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A29 53Persori or firm�oing installat�on ; �; -Address r . - � i y f. � �Noi;of;;pE ; : ,Addition' �macl�iia.e �Miniiriun ' `�Nitr'ifical . :><B .� ':'C u The District Health Department CASWELL - CHi4THAM - LEE - PERSON COUNTIES Water Supply and Sewag� Disposal � f I1�PROVEMENTS PERMIT No. _� � � � ' .�-:� �., Date Owner: -� i t J�'"' /,� (,� 1�..-n �: ,.rn i% T�Ti v`�T Location: ' a . i� �,_. ..f ie ��sn, , `'� \ %� .� � 'f � � 1,,... ., ., � - /� ' J � Contractor: �� Watez Supplp: Private - ��_ Public : ) (/y' " •,' Sewage Disposal Facilities: No. bedrooms "'�Y Dishwasher, Disposal, washing machine, other automatic appliances Size. of tank: ,�� f �., � Nitrification line: �'�`"�'�� ( -� �i V ' �Y v � . p �_ � ..r � �i Other disposal facility: _ Water supply and sewage disposal .facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years •an3 shall be main- tained by owner in such •a manner as not to create a public healtih hazaTd. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVEB BY A.MENfBER OF THE DISTRICT HE�LTH DEPAR.TMENT STAFF BEFORE ANY :PORTION OF TFiE IN;STA�I,ATION IS COV- ERED ANI3.PUT INTO USE. ;�' ; � ;, ,'j'� � ;� � ��j ! ,i�/ !� t� l ; % ,�.. Date approved: Signed �t�'Y+� � ' � . Well: � ' . ' Sanitaria"�i Sewage Disposal: By: Counter- signed (Owner or hL� representative) Ce:tificaie of Completion ,r'7 Date .4pproved: � '� gy;I� �' U " D� 1 ,QaA ��----' nrtarian (OVER) Location of well and sewage disposal facilities sketched on back. 0 aFi 'b ., a� cC �' 3 `� U O N � 'S '�' 'a � . x � � o � � .V. ~ Y �' � � N �, � � y O y � � O � � H •y ., � � ° � H W � N .ri C� VI �q ,C� Y � O '� . "'� Y � � � �� U a, �y � •y � +� o .° � 0 � Q vtw • � a o � a �n •k � � v c. � H Y � � � :� v � N O O � a q • �, o o `� w u � a � .� w' o �'zz d � � � � � � ti ��' v .� � a ,,._, °z �' y �� N v � Auplication Date: � V \�� Amount Paid: Receipt #: • Tax Maa #: �� Parca! #: S� �`��;��_ �� — _ --.- c� � �T�T'IL�� a=a_�ra.a-oaa�•-+,-+• .esa�mll 7E-1Lm�.71.�I1a APPL�CATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FNLSIFiED. CHAiVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AfVD AUTHORI%�►TION TO CONSTRUCT SHALL BECOME INVALID. � 1) Pertnit requested by: (Owner/agent/praspective owner): 1 � 1 J �� Home Phone: S9 `! `a� $ % Address: Business Phone: �r� kbe �o �.�C 2) Mame and address of current owner. _ � 3) Property Description: Lot size: Township:�� °�� I� Subdivision: Lot # Directions to the property (Includin road names and numbers): �f-R S � 3-e.("- �C�1-EP =�4�or�. 4) P'roposed Use and Structure Qescription: 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 Will there be plumbing in the basement? d) 6arbage Disposal: Yes No _ 5) Water Supply Type: Private _(new _ or existing./ , Public_, CommunityJ Spring _ Are any wells on adjoining property? Yes�o _ If yes, please indicate approximate location on the �site plan. 6) Does your property contain previously identified jurisdictionat wetlands? Yes_ No_ PLEASE MOTE THE FaLLOWiNG: ➢ A PLAT OF THE PROPERTY QR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATIOM. ➢ PROP�RTY L1NES AND CORNERS MUST BE CLEARLY MARKED. � ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT STAFF. I hereby make application to the Person County Health Department 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 represent the maximum facilities to be piaced on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. Owner or Legal Representative Date PCHD, rev. a6f27102 �� ? �f �� ..r-. = ► 4 �/ � � � V 11 � I��.