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A29 257Anpiic::;��cn Daf�e: �'I!?'a� ��20 �ax i1�ac� �: Amounk?aid�. ^ , 1�(�j�}P CUCQ,�S��- Rec�ir�_c'R�, Patc21 �: �..__..,,�� .!l�� ' ----- � :x--.,� � � �� ^ . 11==./3�.'a.�PA9. nt3�t'.L.9.•'SCJ.��Oa.'a.'�.61.� �'�T�ca��1.�JLm .aP��.�ca-no� FOR s�vic�s 'I} Perrrr�t reqtaested by: (Own�rlagenUpraspec�ive awner): � v� � Hon•:e: I?hone: �� - Address: 35'� /i Busine:�s Phone: �'"� -!a o S 2) Naurti�ae� anti ac�dress �o� current owrner. �,�n� `T �he frtrm :f� IPrc�F;��erfy Des�ri�taa��: Lot size: 1 fkre� Township: Qf' e ��) ubdivision: �]f fs'a5�u1 /le� L.ot �� Dir�.r;tions to th�e prr�perty (!ncluding road names and numbers):T�GU� .�q �o c��6i, ,4.0,/ZnY, �G} pras��crsac! 13�e. ar� S�ruc�lure Descriptton: answer ach of the fotlo�Ning questions: a� i�=�rc,ppsed L; Existing ,.Type of Structure: �� ,��i��4-) Width: Depth: b) t��umber of 8edrooms: , 3 Number af occupants or peopie to be served: c) F:tasemsn� Yes�, R!a Will there be plumbing in the basement? d) c;{�rbage flisposaf: Yes � No . • :i) W��c,r Snpq�t� Typd: Frivate �(new ,.,,; or existing�, Pu�lia�, Community� , Spring _ Are any wells on adjnining property? Yes� No _ if yes, please indicate approximaie iocatiori on ihe �sife pian. Ei) Dc�.; ;/eur pra�ses�ty con�Cain praviously �rlentiffed jur6sdictional wetlands? Yes_ No r/� F'LEA::�� l�JOT'� TME F+OCL.t7{Nl{�G: 9+�; PLAT C�F T�fE �RC7PEiiiY G�R SITE i�l..�1P1 [1AUS3 gE SUIBMITTED W1TFE TF81S �►PP�9CAT90RI. ➢;��CtQP�RT1' L.1WE5 i4P1D ��RNE3�S 11�UST 81E CLEARd,.Y MARKED. �, �""NE PROPC35��7 LOCATiaM OF �4L�. S7RUCTURES MUST BE STAKED OR FLAGG�D. A"`3�1E 51'f'E MRJ51' BE �TEAt31LY �4CCESSIBL� �Oi2 Ai16 EV�ILUATIOM B`l iWE HEAL7H D�P�,RTiIli�iVT �'sl'AFF. l hereb}�� n•iake applicatipn to the Person County Health Department for a site evaluation for the on-site sewage disposai s.ysiem �'�3r the above-cfescribed property. I agree that the co�tents of this application are true and represent the ma:timum �acilitie�.:. tc} he pEaced on ttie property: I understand if the site is altered or the intended use cha�ges, the permit shall t�ecom�:. �vaiid. ' ,> � �.�' '��_. :'.i�i� cr' !r'{✓�`�� 9. /`T— �S� ..� �_ .. ) � �wn�� cr L�ga( R resentative Date acN�, ��. �s�z7loz �� S� ��.�� , .1 / 4 ,/�� p�p�y �� / � � � Ji J.L I��mm � ��.