __ 7/ i ___ _ __
Pernut Located: � Yes No
Installation Date: o Desi� flow: ��{gpd)
Current Contract with Certified Operator on file (if required): �_
Water Supply: _� Well Public or Community
Wastewater system �shows no visual evidence of failure on: �(date)
� (Applicant's signature if site visit is not required) �-`� ��
Comments: �-��wt%
� ic� .�cJ�-e.e ( C�a�
. : � �s��itio�tep➢ac���n� A�p�m�es�
�
En ' onmental Health Specialist
11/1�/OS
�} f c.�
Date
PE3�SOR! COUNTIf E9JVlROIVME9VTAL HEALTH
Tax Map #: � Parcel # I$�i Towr�hip t JI �✓ e Nf I f PIN
ApPI(ca� �l � Subdiyision��"1'��'FC�/.7i�• Phase/SecSon LotS �
���: a s`r K � L ' � � ;tl-4�, u�
Improvement Permit �
New �Addition Type of Structure � i J� / �'!�� , D't�D Water Supply t�� �V Q�f' _
# of Occuparrts �# of Bedrooms � Other - System Type�
Projected Daily Flow: 4�� g.p.d. Permit Va{id For. �+ve Years ❑ No Expiration
Proposed Wastewater System: � �
Propased Repair.�� nr�v��,� (' �550 � Cr
Pertnit Conditions: �l S�,a l( � n C� rt �o � e2A; rta ��� ti �il-r� Q 1l �, �pQQsS n�,►.� .(� a!
Owner or Legal Represerrtative Signature: �� Date: ,�--�4""� �
Authorized State Agent ' Date: d 3'��'� � •.
The issuance of this permit by the Health Department in no way guarantees the issuance of other pertnits. The permit holder is
responsible for checking with appropriate goveming hodies in meeting their requirements. This site is subject to revocation if
the site plan, p(at, or the irrtended use changes. The Improvemerrt Permit shail not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisicns of the Laws and Rules far Sewage Treatmerrt and
Disposai Systems of the North Carolina Administ�ative Code.
Authorization To Construct Wasbewater Svstem tRecwired for Buildinq Perrnit)
Wastewatet System Description: T u,m D"��1,r�oY��-,`Y� ___ Wastewater Flow: 0� _g,p.d. Type:�—�
Faality Description: � � �"Ie �a New a� Repair ❑ Ezpansion ❑
Basement? 0 Yes �-PdQ Basement Fixtures? � Ye q,Dlo-
Wastewater Svstem Requirements
Tankage: Septic Tank size 1� o gal. Pump Tank size ��D gal. Grease Trap size � gal.
Trenches: Totat tength �` �' � ft. Trench Width �ft. Total Area �00 �� sq. ft.
Max. Trench Depth: _� in, Aggregate Depth:� in. Soii Cover. � in. Trench Separation �ft. on center
Permit Expiration Date: D 3-/y-(� �
Authorized State Agent�/�ip,°� - l.(� ,:� Date:�����
*See attached site plan and addendum pages for additional permit conditions.
The type of system pertnitted ❑ does O daes not d'dfer trom the. type specified on the application. 1 accept the
specifications of this permit
OwnertLegal Represerttative Signature: _ Date: ��-O
O�erafion Permit
System Type (in accardance with Table Va)
This system has been installed in compliance with applkable North Carolina Generai Stah�tes, Laws and Rules for Sewage Treatrnent
and Disposal, and ali conditions of the improvemerrt Permit a� Construction Authorization Issuance of this permit implies no
guarar�e ihat the sysb�em installed wi(I function praperiy for mry given period of time.
Authorized State Agent Date .
PCHD, rev. 03/07/01
Application #:
Tax Map #: _ �
Parcel #: i �1�_____.
