A29 55A�,�,.'� m- � �! ,S �
The District Health De artmen�
P
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water S�pp:y and Sewage Disposal
IMPROVEMENTS PERMIT Na
Date 3 ' Z—
Owner: �� �� �� �
Location:
Contractor: �-�r..�,l��� � � � �^'� �
Water Supplp: Private � Public
�G, �1, ►�.�
,
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal,
washing machine, ot�er sutomatic appliances
Size of tank: � NitriBcatio � line: �. D1��
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 health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE ALLATION IS COV-
ERED AND PUT INTO USE.
Date approved: Signe
Sanitaz an
Well:
Sewage Disposal:
By:
Counter-
9igned
(Owner or his representative) ,
Certificate of Complelion � �
Date Approved: � ��� By:
itarian
(OVEft)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note §pecial problems existing on lot. Wrate in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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� APPLICATION FOR SERVICES •
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<� 5ervic,es Ret�uesfed , a �; : s
;,� ,
_ <, , . ..; ,_...:.
_ :, __
Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Permit (Mobile Home Replace
Permit (Addition) �0 �'
_ Bacteria
1. Permit requested by:
owner/prospective owrn
A iir�racc• �Q �i.q-
ome Phone #:_
usiness Phone #:
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
__
_ Chemical ._ Petroleum _ Pesticide _ Lead
7. Dimensions or Proposed Structure:
�/agent: Width: �li' FftaN-t- �o�`c�1. `:�
aS 61r`� �� Depth:�' � 4Jtzt�e�<� +t3rJ ��c�t
Name and address of current owner:
Property Description: Lot size: � � � •
. Tax Map#: �� �
Parcel#: SS
Townshin• 6 l �� c�. � l
. Directions to property: State Road #& Road
ames, etc.
qq-s
Number of occupants or people to be served:
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?
9. Water supply type:
private ❑ public ❑ community ❑ spring ❑
Are any wells on adjoining proper[y?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: ❑
Type of dwelling:
House: ❑ Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ No ❑
IBasement? Yes ❑ No ❑ If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
pROPOSED STRUCTURES.
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 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 ( �gned Owner or Authorized Agent
- � ' �' ! � . , .. � 4
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
= FACI'ORS-S1iE:EVKI.iJA7ION =. ;: . .. . "; ARErX t , . .. .. `; AREI 2 '; AREfi 3 ;ARFA 4 '
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9. SI7E CLASSIFICATION(SEE BELOW)
SOIL SERIES
S-SUITAIILE PS-PROVISIONALLY SIJI'I'AIILE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:ViM[PRO�DOCNIPPSEC.SMFINANCE.PC
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B OC34
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �{ � y Parcel # S Sq
Zoning Township o z � „-.� �,�� �L
Owner/Contractor p c �jO�TD/�l Date z�gc�
Location/Address .� s
S.R.# �,•w y •y��
Subdivision Name `-- Lot# —
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank F,��s i �� �r
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �Y is T�� G— _
Max Depth Trenches
Permits may be voided if site is altered or intendec�use ch
Well and Septic Layout by �- ,�
Comments: .� Aon «si � ' _ y �y � // /� �`
c s
Date
ell Permit Paid
ite Apprc
Jell Head
Installed by F,� �STi.u' lr Approved by
Installed by,
S
Required
Air Vent
Require
Well �
Log
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The enviroamental 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 in the application: -�Neither Person County nor the environmental health
specialist v�arrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
D C HORTON
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://siph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
3375 BURLINGTON RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ESO40214-0012001 Date Collected: 04/01/14
Date Received: 04/02/14
Sample Type: Raw Sampling Point: Kitchen faucet
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 1:00 PM
Collected By: J Smith
Well Permit #:
GPS #:
Inorganic Chemical 1(Profile)
Analyte Result Allowable Limit Unit 4ualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium < 0.1 2.00 mg/L
Cadmium < 0.001 0.005 mg/L
Calcium 12 mg/L
Chloride 5.30 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 5.30 0.30 mg/L
Lead 0.006 0.015 mg/L
Magnesium 5 mg/L
Manganese < 0.03 0.05 mg/L
pH 6.9 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.80 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 60 mg/L
Total Hardness 48 mg/L
Zinc 0.17 5.00 mg/L
Report Date: 04/07/2014
Page 1 of 1
Reported By: A�nold Hnll