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A29 22The Di�trict i�iealfh Department Oraage,,Person;:Gaswell, Chatham. Lee Coua.ties _ _. _. -r,' . . � J � SEPTIC TANK PERMIT � � � _ Da� f � ' / I 1=� _ .. .... �.. Name of owner: �� f C%% I') l�? `7 ' Nazne of contractor: - � 0 i� � Address and Directi�ns � �+ # �- �C�,�� i � _ � , ::..:- ��.. �.r. �..i.�.... ^`,. .�...'. .,.�...:_. -�1., ......�._1 1 �T.� Person or firm doing installation: �� ih b f'1 Address - No. of persons to be servea Bedrooms 1, 2,�4. Additional appliances to be used:, Disposal, dishwasher, wasiiing mactiine _ d �"l � Recommended• Septic tanl � � r • ��, x 1 . d...... Nitrification line: �_ � �� _ • Above recommendation based on information received and observed soil condition. 5eptic tank and nitrification line must be inspected!and approved:'by a member of the District Health Departmen3 stafE. before any psortion of the installation is covered. ' Date Approved: � � — /' -� Signed 5anitarian � � O. David Garvin, M.D,� M.P.H. ` District Health Officer =Couatersigned � (Over) � ; . � m 1� ._...... � � Application Date: �°Z'�d ' O� Tax Map: #: �� Amou� Paid:_ l � _. _> �(� Q. RecEipt#: � . Parcai'#: (� � ��'?�� '� � � �� :��,.-�-�-��:�n ��.a��. � APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. o.�l �I 1� av i� � C�-ear � 1) Permit requested : Own�/agent/prospective owner): � ��5� Home Phone: � `1 � Address: < < Business Phone: � 7� ?3 i 2) Name and address of current owner: .��wil ��_ .- 3) Properly Description: Lot size: Township: Directions to the property (Including road names and 0 S bdivision: Lot #: �OS'cv � 1 e � 1_.00 � .. . � S� �� 1 � �ro 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed _, Existing _, Type of Structure: Width: Depth: b) Number of Bedrooms: Number of occupants or people to be served: c) Basement: Yes , No _ Wiil there be plumbing in the basement? d) Garbage Disposal: Yes � No _ 5) Water Supply Type: Private _(new or existing �, Public_, Community _,,, Spring _ Are any weils on adjoining property? Yes _ No _ If yes, please indicate approximate location on the site plan. 6) Does the property contain previously identified jurisdictIonal wetlands? Yes _ No _ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WtTH THIS APPLICATION. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department foc 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 represent the maximum facitities to be placed on the property. I understand if the site is altered or the intended use changes, the peRnit shall b�e invalid. � � � 'a� � Q r ��/� / � Owner or Legal Representative Date - PC1-ID, rev.10117/01 �� )�� , �� `L.1'� ' � � � � �.J.1� �� lE.��a-o� � e��.b ]C�i��.Il� ...- \ � �� .. . � �. � .�. _ ,r�► I r.�■ -• ✓ ' �� SIfiE. SK�TCI� Tag lYla.p #� a°� Parcel # �� Section/Lot# . �3 a�-� . Date . � sy� �o� �� pro��u� �y. � �r �r,�g � �►�p�-�� begrnning the rnstalla�ion to insrsr� that p�opergrade is maintaa�ted � �.�-�� P� �� ` 55' Scale: � � i �.o �r�� .�� -= �--�- � ��-�� .��.�. ��.�¢� WELL I'ERMIT 1'LEASE SEE A�""TACHED PLAN FOR WELL SITE LAYOUT Tax Map #: `�� Parcel # I� Township Applican� Nanni� 2, L�v+s Subdivision: (� ox -k1 a3i� � Section: P�oscui (lL Ty�e of Water Sunvl�r. Individual Community Public Requireanents: Site Approved bp �' �� `�' � � - �3 Groutyng Appzoved by i�'� �l - ZG -�3 �Jell Log �' � �t" �� Well Tag. Air Vent Hase Bib Concsete Sla.b _ M� �'�.. �-r` � l9.' "�",.Y�- is ��` . � i�„� g�`�_�� i ��,�„�Q �,�s m � I �s' WellDriller.