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A29 177� ���,� �, `� �., 1 ��.'3 `,�� �Q.L. ��Z., q .,.� _ . � e ��". - � � a Improvements Permit.(EstablishedlRecorded Lot) Permit (Unrecorded Lot) S`- 2 � � 9�� Reinspection of Existing System (Loan Closing) _ Repair/Replace existing Septic System `mprovements Permit (Mobile Home Replace) _ Permit for New Well [mprovements Permit (Addition) _ Replace Existing Well i� �' rs Z,a¢v��� x� � a ��.� ya r'X '� � a� `°��+bkaY. �ea �:�; r a y �. s"Y e �.��,y ����. s�,t� �:_i�4 ;� ��"^�'���x�±�A" '�'`��.���.q�,as�`Y��',F.s�. .. �' �`� �ti�`�,�s ,,. 'd�;,,@C;iS',�..,dlIln�C`�O �@;,CO�IOC�CCQ• : w �'�.�'�. .�,� �. Y�..n�.#�«.�.at.�R�.,.,rx �x.�.+a�-n3�.:«w.��ee3�`:r•: .�q..�`:xS�k�i". Bacteria Chemical Petroleum _Pesticide 1. Permit requested by: . 7. Dimensions or Pro�v sed�S�tru�ccure: owner/prospeetive owner/agent: ��55� l�• i� Width: a.�s x�r Phone #: � :ss Phone #: %— ��v _ Lead 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? C� 1 _ �'., „ '���cz�- `�6 X z�6 Name and addreSs of current owner: 9. Water supply type: '_ private �( . public ❑ community ❑ spring ❑ � ' - Are any wells on adjoining property?Yes ❑ No [.� (, 9 If so, identify location: . Property Description: Lot size: . Tax Map#: Parcel#: - Township: � � A c, �� flr� fs�w Directions to property: State Road #& Road � 10. Type of structurelfacility: Proposed: �xisting: Q I �'ype of dwelli House: Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: _3 Garbage Disposal? Yes ❑ No � Basement? Yes❑ No 7'If so, # of basement fixtures: �6 Number of occupants or people to be served: � � CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'SOn COutlty Health Depat'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represen[ 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 Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Z �' Signcci Owner or Authorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ i � � � ...i � �, '��", . Signature Date _ , 5��� [ t V � � i • � � � � RECOMMENDATIONS/COMMENTS : SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope pattems, etc.) C:V�MIPRO�DOCSIAPPSEC.SMFWANCEPC , . _ , ' � � - -_ ;�, .� �.. , . �\ .,. "- : - . _.,... . '`. ' _ � : �( � �. �.i' � / � � � , � i i � ��L t: _.�� . - .. `.� : � � a W U � a g 3024 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Retocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � a `1 Parcel # / �% % Zoning Township � e 1 � Owner/Contractor � ��y L�c„�S�n Date �/ - Location/Address y�j,5 '2. On l�c�E�rS �orc 12d � G� /. 5' m�/e T�.Kc (, �bt /�►rinc C/�b, %� on G�C� Chi p Lan� S.R.# Subdivision Name �t55� G��� � � Lot# � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area �, 9y Ac Size of Tank /� (�(.�'j Ga. / I p� SFD � Mobile Home Size of Pump Tank Business # of Bedrooms�_ Nitrification Line qQ7' X �3 ` Max Depth Trenches � 8" Permits may be voided if Well and Septic Layout by_ Comments: �'- M e�-f' E � cand�'t�' Date II- 2"��l is m intended use changed. Approved by Well Permit Paid C�' � WELL S'YSTEM SPECIFICATIONS Individual ✓ Semi-Public Required Slab Public Replacement Air Vent � � Site Approved_ � Required Well Log Well Head Approved ./ Well Tag � Grouting Approved 11{07 W►tncs.kf (,#D� f,,ib Date a-3-��� Installed by°��� �� Ct�. Approved This report is based in part on information provided the tiomeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or mislea�ding information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him i� the application. Neither Person County nor the environmental health specialist warrants tnat the septic tank system will continue to function satisfactorily ia the future or that the water supply will remain potable. c:\amiprolpermit.sam O1/95 rev.l.l ' w • AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DATE: �/J�-99 TAX �LaP �: A�9 Il1�II'ROVE��IENT PERVII'T �: �l33t� y PARCEL m: I � % ow�x�ow��°s �xxEs�rrr��rrvE: i�i I c y La r,� s t�r� LOC�TION/ADDRESS: �� P�rm�'� - SL'BDI�ZSION �i�:V�: ��55� e. {�i I � LOT �: 3 SECTIOti OR BLOCK .TIOv EOR CONSTRUCTION ISSliED BY: AUTHORIZATION CO�iDITZONS I. 