�n,��.��¢�.Il u 33L��.Il�l� Applican� Location: T��x M�� i • � P�rcel # Suhei'ivis�ioi� Ph��s�e Sec�t�ion Lot # Improvement Permit Permit Valid for ' Five Years _ No Expiration Type of Facility: - New Addition _ # of Occupants # of Bedrooms Projected Daily Flow Proposed Wastewater System: Proposed Repair: Permit Conditions: Owner or Legal Representative Signature: Authorized State Agent: Water Supply �.`G g.p.d. Type: Type: Date: Date: The issuance of this permit by the Health Department in does not guarantee the issuance of other pennits. 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 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 for SewaQe Treatment and Disposal Svstents' (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 will remain potable. • Authorization to Construct Wastewater System �Required for Building Permit) * See site plan arid additional attachments (_� Proposed Wastewater System: �n�/�ry�i-� 0�1Ct..� `I'ype �_ Wastewater Flow �o� g.p.d. New Repair�xpansion _ Soil LTAR: �,_ S•p•d./ ft 2 Type of Facility: ?, �,�. SG � Basement _ Yes _ No Wastewater System Requirements Tank Size: Septic Tank: 'L �� al Pump Tank: NV'� gal Grease Trap: �� gal _� Drainfield: Total Area: ,�� , sq ft Total Length 5� ft Maximum Trench Depth in Trench Width � ft Minimum Soil Cover: �Q_ in Minimum Trench Separation: � ft Distribution: Specifications: Authorized State Ag Permit Distribution Box �erial Distribution The type of system permitted is the permit. Owner/Le�al Renresentative: Pressure Manifold Date: �� w Conventional Innovative Alternative. I accept the specifications of Date: ��'� j�� J 4�� ' ��A V �� I��ca:�n.m�a-n.uaa.�m�.�xn.lL 7HI�e.En.11�lL-n. SITE SKETCH .x:: -�t� � � R a ` t� i4 �. -' e `M��P'��:�r`$r . .. av^s.�. . .. .. j�`�'Yt�, ti..( 1y1y,, . � �' tt'� ti �� . �� ,�,f� �iJ �'Jk's�r� - 4 Z..: V . �' ': ' J�+ N � � J�' ��'`1a I .Tax Map # I�a.� Paxcel # S3 s S b' is' n Section/Lot# �_- 03 ;, Authorized Sta.te Agent Date System comportents represent a�iproximate contours only. The contmctor must, flag the system prior to beginning the iristallation to insure that propergrade is maintained � . _ � c�r w�� ,�� y� • �'�: �l ,�r %� �v�� r►-S�' . 1' � �� 1 �°�o p p,� c��r L.. �� , \� \ i � \ /� � �1��` � �; � 2 Q; �,r� � M�� ,� �c.,11� �< � �o r� h `� `A`,n�°�. �(OM o �V� � � ' �nCL� , �,��pn r, �,�5 < � <<� t� �% �`'S� �� p (�' �� V- OS� � o P �P Q °�� .�o� pu�Ps ;, � �. �c,� �cS� P w �itl . �; �>�%, C`o� m�n,�p,�,i(�t/'�'�.,� �� .� � F / 1 V . �a0 A ��`Lr �. CI' � � . 9Z. o� / �+ r'i1 � �'� � `� Q . � $�perl� � . � � ' �„__.; ��.��. � � � r� d �P � �"�`' � c� �� l � � � ��t �'�' "4 *x t�' �°�s / � � l� � � � � rnu{Yl F r �as . p � O � M�n� ` �� o. �"^� 1 �f `� T�= �� + 2� d cpk�`• ° f � ya � ''�. p � �'�' i ° S� � �� e ;��°n:� 5�� J°`' ��'�o�'� � Ca 0,� .�3 s 3 � �.,� t��;y v 1 S� •�j. c9• _ 4S �,� 'I2'� �' •.�,,�q,� . '�,�•r� /�Ga'��`� `#'�y.� p 1 \ � � �y v l _, : . . .; �- 0 � fi . : - f ��4 w . �� y' � Y �/ V � � �` �+. 7G��a-.��.��¢m.3t �.�.