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A29 116
�—�.�, ; ��� ���� �� �.�...� � � ���� I���n�- �,��� � �.�.11 I�3[ � �.]l �I� Applicanl Location: Ta�x ���a�� � � Parc�el � � S��hc�ivi�sioi� �:il� � ' � �'•' / Ph���se SecMt�ion Lot � � Improvement Permit Permit Valid for �ve Years _ No Ezpiration � � Type of Facility: �� �l� New �/Addition _ Water Supply P�� —�-•. � # of Occupants �,�pl,x(„ # of Bedrooms Projected Daily Flow ?�b� g.p.d. Proposed Wastewater System: Typ.e: Proposed Repair: l'1 Type: Owner or Legal Representative Signature: Authorized State Agent: �� � p � Date: Date: �_J� The issuance of this pernut by t$�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 Inspections requirements are met. This Improvement PermIt Is aubject to revocatIon If the site plan, plat or the intended use changes. The Lnprovement Permit is not affected by a change in ownership of the property. This permit was issued in compllance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Authorization to Construct Wastewater 5ystem �Required for Building Permit) * See site plan and additional attachments (_). Proposed Wastewater System:� ���� �-�J (1 V�! Ft �� Type � Wastewater Flow 3�� g.p.d. New � Repair Ex ansion Soil LTAR: • 3 g.p.d./ ft 2 Type of Facility: � Basement _ Yes �iP�o Wastewater System Requirements Tank Size: Septic Tank: � gal Pump Tank: N� gal Grease Trap: �,� gal Drainfield: Total Area: � sq ft Total Length � ft Mazimum Trench Depth � � in Trench Width .3 - ft Minimum Soil Cover: b in Minimum Trench Separation: � ft Distribution: Distribution Box �erial Distribution Pressure Manifold Specifications: Authorized State Agent: � I`; Permit Expir ti n Date: The type of system permitted is Conventional the permit. Owner/Legal Representative: � Date: �� U `� Innovative Alternative. I accept the specifications of Date: Aaoiicardon Date: ,�„_ �,mount P_�id: $�. ia�c�� �' - .�,`��4S�s�" 7P'I��� �� � � ���� ��r•..-�a-��,em�.,n. ��.e,�a..R,�LEa�. �ove��c PermR - 515D.Ov (hbbile F�e Repl�ce�n�t��1d�J�+�) ��G��� • :�� � • �- �+� WeQ Pemlft (N�wf�epncamat Coftstrl�GZlOii �� ti�i' it:Sa-dOfS20C.00 Pemrt Rev�+on Feo - 575.00 . ,�' 1) Peemi! requeated by: � , L�onl � �. Ou+m�r1 entlprospactive aw��'I��� Hom� Phane^ - 7 A,ddress; 4�I �- «'.oFF��o b�- 8usiness Ptto�le. 1^ " x� b�r��s�;,= NG a']70..�" 2) Name and address of cu�rent owner. �� -- 3) Property Deacripi7o�: l.ot size_ �_ Touvnship: ��.. Subdivi�ian: Lot# +�! Direc�otts to the property (1ncEuding road n2mes �nd n►anbers): — d l� 1�Jsa artid 3#ruc�u� Descri�tion: answe!' each af 1he follawitg clu�stiatls: . i �� T of Strur�rs: VYdth:�^_ �'��—.� aj F'roposed``�� ExiS'tirt9 ..� Y� le to be served: � b) Number of Bedr�oms: �,. Number af oa:upaots r�r Peop c) B�,sement Yes_, No �r YUII the� be piurnt�ing in #tie basemeni? — d) 6art�ag� fl�ipos'al: Yes,�, No'� � Water SupA�7f TYI�� �rnra�s `1 (new'V or existing,,,�, PublicJ CommunitY�,._+ sP�9 ,�tia'ti �n ihe Are ��y welL� ori adja'vting proPe�hl? Y�s� Na _ ff yes, Please indtcsde aPp�'asclmat� 'sltr plan. 6j Daets your pivpatty cantain p�'�iausly identifled juriadlctio�fai wetla�da? Yea_ I�o^ pL�4S TE TH� LLO