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A29 176� 6� . Ao lte�lon• Da�s: � °2'2� � � � a, c� � .. n� � T�r flAaa �k � . .. �a� . . .. . . ,�mourr�Paid: � _ ... ./1 �� , ° . �� . a � � �a ' � � �� . . �� . � �� - - � � �-��'�� : . . ��.�.m� -��-�� r��. • APPtlChT10N FOR 5�•4 �-� i � �►a`� � �.� v � 6�.;� >>> ,�`� a � e 1) Peradt reque�d :( erlag ownerY -�'�"�' '— Sa $�cs� Home Phone: � Z.a -- a6 �A+ddr+e� Business Phon � ` . � - �.�I�-� 2� Wa�e �nd �ddness oi ctitre� ovrner: ��r+ n ��'�a- l _ , .►, .�8� � :-^ i/�n�� _ 3) PraperLy D'esc�ipt9on: Lat siz� � Taw�ehip: Dir�lons to the ProP�Y i�� • � and 4) a) b) ) � Wa�er � Are-any � , Emsting _,, �Tj�pe of Struc� of Hedroom� , ,� �'�v Nu�er of n� Yes _, No _✓�.,1,�%iil �+he pl 3 Dtsposat Yes ,� wa �{,''�1� w ��pa Priva� �t�w � ar � ��9 P �� rrts ar in ttte «: Ct�il.an�� ,� a � '�� quest�or� . _ _ � =1A�dtk � pepth; �n be �rves� , ._ ' g �. Public_, Ca�u�nitY �, SP�9 _ _,,,, No _ I! yes, pfease i�kafie apQto�fie loc�ion on @te s�e pi�. b� Does t�te p�+op�Ky c�ntain �ev�usl�► ide�ed jur� �? Yes _ No _ PlEASE NOTE TNE FOLLOWING: � . '➢ A PL�T OE Si� PROP�RT'Y OR Si7"E PLr�1N NUSi HE SUBWiTF� WIT�� TH1S AI'PLiC�►TtOM: � PROPEi�TY LUIES AND CORNE�S BH1ST 8E CL�l1RLYliAR�D. . ➢. THE PROPOS� LOCATION OF ALL �'TRUCiURES 91�iST BE ST'AI� OR A.AGGEfl. • . D THE SiTE 11/U3T BE 4�ADILY At��SS1BLE FOR �1i�! EYALUATION 8Y THE HE�►LTH D��►a2T0i@IT ST�. 1• herel� maic� a�cn fio the P�sson County i-f�tth Oe�artnrent foc' a s�e �valua�cn tar'the ct�-s� �Ae �P� SY�rn for the abave-descnbed propeny. i agree that the cantsnts af thig aQQQcaiion are true and represe� the nr�dmum f�ittes to 6e pia�ed on the preperiy. 1 understand ifi the s�e is aite� ar the inte�ded use changes, the pemrit shail c�_ ' . - �.� � �, d � . OUmer or L,�gai Repre�i�ive - �� - P�.}D. �u 10tRl01 ��, ; ,.J� �� _ � � �� I��.�aa-��.�. ��.�.71 IE—ZL��:II¢]�a. Applicant: Location: 1,�� i tc, T��x N1��E� � • � P�t�cel # S�ethcl'ivi��ion Ph��•se Sect�ioi�� Lot : � e�:� WG.: J ��.on - � Improvement Permit Permit Valid for Five Years _ No Ezpiration Type of Facility: New Addition # of Occupants # of Bedrooms Projected Daily Flow Proposed Wastewater System: � Proposed Repair: Pernut Conditions: Owner or Legal Representative Signature: Authorized State Agent: Water Supply g.p.d. . Type: Type: Date: Date: The issuance of this permit by the Health Deparkment in does not guarantee the issuance of other permits. It is the responsibility of the applicandproperry owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met Tlus 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 conipliance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will coatinue to function satisfactorily in the future or that the water supply will remain potable. � " Authorization to Constr t Wastewater System �Required for Building Permit) � * See site plan and additional attachments (_�. * Propose Wastewater System: ��.