A28 36Person County Health Department
Sewage System improvements Permit
;e: � is Pe it Void After 5 Years J�
�n r- � .� I - �_ �/7aG��.,, SR#
Subdivision Nam�: ��"`'1 1 � Lot # [�, t,{;
Lot Size: � � i�+ Type of Dwelling: .��✓a
Water Supply: Private: Public: Community: ,
Bedrooms: c��i � G age Disposal �
Basement Basement Fixtures
�
INFORMA'TI � D BY
$�1��: aner or repiesentative !
REPAIR; � E UATI \
Size of Septic Tank: allon Size �f Pump Tank: ,
Nitri6cation Line: �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP P�mp
Remarks:
�
Date Well Approved: Well should be 100 f� from any sewer system
BY _ Sanitarian
Date Se a Sy roved: - d
BY Sanitarian
,rC�TIFICATE OF COMPLETION
Contrac[or. �) , D���
------------------------- �
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 hazazd. Septic tank and'd
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernrit is subject to revocation.
(G.S. 130 A-335F)
L,ocation of sewage disposal sewage system sketched on back.
(OVER)
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. �
1
; .. ��rson County Healtf� Department � . �
_ - Well Permit �
Date: g-Z9- 9 0 lfiis Permit Void After 3 Years � SR# �%�'
Owner. � ( (
Location/Direcaons: �. ,� � a � 1 {- ! Al �
Subdivision Name: Lot # f �
Drilling Contracwr. �- r� �- r�. .t IQL:�/ �
WEL[. CONSTRUCi70N
Distance from Nearest Property Line 7- u.. � Distance from Source of
Polludon / (� d J�/G-S ;
Total Depth: J�Ft Yield: � GPM Staqc Water L,evel �FG
Water Bearing Zones: Depth TF� FG FG FG
Casing: Depth: From a to Ft'�-Diameter: _(, �, , Inches
TI'PE: Steel ' Galvanized Steel � —�—
If Steel, d owner approve: es No
Weighr. � Thi�ess: eight Above Ground: �� Inches
Drive Shce: Yes No
• Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason•
GrouG Type: Neat '`-� Sand/Cement Concrete
Annular Space Width 3 Inches
Wuer in Arutular Space: Yes No �
Method Pumped Pressure Poured , _
Depth: From � to _,.� F� '/
�M Used: No. Bags Portland Cement Y' Weight of 1 bag
lbs. --�—
If mixture (sand gravel, cuttings) - Ratio: L�- to (
ID Plates: Yes v No
4 x 4 slab Yes �— No
i IiEREI
'�'fiIS W
; 'nRTH
_.;:e[Ch weu ivc:au�u wi icrci�o �iuc.
�
h
�J
�.
. L70T�: 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.
� (1) � (2)
,
�
.'�
A�iplication Date:�'�b
Amount Paid: ��D
Receiat #�
Tax Maa #• �Z �
Parcei #• 3 �
Petson CauntY Health Department
Environmental Health Section
. APPLICATION FOR SERVICES .
IF THE INFORMATiON IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS FALSiFiED, CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownedage�Uprospective owner):�� �-'� �� �����"��
Home Phone: Address: ' L,, �=`'�j �;1c� 9 r/2
Business Phone: /7 1 F�_�x (� c� jt.
fi �
2) Name and address of current owner. ��
3) Property Description: �otsize: � Township: _�� ��`'� �
Oirections to the property (incfuding road names and r�mbers): S ��__���✓`-`,
-�t' a ��l�t � /L,,,t, /'� � ..,' _.
4)
Proposed Use and Structure Description: answer each of the following questians:
a) Proposed �. tirr9 � ,,�- ��—(J �t9-�� /�-
b) Stick Built , Modular �, Singie Wide t7, Double Wide �
c) Number of Bedrooms: ��j>Ll' � Number of occupants or people to be served:
e) Basement: Yes �, No e-If'�jes, # of basement fixtures:
� Garbage Dispasal: Yes ❑, No �
g) Dimensions of Proposed Structure: Width: � Depth:>� f
Water Supply Type: Private new � or existing 0), Public q Cammunity �, Spring ❑
Are any weils on adjoining property? Yes ❑ No � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
'� Conventlonal Modified Conventional Altemative Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR S1TE PLAN TO THIS APPUCATION
I hereby make appiication to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. 1 agree that the conte�ts of this application are true and represent the maximum faaGties to be
placed on the propecty. I understand if the site is aitered or the intended use changes, the pertnit shall become invalid. i understand
that as applicant, I am responsible fo� identifying and marking property lines. comers and making the site axessible for the
personnel of the Person County Health Department to condud then evaluations. l understand that I am respo�sible for notifying the
Health Departrnec�tif �y p e con '� ny wetlands as designated by the Army Corps of Engineers.