'Ihe Wastewater system construction and installation must meet all of the conditions of the auached site plan and specifications as set forth in Im�rovements Permit ���_. "Ihe consuuction and installation must also meet all applicable rules and laws. 2. No portion of the Wastewater system shall be covered or plac..-d i�o use u�1 inspected and approved by the Person Couuty Heahh Departme�t. 3. Any atteratiens in site or soil conditions (including structure locarions) or modification in use, desi,ra wastewater flow, or wastewater chaiacteristics as specified in the associated improvement pennit and application, may void this authoc�ization and associated permits. 4. Conditions: Schedule 40 soIid Qipe over dams Keep seatic 100 feet from anv wetI 10 feet from anv _ progertv line 15 feet from basement wall 5 feet from anYvart of the house. Keeo well at _ least 25 feet from anv foundation and IO feet from anv propertv line T/� ✓`�4 /I % nc_S pn Co�lfac.�r, 3'c�;d��, 9'on Cen�tcr �'av Cfosc �4�-Eriifa� � StAf�' �rtc� �/h,�c t E/fS on .SiiE,c Fa� IaVDc.��� :rsaa Requesting: _ ,. _ � `: .,r .._._-��'� �.�-� -- . _ _ -. _ _.._„_ - _ ,.� . ��:..�., • 0 . .. _ . ...�-:� - -� � . ';�•. . T . . .• . � .. . r� - - . • .. . . `.Y'' `j�`r �t .� / r'� .y �;�L �� � -4 _ �... ��_ ,. � v _r;- � � c�.. ., z•':'' - . .. 'r ' . '. •7, . . .y i. :i•:; t'��ts ,!� y`i " �.. �t' . . �►' rNi � �. , _ r!, ��'*. . '� � V �� fl•',� '�.1!':. J� . . ; ,. " ��. `. _ . ��: _ �4 .J%' ` , � . j . �/. ,' , t t/:� .. ,,; ,.,�, `` .(� ..a• ' . . , �. � r •,• . . l . .. t � l. ♦.I � 1r�.(•� C�� '^�'.�t.9,J� y ^ `� _ .� v'� +. •Z. ! _SI{• - . . /.� , ': Jf v 1F �_ ,� . . ^ �. _.. . ...�. .� � r.--L-�' �. r : ti.'�, . ` . . . � . �IO V � t � � _ . . . - •� ::s=•.. -:_�Z:: _'� _, r� � � + �: . > . '.•� .�. .�.��. 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T�S WELL WAS CONS"1'P.UC"1'L�) �[� ACCORllA.NCE WITI-i REGECT AND..' ��RTH �3X•Tki� P��ZSON C:n(1NTY I�I1;A1.TI-1 DLPAI:'I'M •-, ULA'TZON ,, . �N I . ... _. . _....��/�_ �,. .�Il�11:1(11!'C O� �pl]11,1<:IC)�' � :�: "� -_____-_--f � ��.�,;;i. � Datc �'`,';,. . • ,-•i t; ,' . North Carolina State Laboratorv of Public Health 06 N. W?mOngton St. Environmental Sciences Raleigh, NC 27611-8047 htto://slph. state. nc. us Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH LUKE WHITE 325 S MORGAN STREET 131 WOODCHIP LN ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 StarLiMS ID: ES123109-0014001 Date Collected: 12/30/09 Time Collected: 2:15 PM �norganic ID: Cate Received: 12/31/09 Collected By: J Smith Sample Type: Raw Sample Source: Well Sample Description: Comment: Sampling Point: Outside spigot Temp. at Receipt: Well Permit #: GPS #: Inorganic Chemical (Profile) Analyte Result Atlowable Limit Unit 4ualifier(s) Total Alkalinity 43 mg/L Fluoride < 0.20 2.00 mg/L Chloride < 5.00 500 mg/L Sulfate < 5.00 250 mg/L Arsenic < 0.005 0.010 mg/L Copper 0.12 1.3 mg/L Lead < 0.005 0.015 mg/L Manganese < 0.03 . 0.05 mg/L Zinc 2.60 5.Oc� ' � mg/L Barium < 0.1 2.00 mg/L Cadrr:ium < �.OJ1 - DA05 mg/L Chromium < 0.01 0.10 mg/L Silver < 0.05 0.10 � mg/L Selenium < 0.005 0.005 mg/L Iron < 0.10 0.30 mg/L pH 6.8 N/A Calcium 7 mg/L Magnesium 2 mg/L Total Hardness 25 �. �g- mg/L Report Date: 01/22/2010 Page 1 of 1 Reported By: �e�ie �a�ceaC Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria aze 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 mg/I 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 " D� � J� �,,�;� �,��,,�. �5 s���y � ���d,� 5/��/a9 �i° � ,� .� � r���. � � ��'�" �� � ��� �� /'z � U in/� a�v,�/t� o�' �� GD7' -��✓D T% ���-�r' ��'�' �� '�' �✓ G �v � ,�� � .� �� ���� �%�� ��`'��� � � � � � �f��� • ��y�� ��� �' '� � � � � � � �, � �/ ��' d�' �/�1 � ��/�� �y � � ��� /� i�� �f�'✓ 6'BT�y✓ � � B� � �