�D �n n��a�f, i ��- Type � Wastewater Flow �� g.p.d. New � Repair Expansion _ Soil LT , o� �7S .p.d./ ft 2 Type of Facility: !'Y1 Qf �i 1 t. i-�om c Basement _ Yes �No Wastewater System Requirements Tank Size: Septic Tank: o'�SO gal Pump Tank: ��aso gal Grease Trap: �/ f� ga1 Drainfield: Total Area: ��Q sq ft Total Length 44o ft Mazimum Trench Depth � in Trench Width �J ft Minimum Soil Covert �_ in Minimum Trench Separation: � ft Distribution: Distribution Box Serial Distribution � Pressure Manifold ISpecifications: F0� � ('nvcr �,�i�/ bc. Authorized State Ag� Permit ,, . �, ROAroXim4 E� f� 07 �. DF- . 'V - r�c 'dc " t�cacr.—, Date: /' (r -03 Alternative. I accept the specifications of Date: PCHD7/30/2002 The type of system permitted is the permit. Owner/Legal Representative: _ Conventional � Innovative 0 , . � • ' *Block, Brick , or poured *Cleanout Plu¢ *Note: Cleanout vlug adapted to accomodate stand pipe to adjust pressure head. or and additional tap may be used to accomodate a stand pipe for pressure head adjustment in. Threaded Tap or saddle tap Sch. 40 PVC � ;� � 3 _ �I/2 , in Sc-fn. ��-�-�aPS -� ��L,i��s `� �''�-3/t�, i,� Sc.h $Or f�Ps s�n. so _ - PVC � : y 14O' ��s � Pressure Head to be set at � ft. __... ,,�. � Taps and � �� Mechanica! Connector Nitrification lines pRESgtTRE AiANIFOLD DETAIL SIDE V1EW Support Straps Concrete Pad. Le�•el END ViE�V Support Block Concrde Pad, Levei TOP VIEW ,� in. Manifold :. Sch. 80 PVC ' From —�_ Dosin¢ Tank Gate Valve To Nitritication Lines Support Strap �g � ng la�u� . • �� j � " � ��LL �1.OJ �� V �� I�v.a�nm�,�-„,� �xa�tn.B. 7�3Ia.m.AtElla si� s�TCH 0 Name UfQ/1C�.'v �.i� i''te, .Tax Map #�aq Parcel #/-1(v S b'vi ' i Vc-r� Section/Lot# � 4�i°►-oa Authorized Sta.te Agent Date System coynpostents represent a�'ipmximate conto rs only. The contractor must, flag the system prior to beginning the iristallation to ins at propergs�tde is maintained F.l / . ---- 3� . � �_ � N Q� R � , v� Y N 4 s a d 8 � r r � (�tpair ��.� . • �� I ��. � Scale: � ��= s� .: � i I 5 Li rtic ��' ios� , I I> ` J! �as' � , � �o i35� ' t`- (�'I , qp' 0 ,- . / � 5a � I �o 10' �� ----� �.��a.9�• I 1 �. 0 0 0 CHD,�v. 09/12%Ol -�_. : � . p��S�N COIDN�'`f E�IVlRflNMEN�'AL !-�EALTi; ' Pl.F�S� S�� ►��Ct�E� �'�fN �OR IME�.L S�iE LAYOl9�' ��u % � T��_ �a9 - TownshiP O' 1 V L�((� ZoNng . ,►,�� ar��ly (,�h� -�� r• �n � G5c-Id�n (�r�nn � - �„-�.,,, L �c1�.y �o�d. ; , . �- Subdivblon• {�� II i�t�u �� : `°� Well Permit T�ae of Water Suaalv: V Individual Community Pubiic � � Reauirements• Siie Approved by C�"SS � 2-z� -�'z- Grouting Approved by �' �5j - � 2- Z� "°'z Well Log � �a-a�-�� , Well Tag z � Air Vent ✓ Hose Bib Concrete Slab ✓ � Weii Driller: �� \ � �\�. Well Approved By �-��L� — ¢ fi.� . � v _L Date• � a **See Attached Site Sketch** Welis must be 10 feet from property lines. Welis must be 100 feet from septic systems. � . Wells must be �at least 25 feet from any building foundation. Other conditions: �t� l��-C 8C� a �0�'� r r'�-� ��, I� �rflm ' all St�-r+c, SYStc-rn5. PCHD, rev.11/29/99 �� s� ��.