G' s* A PEAT GF i"HE PRGP�R'i"Y oR SI� F�AN MUST BE SU�ILR"ik� INTTEI 7HIS A�PpL1CAT1dN. A PROPEiiTY I�NES AND CORNERS MUSi 6E CLEAR�Y MARK�D� •_, A THE PRUPOSED L4CATIGN Qf A�L S7RUC7URES MUST 8E 57AK�p OR FU1��ED. g THE 8C1'E MUST 8E R�A171LY ACCSSSIBLE EOR AN EYAL.IJATIOMI �'Y TNE H�Al.T�f D�PARTM�l�Ci' sr�. I hereby make a�plication ta ti�e P��t County Heaith � for a 5i#� ewak�fion fw' the un-sa�e se�3ge d'�spasai system far tti� above-desa�ibed praperlY• t ag�e tt�at the c�ontent� o� #ftis appiication are true and r�ep�'eserst ttse maodmum f2diities ta be placed on t�te pro(�e�ty. i und�iand if tl'ie site iS aiteted ar tfie irttertded use ct�ges, #he Perrnit shali become i � � ��� ' ../ „ A � � R Own�r ar Legal t�raser�tive► � Paio, cer+. a�tu,+o�z Z/Z R091L6C9£E 47[RoH �sivaw�o��n43 'o� uosa�d , PIV OO�dI 900L/il1£D ft>r � ? '�g ��+� v r J�Y,J`''� `ir� tX i.�,/ � ! �t r:..'�� ��j'' .k{. _ � 7Tri S M.T .- �.. s t � � . f�. u� .. �� k.y� . 1 d. r r y!... s.sa �� $it e t a a- - � . Y �r f{ � „`¢o .ii.ry, � �:.•L�. C � � �.�a � �i t f� K; �a ?jf tYy � .�4, + . . . �''�J„��(• .����J�y�,.t; `'y.:i 4f j_it• ° ti �� Ax4 s)5 • � �K 4 .t �,TJ�.4r� S � K[ �J• � �+ t . �f�,�1��" b��.'E�t ,��yy� �. r. � , ? �. �f t � . 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Qi ' `'� � � • •^ ' �`." - •. y-`:z _ ' , . _ . . � � �j � �� � . �.li.�.i �. �'yl,{�� �, T � � ��.T1�'�� �.�.-�ssr�,� ,,,,�-,�4e�.�.m_li ��m�,.1L�I�. � , ��j cl L`"' . 3i� / `� ti� 1-�,,, . _„ . � 'ra f'�� ^;I, // ' Ci�.i �'C,C) ' ::.' , r- �'� . . � '/ ♦ �ti„�LIL,�'� „�LI� �'IT , `�':_ ;-,'1 r, � r.; � � � .�;� � � . � w �. . � , .:����r�t�0� ���:���$ . �. ' • . �. Sysiem Type (ln Acr.�rdancs Wiih `i'abi�e Va�: �` THlS' S1fSTE3Y1 MAS • BE�i1i fNST'ALL.E33 IAi CD�VtPt.IANC�- .1lVITH APPLICABL�. NORTH CARULINA C�AIE�tAL �.STATUTES, -RiJLF�S ��� SEWAGE."'FREA.TIIAE%IT �M3 i3t5ROSAL, - AI!ID ALL CL3NDtT1t3NS� ..OF : T'HE .tNIPRtflV�fIENT� PEi�iIT AND. -CDNS�RUC"['Ita[41 ' •AUTHO �� - ' . . . _ . �� S� . �-.� �-��'+� . . .. - . _ � `� . � � �: . � �t s� .��t � . . - � : ,� .. .- . °� . - - .� S �'��r�✓ �. S-�. �- �`� _ ii�ea a�r- . _ _ . - . . � - ,, - Fc�. r�+. a��2n!cz � C i i:'�•t' ��'*.� �,Lr'� t_ �,�- ��.���'�i1� �S7 =i�:�i�«��� � Iftl It-Y- • _ - !'! a.11:r � Itls�� 1 tc •1• �1 T.i � I • �_ �. ( Y-; ;f _ i -�`!'1' �•� '� � =�t1! • 111� ■ �'�� jTti-�Tt---r.��T�'G�:-, f �rt �T�I���r-'�;� ri _ o-- _tt_: - ;� {• .�' �I,c�� , �,r_ !� �tc l� _t�c; 1�� - !�e�•.- _1 • � �, =��'_•�! ��.�.ri 1 ' �!_�'_�!���.�_���'�L���i � I l•�'- �f=.�" _ � F� � �l=: �I i ���y � � _ Nll' ' �� _ ��ti. — � .�`,:,5� ������ �� ������ I��rn.�a�-o,.-*,.-,�,. �sa��n.1� ����.]1.vE�a. WELI. PEItMIT I'LEASE SEE A'I"I'ACHED PLt�N FO�t WELL SI1'E LA3�0 1'�'' 1}� P�t' v Tax Map #: � Z� Pazcel # Townshi ,�� H ��� Applicanr. Subdivision: 0 Section: I,o�; l.P � �o c`� � . � � � t�-�-1.a.�- ��.00 T e f Water u .�Individual Communi , ty PuLhc Rec�uirements• Site Approved by Grouting Approved by �-� S—z S-v`� Well Log ✓ Well T ./ Air Vent ✓ �o-a� �,y Hose Bib ✓ Concrete Slab � Well Driller. tTU��t�, � � � Well Appmved B Date: �o-- as-oy '�°�°5ee Attaciied 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 anp building founda.tion. Other conditions: � PCf��, sev. 09/07/01 08/26/2004 06:55 ���� . �-� � �'.