�r'Q�� "�e�� ^��' Well Approved By: Date: '�°5ee Attached Site Sketch'k* Wells must be 10 feet from property lines. Wells must be 100 feet from septi.c systerns. Wells must be ax least 25 feet from any building founda.tion. Other conditions• l� C`� ��; t�� (/� G1 rC cL �J �L� rl PG'��, rev. 09/07/01 �� Sf ��.� �� (1��,,.�.,�,,�j )/% o� ao � --3d�d� � } � � � � � �jj� � o � UU�sWUUI� /b 1 c�_ r /L 1' ��Y 'Z/�- � � Jl ��s��,� �� .�.Il�� D�o �U�1 � y-,�/� d3 Owner: Subdivision: GroutLog Lot # Tax Map f;� Parcel # f0 O Well Construction Distance From nearest Property Line (Minimum 10 feet) �f j j Distance from Sepric System (Minimum 60 feet) Total Depth: �_ ft Yield: �Q_ GPM Static Water Level: �_ ft Water Bearing Zones: Depth �_ ft�_ ft ft ft /v � a Casing: Depth: From ,, to ft. Diameter: %� in Type: Galvanized Steel �_ Weight: Thickness: /�� Height above Ground: '-� in Drive Shoe: Yes No Any problems encountered while setting casing? �� No If "yes" give reason: Grout: Neat: SandlCement Concret� GraveUCement Annular Space Width inches Water in Annular Spa�e—J Yes No Method of Grout: Pumped Pressure Pour—�� Depth �_ to � Ft. Materials Used: No. Bags Portland cement b s�� Weight of 1 Bag �-1 � Pounds If mixture (sand, gravel, cutting — Ratio �Z to 1 ID plates: � Yes _ No 4 x 4 slab x Yes _ No Drilling Log Location Drawing From To Formation 5 a-� � 1 7 \ ��I S i- " }� \�' 1 .� � � � � �. �': � �n �� 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 County Health Department. � z �r G3 Signature of Contractor d,� ,��-��,,��./ ID# d% Date _� �� l � �.. � �•►�� 1 � � �V �� IE�.��¢�.Il IHI��.Il¢l� Date: � / ZS/� Name: �� e[. c� Tax Map: .�a�Q Parcel: �1 Address: �� i � Z Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on �/�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: '� No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, �ooking, washing dishes, bathing and showering, based on the bacteriologicul results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally four.d in the soil. F�cal coliform bacteria are associated v�ith animnal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the water may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive for total or fecal coliform bacteria should be properly disinfected and retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, 'Y � Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 3�i6-597-7808 L`�l 3 � PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERlOL10GiCAL WATER SAMPLE ANAl.YSIS Name of Owner or Tenani �� i-A t t��r+J Address Z��E�bSf ti, ��S LC`F � County �`�' �� ``�;�� .. Collected By �1��--� Date Coltected `C l i Time Collected �•�� Saurce: .�eil ❑ Spring ❑ Other_ Location: �'House Tap o Wett Tap ❑ Other �� :'�� o No Charge 6YGharge a�ar��i��a�■�ft��r��i�1��s��r��s��s��s� Yr&**aY**#�1r�t***�FiF1k*�k�Fit�tir***dr#�F4r*�k**�Fit**i��ir*#�ir*�k*Yrir*�Iririe**ie�k�k7�r�4**�IrYe$riririe�idrisYr*�F&�ir*�k Total Coliform Results Present : , / ■ r / �� / - -. : �!�� . �// ' . . 1��r� - - _ / �. -.. -. �� Report Ca(lad ❑ YES o N� Called To Absent