� �� oo � �� _ _ _ = ` ' � c� � ��°�C� � a� c u�.� w�.� ��.�u,N ��.��.� ��.a��. D�o D�6u�] Owner: Well Log Tax Map 1�� Parcel # ��Q Location: UC�[X�d� �N1�.j� lLU'�2: Subdivision: i-Q i 11 �A�UE.nO Lot # 02, Well Construction Distance From nearest Property Line (Minimum 10 feet) o' Distance from Septic System (Minimum 60 feet) ZO�' Total Depth: / Zv ft Yield: 2- `� GPM Static Water Level: � o_ ft Water Bearing Zones: Depth � ft ft ft ft 1Aa�'� ��- Casing: Depth: From 4 to .3 D ft. Diameter: �_ in Type: Galvanized Steel �— Weight: Thicl�ess: l��_ Height above Ground: �_ in Drive Shoe: ✓ Yes No Any problems encountered while setting casing? _Yes �No If "yes" give reason: Grout: Neat: Sand/Cement ✓ Concrete GraveUCement Annular Space Width inches Water in Annular Space Yes ✓ No Method of Grout: Pumped Pressure Poured �/ Depth to Ft. Nlaterials Used: No. Bags Portland cement ' . 1,�-*�s, Weight of 1 Bag � Pounds If mixture (sand, gravel, cutting — Ratio � to ( ID plates: � Yes _ No 4 x 4 slab �, Yes _ No Drilling Lo� Lacation Drawing From To Formation /R 2 ,? St� �i I � / Z � GiG r. I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person Co ealth Department. Signature of Contractor , ID #�_3 �% I�ate % Z��i ` i� �i PCHD rev O1/16i02 �� )� ZL �� ' �� s.a�'na-�,*-n ,*-„-,i �7L��.J1 ��.Ss.�.��a Applican Location T��x Nl�� ' . P�rc�el � S�uhd'ivi�sioii Ph�s�e Sec�t�ioia Lot � — Operation: Permit 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 TkIE IMPROVEMENT PERMIT . AND CONSTRUCTION AUTHORIZA ION. . .. . .. . z � d3� Authorize State ent Date � � Instai�ed By: �aY �o bb . ` �1 ,� , � 3�' �'. . .. Date: � "' j � - �3 2,�0 • . �. � � .L�,o Z�io 3 �' 3} - :��.:�.. . -Z2. 3,a . ......3��. � ''�. ' . � .... -. . . --. .. : . :_ - .. � .�..-., . 3�y . 3�y .. ...:...._....._... a' L � �� 'I�'!Z 3,��'L � _ too` Z' ��/' `p0 q _ � 3.� q 3�' 13' S N-a� � iz�S Pr 30� �o-��-�z S+�o�� r2sa 5 i�s 3��1 `I'Z!-o�. PCHD, rev. 07/29/02 0 S��TIC YANK IPISPECTION �HE��CLISY (Type 1! - IV� Tax Map # R a Parce! #�-1 System Type (Tabie Va) � Owner/Appiicant f` t,�hi Subdivision }�i�ll tiu,vcn Address/Location o F� W� tdon W rcnr► 2aadSec/Phase Lot # State ID/date �7F 3$9 Capacity, f a Sp Tee and Fiiter Baffle Sealant Riser (if applicable) Tank Outiet. Seai Permanent Marker Pump Yank ICa /Sealant Riser Water Tight Pump Check Valve/Gate Valve Antrsip on o e Floats/Switches � � � Alarm (visable and audible) a�-o�I Sh� � Rate (gpm) Approved Pump Model Biocic Under Pump Pump Removai Rope/Chain Distribution System Serial Distribution ' ressure an o Low Pressure Pipe • Appr. Pipe Material and Gtade Vaives ✓ Trench Width Trench. Depth Trench Lengtt Trench Grade 0 nes Initial/date � ft. 3�t I�i�-� in. � � � p ft. .i . Rock Depth and Quality Dams/Stepdowns etc. Pressure Laterais Hole Spacing o e ize � Pipe Sleeve . Setbacks �/ From Welis �. From Property lines .