�]l�]� D r'tll I ea' 1 D� C a r�� r� y N a:rYrt c �, � D��t�e Drilllecl , • GroutLog 4wner: � / Location: c 7 '� Subdivision: Lot # Tax Map ��f Parccl # �� 'GVeU Coustructinn Distance From nearest Property Line {Minimum 1 Q feet) ]7istance from scpCic system {IVliniiuum 6a fcet) Tot�1 Depth: �nt� ft Yield: I GPM Static VS�'ater Level: �� ft Watez Bearing Gones: �epth��ft ft ft ii Cas�ag: Depth.'From �_ td r�Q �t. Diar�eter: �%� in Tyge: Galvanizcd Steel c 'Weighfi '�'h cknes�- j�Q Hei.�t above Grnund: � in Drivc Shoe: _� Yes No Any problems encauntered whilc setting casins? Ycs ✓No If `�es" give reason: Gxoat: Neat: Sand/C�ment � C4ncrete Grav�UCement _ __ _ __ _ Anaular Space Width inches Watcr in A,nnula/r Space Yes Na IvLethod of Graut: Pumped P�ressure Pdured ✓ Dcpth ,�_ to 1� Ft 1VXaterials Used: N�. B�gs �ortland cement �� Weight of 1 Bag ,�'� Pounds If mixture (sand, �ravel, cuttin�s) -� Rario to ' � plates: ✓Yes _ NQ 4 x 4 slab �Yes � No Drillink Lng Location DrawYng �'rom 'io � Formation F��/c. : E - Qax ( $ l r.5 / ��6$ � r,X l 8' � . G'oc L� . , �� r�� _ , �p}�� r0 Z hereb� c�tif'y that thc aba�ve informa�ion is corcec anid thdt #his wc11 was constructcd in accordancc wittx regulations set forth by the Person County i�ealth Dcp nt Sigua#are of Con�t��ctar � # ,��-�� l�atc ,� � ��O � ur�xrn .P�, nt ri �rm T00'd d6T�S0 80/60190 SGZ6 86S 98� �uI 6uijji.�.Q 1TaM ai�au.aea North Carolina State Laboratory of Public Health �_�--- � � . ; � . . .--�_� Department of Health and Human Services �� ,. �� P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 2761 -8047 �' 7004 r � �-T, `._ INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM !`— Name of System: Stegall, AI Address: 3568 Burlington Rd. Roxboro, NC County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro NC 27523 Zip: 27574 ATTN: Janet Clayton (336) 597-2371 Source of Water: Ground Source of Sample: Type of Sample: Raw Type of Treatment: None Type of Analysis Private , _ _______ _- �__ Courier: 02-33-15 r�`�`� � �`'e,� Coilected By: J. CLAYTON Date: 9/23/04 Time: 1'1:10:00 AM \ , Location of sampling point: Kitchen Sink-New Well �� Remarks: ' � � ,� Parameters Results Units , _._. Date Anatyzed: --; 't, � i � � � �- '. � Alkalinity as CaCO3 56 ' mg/I �=� ; �,__; 9/24/04--� � � Arsenic <0.001 � � �mg/I�� _r=9/24/04---; E r Calcium 7.4 mg/I 9/24/04 ` Chloride IC <5A � mg/I � 9/24/04 � i� Copper <0.05 mg/I 9/24/04 f+ Fluoride <0.20 mg/I 9/24/04 Iron 0.05 mg/I 9/24/04 Hardness as CaCO3 (Ca,Mg) 31 mg/I 9/24/04 Magnesium 3A ' r�ng/I 9/24/04' Manganese <0.03 - mg/1 9/24/04 Lead <0.005 mg/I 9/24/04 pH 7.2 Std. unit _ 9/24/04 Zinc a 6.39 mg/la� . , 9/24/04, � �_ Date Received: 9/24/04 Today's Date: 10/8/04 Report Date: 10/8/04 Ref: 12140 Login Batch: � � �o�«ti� � Reported By: Sample Number: A 17567 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. Pr�sence 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 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 North Carolina Stat� Laboratory of Public Health ,i �%;� Department of Health and Human Services �� P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-804 �� _ � ., `' ' (r. �� INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM/ :��' �� •' ,, �; , �� Name of System: gtegall, AI Source of Water: ��und Address: 3568 Burlington