�s..���ts�.u� pwner: .� Locatian: � Subdiviaion: 4773708 ��� �� '�J� 'iJ 1 �i SL 1L :��.]l 1E�C��1L+�� 1 ■ ■ �� � f � ! r D t� I, t I'D '•. .,.r .�: f:c•,i»��,�ri;; N;�r,,i�• .. ., • �• a► l�i;�t�� p� �IV�.�cl • ,• Grant %o� _ Tax Msp Lot # tn.,�,= parcel # � ,la � Th't� _ Iri� :�� �' tCC� � WeII Construttion Distaiscc Fram neaxest ty Line (M�n�mum lU fat) _,,.).b_.�..��—. Distancr fram Sepric Sys (Miitimum 6U fecti .�p=-' '�' ft Totul Dtpth: �_. ft eId: ��� � Ststtic Wattr I.evcl: ��. Water Be�uing Z.oncz: ._.L�►„ �— R-�----� ti Cstsi�g,: Dcpth: Fmm __,._L„� Typ�: G�►lv�i�d 9toal _ Wci�ht: i Ihivo Shot: e1 �� _ if "ycs" give reason: �. Grpat: Neai: Asmulsr S� Ivlcthod o1 :Vi�kerl�ly 1Jsed: Nc. Sags J If rnixtun II7 platcg: i,i,ner: Depth: ,_ k`rdm ;,,.,�___ ._ t 1 hrreby c:ertify that the by thc �eraon Couaty H� Si�n�ture oi ContrA� pump In�tallation Contr P�smp Depth: pum�+ 3.Vlmicr dIG Mcxicl: _ I hcreby certifY tbut this an this dAtc and ttu►t a a fl.�0 Di�metcr: ` � iu R�Cea e d' HCiQht �b4ve C3Totmd: ,_^��. � � YcS �No No Asly problemt a�noou�ntared whilo aetting essin$. „� Sa�d/Ctment � Coacrete _ Gr�►veUC�m�t — G y� ✓ Na widch �._ ��� water in A�nufar Space l.r. � F� uR: pumped Pouried �; D�p� ._ �� to �_ ►d ccsn�t �.,^ Waight af 1 Ba� ,�'d�. Pou�td� �vel, ct�ttin�) — Rttia �.-� r.,L...._ cs �, 2do d x 4 slab � Yes � Na Datt 1r►atallcd: �� Grout: �_ Tnstalled by: � Drillin� I.� Loc�flon Drawio� �'ormation w,���� � ['i U bove infarmati4n is corrcct and tt�t this woll vvas conspvcted in accordtnce with regul�uons aet f�rth atb D�spaci�rncnt. • �#�7 , �� �! . Pamp Installm�nt ��. StacC RGgistrauaal Number: _ � $ Ststsc Watcr Y.tvel: ft p�p 3i�c arld k�nti�►�: ��bp .� SP� [np w�s ipatslled aad the arell head co�letrd aacording to tb� T'crson Cau�t?' Wsk� �'�1Gs ia ef�'ect of this rocord h� beca providcd tu the well owacr. pA�: � pCf�ID rev 011�7/04 Pumr �lt�tt�tlltx $I�'II��► . 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: Coleman, Teresa & Wayne Address: 438 Hesters Store Rd 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: J SMITH Date: 4/27/2009 Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: Type of Analysis Private Time: 9:55:00 AM Location of sampling point. Outside spigot Remarks: ° Parameters Results Units - Date Analyzed: Alkaliniry as CaCO3 84 - mg/I 4/28/2009 -` Arsenic <0.005 mg/I 4/28/2009 ; Calcium 26.1 mg/I 4/28/2009 Chloride IC <5.0 mg/I 4/28/2009 Copper <0.05 mg/I 4/28/2009 Fluoride <0.20 mg/I 4/28/2009 Iron <0.10 mg/I 4/28/2009 Hardness as CaCO3 (Ca,Mg) 80 mg/I 4/28/2009 Magnesium 3.6 mg/I ; 4/28/2009 Manganese <0.03 mg/I 4/28/2009 Lead <0.005 mg/I 4/28/2009 pH 6.9 Std. units 4/28/2009 Zinc 0.27 mg/I ' 4/28/2009 Date Received: 4/28/2009 Today's Date: 5/8/2009 Report Date: 5/8/2009 Ref: 5845 Login Batch: Reported By: \ (� Sample Number: AB88566 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 regarded 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 mg11 No established limits 250 mg/1 1.3 mg/1 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