�v.pT : .. � StructuresBasements :: �-S,�,s p��n rtc es ramage ays . . __ � . _ . SurFace` Waters � � - Public Water Supplies Vertical Cuts >2 ft. Water Lines Vehicle Traffic Easements/Right of W� Other Easements Recorded ert e perator on�� Tri-Partate Aqreement Comments pchd rev. 3/13/01 Application Date: y n 13 Amount Paid: Receipt #: C�ed �� C�ard 5-� -I 3 �i ,� oo ��.5 f �I��$.��T � � �� 7�.�rav nn-�anaxas�.and�.Jl IHI��.]I��Ln. n for Services Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) G Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Wcll Permit (New/Replacement/Itepair) $300.00/$200.00/$75.00 Tax Map: D 29 Parcel#: I7� �✓Olt .� /�Lc,,¢�,,,G' G,�fEcS.�G cYt/ �2DP05C� 1�DL��f^ L ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision , $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: ^-�I_ 1 Name: Vilt � � vUl'U.(-�. Address: ' G e bo o C 2) Name and address of current owner (if different than apglicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or dir�ctions to Property: 75 �c Phone (home): 3 3� --599 a3 8� (work/cell): 3 �(� -�SS3, �,�(p Phone: ❑ yes no Does the site contain any jurisdictional wetlands? ❑ yes Q'no Does the site contain any existing wastewater systems? ❑ yes �' o Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �o Is the site subject to approval by any other public agency? ❑ yes �o Are there any easements or right of ways on this properly? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of 5tructure: ❑Residential ❑ I�,`ew Single Family Residence Maximum number of bedrooms: ❑� �xpansion of Existing System If expansion: Current number of bedrooms: t�'Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes 0 no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage �f �3uilding: Maximum number of seats: 5) Water Supply: ❑ I�Tew well l� Existing Well O Community Well ❑ Public Water ❑ Spring Are there any existin� wells, springs, or existing waterlines on tnis properiy? 0 yes ❑ no 6) If applying for `Autho: ization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑ Any I cert� that the infornaatinfa provided above is complete and correct. I also understard tl�at if the information provided is inaccura e, or if the si�e is subsequently alterec�, or the intended use c.hanges, nll permits and approvals shall be invalid. � �� - `� 3 0 -13 Signature (Owner/ Legal Representative*) * Supporting documentation required. Date Permits are valid f�r 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) _��.s� �� )[�s��a��.� ��Il IL��.Il�I� Applicant: _j(EV�� ' Address/Location: '1S Permit Valid for: Five Years Type of Facility: Number of: Bedrooms / Occupants Proposed Wastewater System: Proposed Repair: Permit Conditions: Tax Map: A a 9 Parcel: l`1 b Subdivision Phase/Section/Lot # Improvement Permit Non-expiring New Addition _ Water Supply: / Employees / Seats: Projected Daily Flow: Type: Type: Authorized State Agent: Date: (X) Owner or Legal Representative: Date: gallons/day The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with t6e provisions of the North Carolina �Laws aird Rules for Sewage T�eatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (� Proposed Wastewater System: piir,4 �1cc'cP�Q i.CN+�r�c�.