��.31 ]�3L��.]1�.11a % T�x M�p ; ' Parcel # , Su�bd�ivis�ion ., � !. � Phas�e Sect�ion'Lot " Improvement Per�nit Permit Valid for ✓F've Years No Expiration Type of Facility: New ✓ Addition _ Water Supply �� t( # of Occupants # of Bedrooms 3 Projected Daily Flow ? o g.p.d. Proposed Wastewater System: Type: � � Proposed Repair: lii pv.y,� Type: Permit Conditions: Owner or Legal F Authorized State � � Date: �kl a a� Date: 7 d The issuance of this perrnit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure 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 Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules %r Sewa2e Treatment and Disposa! Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply wili remain potable. Authorization to Construct Wastewater System (Required for Building �'er�it) * See site plan and additional attachments (_�. � Proposed Wastewater System: New _� Repair Ex ; Type of Facility: yn�� Type � Alif� . Wastewater Flow �.p.d. T'� Soil LT - Z� g.p.d./ ft 2 Basement _ Yes _�To Wastewater System Requirements Tank Size: Septic Tank: 16co gal Pump Tank: l�o� gal Grease Trap: gal Drainfield: Total Area: ► ao sq ft Total Length a✓So ft Ma�mum Trench Depth /8 in Trench Width 3 ft Minimum Soil Cover: �_ in Mini.mum Trench Separation: 9 ft Distribution: Distribution Bog Serial Distribution k' Pressnre Manifold Specifications: �"' �,�/y G�" �A � Authorized State Agent: Date: 7 Permit Expiration Date: i The type of system pernutted is Conventional ?� Acc pted � Alternative. I accept the specifications of the pernut. / Owner/Legal Representative: �Z �t%� Date: (� ! ! a �O� PCHD rev. 11/10/OS �� a �� ,� � � �� I��a-��r��,.¢�.71. ZE-31C��.11�1�. �f.�. PE�'�'� �'�A.SE SEE �33�A�D Pi.Al�t F�R �5�. SI'.�2'� ��iOiT� 'T'ax lbtap #: 2q I'arcel # 2�� To�wnslup ., ,, r ..;, � � i � r „ - �� t • �� 'i � r. ` i/.tJ'� /' �/ � :.�wr-�..�, . ,�, . ! ..�� .- � 3'I - r ,a ' • � � • u . • u u � � � • ��11II1�ffiC411:3' Site Approv�ed bp >� c•J D� Grouting Approved bp . �ell Log , �e11 Tag,. Air Veat : Hase B� ,' " a `�� Concre�e Slab � '�eI1�� a.,S �� /��l� We.� �p�roved. s a ,,�.� (� �1-13 d °z �SeeArtac� Site Sketch�'* Wells must be 10 f�t from property' lines. WeDs must be 100� feet from septic systems. �ells must be at least 25 fie�t from aap bu�diag foundation. Other coaditions- -- � K�� P�I-�, rev. 09/07/Ol Z/C� PVC Cmte Vaiw �� ,-� �,�� ,4�T �� S `�,as�� l� �_.. � �1le�� ..�-r z� �- � � �� ]�.aa��.�mm � ��¢�ll IE3I��.Il,� Owner: �o � Tax Map: � z4 Parcel #: � � � Date: �i � 2� 8 Line Tap Tap (Sch) �ap Flow Line Length Flow / foot # Diameter(in) ( m) : � (ft) 1 ��z _ i 7b" .io 2 3 4 5 6 7 . � 3Sa H iVl L . �T. 9 10 �� ft of line x,65 gal. per 100 ft = =100 = ZZ7 gal 75% x Z27 ga1= � D gal per dose 35. 5 gal per minute (gpm) = Flow Rate Friction Head Loss: 2-3� ft per 100 ft of supply line x Ido ft of supply line � 100 = Z•3� ft �.