• Person County Health Department
Environmental Health Section
SITE SKETCH
��vn ��'o �,� ,/ 1,�� ►� 5,��si,r �-of3
Applican s Name Subdiviston/Section/Lot#
, � ���7-d%
Authorized State A nt Date
System components represent approximate contours only. The contractor must flag the system
to be�inning the installation tn insure ihat F
� �Q-« ��I �,l'('�-��• �'
�—�-jc�u�' D,� C����'�
s�ie: 1" ; ��o'
xs mainrainea.
wT�
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,
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PCHD, �ev. 90/12J99
,
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TROL i
NER
IFL
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S8p��0�48n
277. 72 ,
5
1.63
ACRES
`i`57��5
258, s�, ��W IS
6 50. oo ��
1 . 00 IS
ACRES
60'
IS
�
IS
�"0�0'4�=„
226.6j,
�
D
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IF
i
^�2'48"E IF � _ _ _ — _ — -
117.69'
� S86°30'05"E 393.18' TOTAL LOT 1
IF 142.76' IS 80.00' IS 170 42'
rn
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cn o
J .p
RICHARD L. BROOK
D.B. 248, P. i
S89°54'10
Z � � • jF 269.25' TC
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t,ti (p.._._�-
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NF "S -��-- � _ `` , ACRES o �, S
45.86' IF 34.91' ` dS P _� , A C RE S
� - - \ NS � 32 . 00' � o ;!' �
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7 `° `' - \ ""P �
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�, ARTHUR S. KATZ ` �� '��'�i'��"�. �pf � .'
1. O 0 0 o D.B. 200, P. 864 � � � w�C /
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ACRES � � � �;°�� Q��j' � Mp �' �
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327. 99' _, wi^ / / � %'�
N87•,3�54��w --------- TT'''�' A�P ���
I� 1_—�__ ' 32.00�_----'� /�,O
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JENNIE W. MORROW J ��
90-E-228 � j!/ � %��� � TRACT 52
D.B. 193, P. 494 � / -� ��"pv "WINSTEAD I�C.,°
TRACT 51 � / � f �'�P. 146
"WINSTEAD, INC. " � � `''" Pi� ��iC��'�''T
� ' as�s /4 .%
P.C. 1, P. 146 ///�
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�a,re%a ��� �Of.� �gT
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ��U Pucel # I U I
ZoNng Township �/� r G /�. �J
Appliwn�
�eo�:
1VI 0-seS C--1 a y
- �� r/. �;.
s�� . .•. �li�i(L'G'"�=�� ' �.71�'/J '
_i�11.� t »� .
T�ae of Water Supalv:
Requirements•
Well Permit
dividual Community � Public
Site Approved by f Z� "��� ��
Grouting Approved by / " � �D�
Well Log ��►t S�r S-o �
Well Tag G y- 23 � �
Air Vent �-c - -c�
Hose Bib - -a
Concrete Slab � �{ Z3 � �
Well Driller
Well �Appro
Date: s � s� O j
**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
„ Person County Health Department
I/ Environmental Health Section
Tax Map #: �L�� Parcel #: � ��i
Zoning: Township: ( ) � � �� �� �
Subdivision: l� i(� ��� �. Section: Lot: --3
Applicant: � O(x� � �
�
Location• � `
Operation Perm it
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 PERMIT AND CONSTRUCTION
�-"//-o/
Date
Parcel #: � U `i
PCHD, rev. 10/12/99
,- ,
Person County Heaith Department
Environmental Health Section
Zoning: Township: � � � V'�_ �► � (
Subdivision: l J�� ;✓1���i .�—riC. Section: Lot��
Applicant� - _
Location: � ��L ��i, � �
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �
B) Distance from system to any wells tnD' �
C) Distance from septic tank to foundation q+
D) Distance from system to property lines ���+
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank t�
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, ai� vent,
bottom, and water tight outlet �'
C) Date of tank manufacture %�-� 1