� (*)Type �� Design F(ow a$� gal./day New Repair X Expansion _ Soil LTAR: . d`ls gal./day/ft2 Type of Facility: f�¢,.��,� Q.Es�a�i�►c� Basement: _ Yes � No (*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank �xtsrtr�� gal. Pump Tank �iasn�ib gal. Grease Trap l�,� gal. Draintield: Total Area �3' Il0 sq. ft. Total Length (�- ft. Max. Trench Depth �$ in. Trench Width ,3 ft. Min.Soil Cover �D in. Min.Trench Separation `I-� ft. Distribution: Distribution Box / Serial Distribution / Pressure Manifoid i� Specifications: k _...c r_.. � : 1 ... � Authorized State Agent: �,Q.1c� �A. 5�+►ii�1 Tlie system permitted is: and specifications of this � (X) Owner or Legal Rep �•I r1�w PatJ��t.s Issue Date: � � 3 � 13 Permit Expiration Date: 5 Conventional /Accepted _�/ Alternative / Innovative _. I accept the conditions Date: � �O / Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev 5/ 12) �.�� ? �� L � J!_eJ�`�dJ ��. �� r~ �� IGaav�n�c-�a+aa3sa��rn�.�R IF��.�-.1�I1� SITE PLAN Name '�t J �w� � ��L „�, �� 'Tax ?��ap # �°l Parce! r-'�.-_ I `11�� Subdivision Secaoa/T Gt# UcQ.i�aul A . .5n .r�.! �l .� t 3 4uthorized Sta.e Ageat ate System componens reptesent approxrmate contouis only. The car_ ttactotmust t7ag t6e sysreai prior to beginning the �nstallation m insure that pmpergrade is maintair�ed. ��. _ _ ... . . � � u^ v;� x �� \ _ "') �� t\�� : -----------�" �� - ��: =��;',t�..t� ��.5�' a �; ��; �' ,. � :. �� "" � �t �:�.. � �— � �' y�� `�, � ,� .. , �, r, � �� s �.� �...��L ��... - � , . �: . : �. -� '�; � �;-t."�" ,1�_ � � c�r � ;� ' `; . . �� , � y � �� :�_, - � � � � � ,�, ��.- � _y €,Y �� \. �U . � ` • � ' � ti ,�i . . . .. ..,., F:�i .. .a�i . i .. � �ri�4.�1 . , 1�.�. :v\.:.�t�• :��, y�,`: \ �' ' _. � ` ='� 4 _ . � � � � . `7'ii.s ;� _ � ,.. �, � �E. v �:�; � � °� { .� � . ��' t �: �,�` �" _„. -e' � � � � �{ � �e ��, �. �..�h�: .��L, ;;& �� ;r� \��_�jt'q•�, i �` � � �� ,�« � ��. ��,. � �� i � � �� ;�;, , �� a � i�. � ��~�; �� . .. � y� x\`\.��.�„"�----.^"�"` s.8 Y�. .�. . �� " � i � C�.�. `� � % \•'y' ��r...-.-,.�" 1 ..J. ...,.��"...�"-�'� �I�A .. i .._..r------ ' 4 � �;�� `tl � '' .� � i a_ �i.F�.�6� � ;a��._�- —.� � __ � �. *�i _,i �� t �; t��--- -- ' � . - .� -�k. �-:, � - ��.z��.. � ., ,� ..� ��` ;� - �� -� �,; . '"'`�� .�.\. .. � ... . . ... ��.sf ��.�� I��a�� ¢�.Il IE��.IL�I� Applicant: �uK,� � ��.a�%Y wN� Location: �13 wvct�ct+��P �.�a�J�. Tag Map Aa9 Parcel # tnb Subdivision ��u-NAv�i•� Phase/Section/Lot # a- # of Bedrooms a Operation Permit � ��w�l�. � System Type (From Table Va): 7I1.�,, Product (IIIg): Cl�t-+A�.tL. Type V& VI Expiration Date: A Type V& VI Renewal Date: �� 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 Authorization. r 34' ��a¢ �.��. a � (Authorized Agent) C�-YoE. sv�,oe^o�.1 (Licensed Contractor) �` - _ A�� -•- � — .� _ — � P�,ss�s� � � � � �� ( ate) 5 t3 1 ( ate) � � � � �+ . � 5- ��' .