�� ft x 1.2 = 3 ft of friction head Manifold Size: � " Force Main Size: Z " PVC � Total Dynamic Head = 1 S ft of Elevation head + Z ft of Pressure head +� ft of Friction Head = � Za TDH � Pump Requirement: 3S � GPM @� ft of Hea Drawdown: L?a �al per dose = 21 gal per inch =� inch drawdown per dose General I3es�gn Ynformal3on Schodule40PVCTaa T1aa-up�mp PLSF-P9V 2» min Schednle 40 P� �� ■ ■ �� i . - I�ad11�q Iad/mea�toa gm� � ' s � _ � � - •• � : � �. ' �I��1�00�0 iiiiiiiiiiiiiiiiiiiiiiii�i�iiii ��ii��:i�iia��ii�ii�� a Y: i%ld Size I # Taps Maa No. Taps off one side ace b 1/= for ta �in both si ta s 3/." ta s 1" te t Z i _5 3 �a {„ 4Z}+. 21 ( 12 � . " Flo� er Ta Size lt�aterial Flow GP.�I 1/.. " Sclied 80 5.5 ;.'� Scned40 7.1 3/, °• Sched 80 1 p� 1 ,,'. Sched 40 1? � _ . t,ot zl�. 1=-�+.P-� ��Y ��,(� �l � NEMA 4X Simplex Control Paxel � '1 4" X 4" Pressure Treated Post j Sloped To Shed Water �2" Separation � E12CtYLC21 COYl�llt � • . . • �. 6" Cover • ' � Access Cover. � • , • . ; ' 1 � , . _ � ; •.. I. ' ; ,+ ; '` � ' . : �., Openin= Filled With Anti Siphon Hole ` Inlet Fmm Septic Tan]c Portlax�d Cement Graut �� g�� 4" SCH 40 PVC Pipe � �� . Valve High Water Alarm Level ' (6" Separation) Hish Level - Aunp On ' �Vipoz Lock " '•, � Hole . . .; Drawdawn �Up H�71) , Law Level -Pump Ofi Duct Seal Both Ends Of The Con,�it Concrete Riser � � 2�}" �inir�n�m +• •' • - • ' • • . 6" Separation Thxeaded Gate Valve ; Union . •,' . ' ;� �• . ..rt.• ;�.�Poztlazud Concrata C:xout _ _; Mutic • - : . Zip Cord . � Opening Filled Wiih Tus Suppiy � portland Cement Crrout Lin.e • • Outlet To Dutnbution .LNvinn 2" SCH40PVC Pipe , ROp° Float Wires � � •r i i � Floats . . � • .. � �R.emovable �•�. Float Tree , , �• ' �np • „ .. • . 4" Concreta - : �. ' P:ecazt Concrete Tank . � ;.; (MatexialStzen�th>3500PSn B1cck r � •�; � .,`-, " ' • , , • • _ _ ` • . '. • ' ; . . '� ' , • � ; ` t ' .' . 00o GAIS.�N PTJ1Vg' TANK � � �� J �� .�� , 1 X ./` � . \.�.r.. 1 � � � � � � � I��,-��.�-��.��n-ll 1L��.+�.�L�Ih,. SITE �KETCH N�me _;��J� • Subdivisi n.::.�` G� �i'/� � , � Atitlieliz d te Agent �� Tax,Map #� Parcel # �� 7 �� Section/Lot# Z�o 9/�/�G� --TDate sj►ste��a co�tapolients �eps�esent approxitnate contvurs o�z y. The contractor naust ftag the system prior to b�gd�zning the installation to insut�e thdt ,��r+a��e�•grade ts Ntai�ztained ' � � 3 /3��✓'�aati/ �� e��A .�� ' /G�laO �/"''�'" ,� � �t;C��r"��' .`,r,�5� ; .tf f=';%. d�� '`' ��'��`��rc� ��"��.��'� � »� �v�' � d �' �� '� -:� � T� �i��+�-a . � . . ,,. . "��, vV►T'�– � ' _ . �`'� Ir�lrlh.'�-- ' >;,, � , ..',':;> � ,,,;��1-wt � �r�on . . ,,�� ,�.~�.,- ��,./r-� -S27 g , D` n_ . � 67.5 ��' 13r! w. � $tC11' ' F-lal p ,g. : ��---��:..