D) Tank serial number ,� 1-£--Iz�;c� 5TC3 )�4 S
E) Liquid capacity of tank �2�a gallons
3. SUPPLY LINE TO TRENCHES
A) Grade t/ (1/8 inch per foot minimum)
B) Material suppl line is constructed from ��l 4�b QV �-
C) Diameter '�
D) Length [�8 ' �8 ,
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(S) �
A) Type
B) !s Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth 18 �� inches
B) Trench width '�c� " inches
C) Distance between trenches -t� q�
D) Number of trenches y
E) Length(s) of trenches � oo �
F) Aggregate depth N �A- inches C.�,a.w�.Prc-t
G) Aggregate material and size N�.�
H) Record septic tank outlet ele�vation
I) Trench grade �,t� �. 1 (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth ✓
b. Proper rise over step down t�
a Solid pipe used SCN�
d. Elevations of step downs ✓(Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
Barnette Well Drillin� Inc
336 598 9275 05/15/�l 10:05A P.001
I'ERSO13 CaUNTY ENVIROMlENTAL HEALTH
NEL� LOG
Uwner. _' �C c� 1
Location/Dixections:.i �` `-
-r
Subdivision Name: �
Drilling Contractor: _ � 1.�--1,;�.�
�
�
Lot #
. WELL CONS�tUC1'�ON �
Distance fram Nearest Propercy Line� t v Distance Prom Source of �
Pollution t G o
To�a�.�ep.th:; �-tC.� Fc. Yicld:�_ GPM Scatic Wacer i,evel �?.s"' Fc.
Waur Bearing zones: Depth -�'-�_�� �� �� Fc. �t.
Casing: T?epth: �rom�,,.. c�____to_ L1"2. Ft. Diameter: Inches
TY�'E: Steel ' Galvanizcd Sceel
�f Ste,�l, doe,s owner apprave: Y�s No
� � Weigh��,_. Thickness:�_ Heigk�r Above Ground:� Ynches
T?rive Shoe: Yes ✓ No .
W�re Problems �ncouncered in Setving the Casin�? 'Yes� No -�
Tr "yes" give r��.son:
Grout: Type: Neat Sand/Cement / Conerete
Annul�c Space Width Inches � �
VYater in �mular Space: Yes _�__ _ No
_ . Method: Pumpcd ___ Pressure � Four�;d �! ,� � � �
� Depth: Fr�m_ O :� � Fi.
Iviacerials Used: No. Bags Ponland Cement___�__. Weighc of .1 ba�_Ibs.
�.f mixcuxe (sand, gravei; cuttings) - Ratio: co
�YD Plates: Yes� No� � '
� 4 x 4 sIab Yes� No .
I H�REBY CER'i�FY THAT THE AB�VE �iFORMATION 7S CORREGT AND THA'r
THTS V►jEI,L W�A5 CONS7RUCTED TN ACCORDANCE WTTH R�GULAT�ONS SET
�ORTH 13y�THE PE'RSO� C�vi�("T"Y HEALTH DEPARTMENT_
. �� . ���._.�._----� --
f naturc of Conttactpr D:�►c
�
`�
�
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
� D /2 ��g ��< .� � �
Da of Inspection System Instal ation Date Type ax Map Parcel #
�(
Property Address
Instructions: Check yes or no for appropriate items and explain inspace 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 pum�ing ?
inches of solids:�0'
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Required pumps present & functionai 7
High water alarm operating properiy ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition 7
Effluent free of excess solids ? ��
Inches of solids(pump/dose tank):
Elapsed time readings ?
Counter readings ?
Drawdown rate:
DISPOSAL FIELD:
Evidence of effluent surfacing ?
Evidence of effluent ponding in trenches ?
Surface water effectively diverted ? �
Diversions/swales properly maintained 7
Vegetative cover maintained ? (�
Protected from tr�c/unauthorized uses ? ❑
Distribution devices in good condition ? ❑
Field free of settled or low areas ? �
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REMARKS
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PRESSURE DISTRIBUTION SYSTEM: I 1-
Turnups/cleanouts/valves/taps intact & _ �+ �-,QOwitM,i— �J►'d,�rP✓r ✓1'!i Ssi
accessible ? ❑ � � �
Pressure head properly adjusted ? ❑ � [�li�
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
Ail17I1 iONaL COMMENTS:,
❑
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