� � �lo �1Lw �a� � ��, e�� n,\sn�� }��s� �� Scale �_ PCHD, rev. 12/14/12 � � 5�'P� .— _ � E��.6 �►r%. Line Length 1 �i •�' Total y �' Tax Map: �� Parcel #: 1�1 le Septic Tank System Checklist (Type II-I� System Type: �_ Se tic Tank InitiaVDate State ID & Date: Capacity: Tee and filter Baffle Vent l S Riser Outlet boot Perm. Marker Distribution D-box (levels set) Serial Pressure Manifold LPP Notes • Nitrification Lines InitiaUDate Trench Width: 3 ft. 'i� 3 1� U Trench De th: 1'�-�,yin. Total Length: o ft. Minimum s acing: g ft. � Rock de th/ uality ,q Dams/ste downs c�as sI►� r3 Grade (< .25" in 10') Cover (6" minimum) Setbacks t�s S�ti3�r3 From wells Pro erty lines Foundations/basements SurfaceWater Other: Pump System Checklist Pum Tank InitiaUDate State ID & Date: Capacity: Riser (6" min.) NE'VIA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes: Tank Com onents InitiaUDate Pump model: Block (4") Nylon retrieval rope Float tree and attachments On/Off float swing: in. Alarm float (6" se aration) Anti-siphon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed Approved and secured riser Su I Line Size and material: in. sch. Length: $. PERSQN COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT � �� 3 � � 1��1� Date af Inspection System Installation Date Address �� Aa°► �7� Type Tax Map Parcel # a'15 `1 Instructions: Check yes or no for a�propriate items and explain in space provided for rem�rks and. comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N' and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septio tank needs pumping 7 Inches of solids: Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: P.equired gump� present & functior.al ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good oandic►on � Effluent free of e�cess solids 7 Inches ef solids(pump/dose ): 3-s Elagsed time readings 7 f� Counter readings ? Drawdown rate: 3�1 • � (,P ►`n YES / NO ❑ � ❑ ❑ � ❑ ❑ � ❑ ■ ■ ,: ■ ,� ■ DISPOSAL FIELD: Evidence of effluent surfacing 7 � Evideace of effluent ponding in trenches 7❑ Surface water effectively diverted ? � Diversians/swales properly mair:tain�d ? � Vege±ativ� cevsr m3intained ? �. Protected &om tr�c/unauthorize3 uses ? j$ Distribution devices in good coiid��on ?� Field free of szttled or low areas ? ❑ ■ ■ ■ ■ i! FRESSURE DISTRIBJTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessible ? � � ❑ Pressure head properly adjusted ? � 1❑ COMPLIANCE: Compliant Non-compliant Naeds Mzintenance � ., ►_� REMARKS 5: j. �T /� Cc.x'S51 i3l,t 7a'' �,, � 5. 5 M �J , a� �.� X � �� = ��YSh` � �, 5.Sr�� — 30.5 �p� . w+�tS �u�P �s �cz,v�� ; �FFwt�T St}�'�rtcs S o�t� l.il��. �i Z /�C {}��x. �� Y�t� �i�iTiGivt�L. �0iviiv�iviS. S'l51EM '�GC� S ��PA�R ti�� P��a-�- �FLU.C--� ti� �h'� � �t��o S�.t=a�.E � � '�2r�Eo oFF _ �►� ��. ►�1,s�o� r��.rlrw�n t3ox. ° t1vM�a��1E�� r��r��E� o� s�-�c�oJ LPos��rn.� Cti��,n u�r�tum-s Y�.wr►r�c.hl��n zo H+wx. "fRZS��s Pa��t� �R,vn�. '�O i�ti�C' � YzR�l. �SP�►� GIIC�._ EHS '�Y1LZC.�.. Ar SNrC�1