� t�.. �"��.a�;¢ ��-r��'� <—LOT 27 EASEMENT AREA : � l..c��" r„�. ? ��.�� .. , � <��T2g�ASEMENTqF �� D,r,;.'...--'i..�. �' �Ot�� a=✓� fd��-t� -r �"�+�.t�.�':5 '�'C'+�P�t�;� ��5r `'UpPLY L In►r- _ � /V'�7��' %1%"oi'11� /'i/'I �&, , '� ,�in/� �fc��' �� /�✓<��//,�� *;��% 'yL°�1i w.,7¢- hzi�a�tse� �/t! iOlv, Sc:t�e: 25 �SEM��A�� 2a �5��a -�-;� -��6EqS�jNE�Aq� IOIy�A�BPl/tre • ��I�� Aa�r) . �.-�'f"' "� � ��AA � � -�-�--�- ._ ._. - -- . _ �! _:_- o � ; r Notes 6 All supply lines must be insta.11ed at the same time witlun the supply line easement. s All supply lines must be pressure tested before lines are covered. e Prior to installation, supply line and drain field easements must clearly marked. Contact 5urveyor if in doubt. � Drain field layout is approximate. � p Pump requirement (TDH) is estimated. - o Any questions contact Person County Health Dept. (597-1790). 12i05/2007 1a:17 =365977608 .�"'�;�; ��1�.� ��.i�~''l��l� ........, ,� :�.�.�..�..�.�:. ri�.��,��.�:�� «�,a�. ��,�'m(�i li� � dt r' EN1� �� D F-+��a� u.: �,� �r�ll�h`� � �u �`, �-l� � � ,1— Groat Lo� ��' � ^ % �% Q��; J � � S -e � Tax T�,�„ P�rcel # LooaHon: 3ub�ivi�ion; - .e. . Lvt * . � Wd1 Co� t�rudioa Distanoe Fram aesreea prc�ertY Lizu � 10 f�ct) Di�xace frotn 3eptia Sysbcrn {Miuirnum 60 fcct) '✓ Total Dapth: �— R Yxcidc ,��___, fiPM 3tatiQ Wsver L,cvel: � fk ve Wattr H�aring : Depth�Q,_ ft 8 ft ft Cu1n�� to �'�% �___, ft. Di�metr,x: % fn I�: Fro�s �..._ _ � �j►pe: (�lv�aixed Soea] _ t/' � Wnighr. �3 bs T�a�eae: ,�� Ieigbt �bwe C�roimd: .� �— in � Dcive 8boo: �Ya Na Auy probleuu eavoimtarmd while �tttin� oaria�? _,_„Yee �!No I#� "y�oi" giVts T04�oe't: Ql'01�t: NOQC $iI1CYCCI�iIt L'OOCf01C ,;^,_� QI'�'VeU� �ut� s� w�ac� .,.�_ ��nos w�a � �� s� __Y�, �_ Ma�wa of cirouc: Pu�pca P�qs,ue _ o! Pouiea nepctti w M. M�►t�tl� Uaad: No. Bag� Portlnrxd ce�ent Wai�hht of 1 B�g �. Pounc:� �t' mixtirre {iacu��i, ve? � euttintas) — Ruio ,�,,��o I II3 pLtce: �/Yes � No 4 x 4 elab �t � No L�oer: Dcptii: Date Iustaikd: dmu� Installed by: �„ �� 7 Latittio� D�n►wta� I harcby ccrt�fy thet the ab�vc iafmrmatian is correct aud that ihtt well aas eaiutruabrd m► Rccordanea with regulstiena set fmtb by thc Peraon Ca►mty iiealtk Dtpartmetit � SiRn�.tare u�f Cd�tra�tar , � –'�� C�, i3,�ta .�,�.�t:i��..� Ptitnog In�tml�nR Pua� Inrt�tlstioti Ccmtsactor: SR�cc Ite�imtr�rion NuRa,ber: Pump L)ept�: ft Stade W�ier Level: ft Pum� Mate � ivtoael: � siz� ar:a Rating: ha eP'� i hereby certifj� tbet tYua pump vwa inst�tlled end the well head camplai«i accord'm� to th� Person Cotiusty WeII Rula ir� effect on thfe dntn md that a capy oi 1tix cacord h�e 6eeu provided to tiw wall ownex. Pua�p Xoatali�t 5lpratare A�tt�: ,_,,.,,+,_� PC'f3D nv O1/27J44 a ��,� �� l \ � � � • �=-s � ��.