�-��� �-- � �--c� D
Owner or Legal R resentative Date
. .
..�..�r� r.. �niin�n
A
Yerson County Heaith Department
Existing Sewage System Report For: Mobile Home Keplacement
\/A d d i t i o n- G�iyytp ,�,�p�
Q- ----
Requestee: wi�cS oQ. Home Phone# Z
b B�s���s� � �
1 l �(,f X��. i1C� ���J7� 'Pax Hapn �O `���0
Location/Uirections: ��� ��eS�' [�1 ✓'� ��' ��-�5 ��m
1�oQ�c�,.� ��a.nc� 5'�i� �o e,hz,�d b rnl.,�, 1'v r' ; c,l� �-�-co� .
O riginal Permit Located '
L�
Septic System Uesigned �'or: _
Kesidential __�, Business Other {specifyi
� Sedrooms � _ # Employees Other
llate rnstalled -1'� O' I(� Water supply �r► ��'e-.
T y p e o t S y s t e m l� �%�l ���`� �Y� Q�
Hitrification Line � �� �C3� —
Tank Size V
Certified Operator Required 1v� �
On site
malEunction
Yermission
�
Accordinq
Comments:
wastewater disposal. system showes na visually apparent
on ���� - �
is qranted to: • l�� at-�� �� �`� ��
�
to the at�ached site pZan.
��� � (� �- � �P�,� �
�
Environmental Health $ �� t� �a��
�� DATE
? �� �� • ` � `'�
� �`
�s s'�` ; . F� �`
- y s
N
_ �9N \�� v� e
�� � ��
-: s
65°42'06'E ��� . . �`\ s �
' �
26. 94 ' `�\ BOBBY J.
� ` ` OAKLEY
`' '
�
�: � s� �.ta � ,�.
,r� � p r
, . . Z. � . . . .�{ � ri „ i { .
. - p . � . : i i- � '. �1 z � . . . .
p� 3 .
*�r rr
l�1 0 ��e ; �3 4 K
o � .: � ;:
o . ' ;a i
p O �. ; 3 �
o� i
� i �•, ,
� � I , ..
;+° f `� fi
I � :'
1
1 '`
- t ;>
� -
- � '�S69oS0 ,
. � . .> '?36, 6; 3 `F
.
� N�
i '
� . I
' ,N
_ :U
,
��S . '
. .. . 4 . _ .. . . �.
� N �.
, w . . . • .
�p. .:
. Q�
= 0.�`:93
. ,:-.;.�::, :
, .
. . :.� . :
... � � . , , ' . . ' �L�.,
. . . . . . i�'L.'` � . .
. . ' _ . . � . � �. . . - `:'v y..: ' ..
. . . . � 'i�=' : � ' .
. � . ' . ���� . .
. . ' ' ; �r;: ` �
. . . . � . �':.i.; . .
� 5
�
� .� � �. CONTROL
� CORNER. - .
"�:
`�.;
���
.rC .... _ . . �
t, . . , .\ . . .
AC.
MELLIE L. CLAYTON
D. B. 104, P. 589
LARRY Cl
D. B. 1 B 9,
D. B. 192,
D. B. 175,
oPERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of O��ner or Tenant 0 �
Address�_ 1� County �� r�n�
Collected By�s
Date Collected 3— I S��d Time Collected �? �`�b
Source: C�Well 0 Spring ❑ Well Tap ❑ Other
❑ No Charge [fJ�Charge
�c*�c:�x�k:kxx:kir�c�c�kkx�k�t**ic**�*�kx��'c�cic*�c�c�c9:�c�'c:k**�F**�F***tF**9c�kdc�c�*�k**o'c�'c*�F�c�c*�F�Fic�c�F
**9:*�c**�k�F*ok�'c*�t*�k�c�'c�c�c�F�F�'c�'c�'coE�cir�t*9c4c*�4*X�c�cx�F�k*�c�c*�k�ct'c�F�k�c�F**�'c��kdc�':*�c�c*�:�tic*:k�k�c9c*
Total Coliform
Fecal/�. Coli.
Reported By
Date
Rescclts
Present Absent
0 �Y
❑ �