Rd. Source of Sample: Roxboro, NC Zip: 27574 County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27523 ATTN: Janet Clayton (336) 597-2371 Type of Sample: Raw Type of Treatment: None Type of Analysis Private Courier: 02-33-15 "� ��`~�. ' ~�� Collected By: J. CLAYTON Date: 9/23/04 Time: 11:05:00 AM � �� Location of sampling point: Old Well, Well Head ��l `� Remarks: , Parameters Results. - Units -_ ---- -Date Analyzed: -; � �� 3 : Alkalinity as CaCO3 36 ' mg/I --� ; ' __�� 9/24/04 �-�` � '� Arsenic <0.001 �� mg/I�� ,--- --'9/24/04��; ; � � � , Calcium 5.7 mg/I 9/24/04 _ _ ,' Chloride IC <5A � mg/I � � 9/24/04 %� 1 Copper 0.15 mg/I ` 9/24/04 Fluoride <0.20 mg/I 9/24/04 , Iron 48.68 mg/1 9/24/04 Hardness as CaCO3 (Ca,Mg) 25 mg/I 9/24/04 ,' Magnesium 2.5 ' �mg/1. 9/24/04 ; Manganese ` ; 0.09.: mg/1 9/24/04 : Lead . : . : 0.053 .s . ; mg/I. . 9/24/04 , pH _ 6.9 _ Std. unit , 9/24/04 :,. Zinc a 0.42 = mg/I �� _ mu �_ � 9/24/04 �.-_ �o`�� (� C� . •'0 Date Received: 9/24/04 Report Date: 10/8/04 Reported By: � Today's Date: 10/8/04 Ref: 12141 Login Batch: � 090054_� � Sample Number: AB17568 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes.•If coliform Uacteria are Present, the water is considered unsafe for drinking purposes. � Pr�sence of E. coli (bacteria) generally iiidicates 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 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 0 � SEPTIG T�►IVK �NS�E�'9"iOPI C�IEC�(i.l�Z (TyPe II -11/� Tax Map # Parce! # System Type (Table Va) Owner/Applicant Subdivision Address/Location Sec/Phase Lot # • � . . " � State ID/date Tee and Fiiter � Baffle Sealant ; � - Riser if a licable Tank Outlet Seal Permanent Marker . Puma Tank ° Capacity � gaL '. ' Watemroof /Sealant Riser ' Water Tight ' ' Pump Checfc Valve/Gate Valve Antt-sip on o e Floats/Switches ,Alarm (visable and audible) Electricai Components � Rate (gpm) Approved Pump Mode! r� Block Under Pump � Pump Removal Rope/Chain ��Distribution. System = Serial Distribution ` ressure ani o Low Pressure Pipe Appr. Pipe Material. and Grade �' Valves �' 3 Y �dth Trench Grade � Trench Spacing Rock Depth and ft. in. ft. DamsJStepdowns etc. Pressure Laterals � Hole Spacing o e ize Pioe. Sleeve . Required� Setbacks From Welis ' � � � From Prope lines � StructuresBasements i c es raina e a s Surface Waters Public Water Su � lies Vertical Cuts >2 ft. � � Water Lines Vehicle �Traffiic ^ EasementsJRighf.of Way other Easements Recorded .; . -- , - ` -, . , , � . - , . ,� . . y . ^' �4 ♦ r� ^ t s..1• r� pct�d rev. 3113/01 ��, ; ,, �� .. � � � � �J � � 11 ��n.�n�-�aaa�.��..��.� �`��a.��a ' � • - i��s�f�/l �/ �� = `;' : �. ';� ; � � ', T�x M�p � � P�rcel # Su,bciliviFsion Pha�se Sect,ion: Lot # # of Bedroom�s System Type (In Accordance With Table Va): �_ THIS SYSTEM HAS BEEiV INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH GAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AtdD ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiOR! AUTHOR(ZAT ON. as Authorized State Age . Date � Installed By: Date: � D,�-J I . �v��.G ._.. . .. t . ,. . � "�d � • � . � �� 30 " f �/�'t a�'TFt � � t �P � � � �/' t� ��' � , ��,1� �'' �,co Ff'u- � � � � �e' , ,,,�,�,� �, � - 4� ' : ..� . ..... ._-_- �-' A 'i ,�G� : �� ' �-� ��✓p � � . �� -w� �,� PCHD, rev. 07/29/04