��'��s � �d��-�-�..� -�--,--� ��.�.�. ��.a.� Anp{icani: Locafion: a �� " � � � � �_ _ , v� i,� A %q ?�� _ Zs7 � � ^ �� ,��trrr (� naS2v1 Tie t°r'�l�^" �r�C�"ss�0[P9��t� ;� � �� o, ao � .. . Sfstem Type (in Accordanc� Wiih Ta4�ie Va): �L �,,q �C�) THBS �YS�� :.� i�iST.�LL�s'� I�! CDPs�iPLl��C� V1lI i�-1 �P.��lC,4�L� . N�RTH . C�1�OL1NA GE��L S i ATilTES, �LIE.E� Ft�R Sc'�ilAC-E TREA��ftE�T �a�dD D1S�OSAL, .�ND •,�Li COlV�[�'lC��lS c�� ' T�E I�i1�R01�'�3�(E�T PE�,�It i.��D G�}i�STRLICTIO�i ACtT9-!�� . � . . . . � � �-,Z-4q � . Au oriz�d Stat� gerrt � Daie . 1 nstalle�. By: 1. e.o t� i�. Date; 'j b—�-2 -- o g . . � � � � � �o � �� . . . . � . ut� � � � � ,� P_ � r � +' ,I � e � �v � r � �. =C;-�C�; rt�. 0 � l��i�',,� a a ��:� ; 3� �.��t� ��5�'�� u�E��S a � � ;9�� 99 =1° i a� Ni�a f�g_ Farc;,! � 25`1 Sy��e:�r� Typ� (T�b�� Va) �2 O��er;P,�pliccnt � S�bdivision .,'lle A.ddr��slLo��ion Se�; Phas� Lct � � ��a�Il�. T�r�� i��d�� o��a��c��oa� �� in��a d�� Stat� �ID/date - 2 -Z3 -o SS ro - Zz-a � r��cfi V�/�df� � 3 �. SS �-2z- Capaci - f000 csal. � � Tr�nc� De�ti� 2- in: Tee and Fiif�er � , � Tre�ic�t Lsn�th �. �af�ie � ir��ct� Ca�ade � � Seai�nt ir��tci� S �c9n . Riser ir applicable �� Rcc:� De and Qt��i"' � �'�nk Outi�t S�ad � Daens/St� do�s �#c. Perr�an�rrt t1l$�t�ker Pressa�re La��ral� � . d��m� Tank • � l�ole S��ceng � e.� 7 � ►06p �SE3��1$ �IS��' �r�t�� rgr,t � . � �� C�ec� ValvelGate �«i�e �ilarm visabie �nd audi�d� �3e�irical Cam �nents . � �2$� Rl , . — � roves� Pum 1Vlode� Bioc� Under Pvmp � Puen� Removai �Ro�eJC�ain . ��is�a�aa#aon.: S�#�an � Se�ial D6stribution k�ress�re i��nnod Low Pressur� Pi�� A r. Pi e N9a#e�iai �r�d Grad� �" 0 • u-og � e :.�z� Pi��. Si�ve ��Ut�� fo�r,� vv�� . ��om Pro�e�v rnes � Surfac9 V�laters Public 1]�a#sr Su��i `��sticai Cuis (>2 �i. us 1.l1�a�r Lin�s O�e�ocl��Tra�¢c � ��serr��igi�rt. o� � �� as��n�nis R�ard� e�e �e�to� a� �ri-��rtate A�ce�mer� ��m��a� � ;c:,c �r.2t'�31G-t Report To: d North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES071409-0040001 � �� ES Microbiology ID: 7013 GPS Number: Sample Description: Comment: Name of System: Farm at Roseville Lot 26 Collected: 07/13/2009 09:15 Received: 07/14/2009 08:20 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 httq://slph. state. n c. us Phone: 919-733-7834 Fax: 919-733-8695 J Smith Angela Heybroek Well Permit Number: A29-257 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Joy Hayes 07/15/2009 E. Coli, Colilert Absent � = Joy Hayes 07/15/2009 Report Date: 07/16/2009 Reported By: Susan Bea ley . . . C(��J � k�� 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 mg/I No established limits 250 mg/1 l .3 mg/1 4 mg/1 No estabiished lirruts Ir��n Lead l�iagnesium 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) l.0 mg/1(as N) Not less than 6.� units 5.0 mg/1 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: Farm at Roseville Address: Lot 26 Zip: County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Ste C Roxboro, NC 27573 Courier: 02-33-15 Collected By: J SMITH Date Location of sampling point: Well head Remarks: Permit # A29-257 Source of Water: Source of Sample: Type of Sample: Type of Treatment: ATTN: ; . - -----.� - -_ Type of.Analysis Private (336) 59� 2371 � ; � .�__ . _._ ._,.._ i_. . . � �;. j _ � ,j A�i��; ,! <; - ". 7/13/2009 ' Time: ' 9:15:00 AM � � -�- - -� _ �; , _ t ;':' �� y -- -_--- ._.�.i Parameters Results Units Date Analyzed: Silver <0.05 mg/I 7/14/2009 Alkalinity as CaCO3 70 mg/I 7/14/2009 Arsenic <0.005 mg/I 7/14/2009 Barium <0.1 mg/I 7/14/2009 Calcium 20.3 mg/I 7/14/2009 Cadmium <0.001 mg/I 7/14/2009 Chloride IC 6 mg/I 7/14/2009 Chromium <0.01 mg/I 7/14/2009 Copper <0.05 mg/I 7/14/2009 Fluoride <0.20 mg/I 7/14/2009 Iron 0.11 mg/I 7/14/2009 Hardness as CaCO3 (Ca,Mg) 78 mg/I 7/14/2009 Mercury <0.0005 mg/I 7/14/2009 Magnesium 6.7 mg/I 7/14/2009 Manganese <0.03 mg/I 7/14/2009 Sodium 11 mg/I 7/14/2009 Nitrite as N <0.10 mg/I 7/14/2009 Nitrate as N 2.92 mg/I 7/14/2009 Lead <0.005 mg/I 7/14/2009 pH 6.7 Std. units 7/14/2009 Selenium <0.005 mg/I 7/14/2009 Sulfate 18 mg/I 7/14/2009 Zinc 0.61 mg/I 7/14/2009 Date Received: 7/14/2009 Report Date: 7/29/2009 Reported By: � Today's Date: 7/30/2009 Ref: g702 Login Batch ��Q��p�� .� Sample Number: AB92015 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 pucposes. 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/1 No established limits 250 mg/1 l .3 mg/1 4 mg/1 No established lirrucs Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No estabiished limits 0.05 mg/1 ( 0 mg/1(as N) l.0 mg/1(as N) Not less than 6.� units 5.0 mg/1 PERSON COUNTY HEALTH DEPARTMENT SLTBSURFACE WASTEWATER SYSTEM MONITORING REPORT - 2-�- �� I D- 22 - D$ � 25 7 Date of Inspection System Installation Date Typ�� Tax Map Parcel # 7 jR Gear�,,�a-�er n� Properiy Address Instructions: Check yes or no for appropriata iter,is and explain in space provided for remarks 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 ? Septic tank needs pumping 7 Inches of solids: Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps p:esen: & functiona! ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids 7 Inches of solids(pump/dose tank): Elapsed time readings ? Counter readings ? Drawdown rate: YES / NO ❑ � ❑ ❑ � ❑ ■ ■ REMARKS Ivr�" Q�(.e551 b�� he�o�.1 q�auh c� J ❑ / ❑ ❑ � ❑ I I • ❑ � ❑ ��-f' RcC�eSSIb'� unde � 'an�SCl��I . � i ❑ 1�I I e i� �' �� wou�c� i2Com�+lend �'1 � �and`�a�inc�l�ine5 _}� o� ��1 �A�tA box C2 e,cal I�bx). DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ / Evidence of effluent ponding in trenches ?❑ / Surface water effectively diverted ? � / Diversions/swales proper(y maintained ? ❑ � Vegetative cover maintained ? � ! Protected from tr�c/unauthorized uses ? � / Distribution devices in good condition "❑�/ Field free of settled or low areas 7 [� � P��u�e mu►�ri�� ur�de►� �a��dSCa��nc v��ne5 PRESSURE DISTRIBUTION SYSTE\iI: Tumups/cleanouts/valve�/tapsintact& / Vp��eS � fG±�S UYl�fl ��P«� VIv1�S accessible ? ❑ / [�, Pressure head properly adjusted ? ❑ / �� COMPLIANCE: Compliant ❑ Non-compliant ❑ / Needs Maintenance �' e :.'2 � r�i (� �_ �,.1�� 1 M�r�►�%rl�d d� acc,�ss��bl�e. � �� , . _ _ � � : { . .. . .. .... .: . ��:�: :-� . :. .. �'�=� �� .�.�JLJL.JL',JL,iL��1/6.W.!} �� Building Additions/ Mobile Home Replacements Ta.x Map #:�7� Parcel#: , 7 Address: Approval Requested for: Mobile Home Replacement � �/ Building Addition /� �` �� Applicant Name: � � .t/ Address: ,� � _ �i� • .� G z Phone #'s: Permit Located: t� Yes No Installation Date: Zoo � Design flow: 3G�b (gpd) Current Contract with Certified Operator on file (if required): �✓� Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: � lv l/d (date) (Applicant's signature if site visit is not required) ° i!� � .; � �� / . i/ � Addition/Replacement Approved Enviranmental Health ecialist ��/� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount .�net .�. �} . _� �+ ~I :l i ,7��\ \ . �� '� ?, � ✓ ��`a ;�.� '� ;� • � : O � � � ! ' ! �' _. ``�. � �'�� .. �� -�- ' -�—�--�� • ', T� '�� a T ^-. s' ^ , � .. :� i�; ��\� ! f � � � �J � � �� —" = � ^ "^ - —�:� ."i.�l_� i � ""'-`t��i. F"' =i;^�:-' � aY11�' . � ...._:....._ yQ S -- f� Yi �!� �_ ��uC�� i;� � ��.— e,"�'Uila oi�e�Q�1�a�M � hbS�.Y? i�Q Lr":�,�'�eC� 'uOo I-A;.�ZL-�LS N � :r ro� 'v,C oii a o � . ��'�� - �� S�isicrr: i y�e (i� Acc4r�anc� �lliiih i 2�IE V2�: ��} �_Z� :::�� Y� ��i� �?r,S ��:� l�Si.��L�� l� C: ii�C�L1�AdC� Vi1�T�i ��?P�.ICABLE . �1I�RTH i.;;:c: L'•i�'A Gci�l: :�.AL S:�-LTE�, �Li� �� CR Sc�ACE Tr �t; i'!�(1E�T ��lD DlSPOSAL, �� ?L� COi�l�[ i]C�� G� � TH� I�rRG4'��I��3T ��?�fla�t ��D G�i�ISTRUCTiQl1I �l l!"f' � ! ��=±�i��1. � " . � �s `p4 � :Z � . .�•.. iGr=� �ICL� ^.CC: �l CQIG^ - - �� ; "� L' a � � i �.. 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