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Permit (EstablishedlRecorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Permit (Addition)
Repair/Replace existing Septic 5
Permit for New Well
_ Replace Existing Well
1. Permit requested by:
�wner/nros�ective own�
me Phone #: .� yy- /J(2/�
siness Phone #: S��e
Name and address of,current owner:
Description: Lot size:
7. Dimensions or Proposed Structure:
Width: �� �
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 C�public ❑ community ❑ spring ❑
Are any wells on adjoining P�roperty?Yes No
If so, identi y locat'on: ��t" i� A�' ���
�/�,�!'� /o /
Tax Map#: L�- Z% �� \;�\ 10. Type of structure/facility: Proposed: C�Existing: ❑
Parcel#: RbSe'� Type of dw,�el�li
Township: D i�� �.�/ (Z�`� House: l� Mobile Home: ❑ Business: ❑
Directions to property: State Road #& Road Type of business:
ames, etc. l��J S T/� Number of Employees:
/ Z �� � e A� Number of bedrooms: �_�,/
� .� r,�/rs oN �i�` � Garbage Disposal? Yes ❑ No L�'
Basement? Yes ❑ No C�7'I�f so, # of basement fixtures:
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 Pei'sOn County He81th Depat'tmeilt 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 • Sign Owner or Authorized Agent
Permit Issued ❑ �� Signature Date
Permit llenied ❑
Plat Observed C�
���.�i�- :. ,�
���/'S/
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_ _
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3. SOIL STRUCfURE (12-361N.) S S S
(CLAYEY SOILS) P S� PS PS PS
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4. SOIL DEP77�! (IN.) S S S S
S 7( `� PS PS PS
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S. RESTRICfIVEHORIZONS(IN.) S S S
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8. AVAII.ABLE SPACE S S S S
PS PS PS PS
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9. STfECLASSIFICATION(SEEBELOW) �
50I� SERIES
S-SUITABLE PS-PROV(SIONALLY SUITABLE U-UNSUIiABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WMIPRO�DOCSIAPPSEC.SMFINANCE.PC
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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. K�� i n C(q,y �y�
Tax Map #_� �� Parcel #
Zoning Township ' � '
Owner/Contractor - � Date lZ — %F cj,�
Location/Address � C�►-.��Y �� S� 5' 1
✓� . ., � .� S.R.#
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
� Repair Lot Area ��3(73ac�� Size of Tank /(`JUU ��n f
SFD Mobile Home Size of Pump Tank i A
Business # of Bedrooms � Nitrification Line �(�D X 3�
Max Depth Trenches � ('�'�
�
�
V Permits may be voided if site is
� Well and Septic Layout by
a Comments:
�
`�
chan
Date — Installed by J�^� �-�... � c Approved byJ
Well Permit Paid WELL SYSTEM SPECIFICATIONS '�
Individual Semi-Public Required Slab
Public Replace ent Air Vent
Site Approved Required We11�L�
Well Head Approved Well Tag
Grouting Approved -
Comments:
Date -
Installed by �� �'t h f Approved by
v�o
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 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 in the application. Neither Persoa 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.
c:\amipro\permit.sam O1/95 rev.l.l
P.O. Box 28047
North Carolina State Laboratory of Public Health 306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
httq://slph. ncpublichealth. com
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH JANET CLAYTON
325 S MORGAN STREET 240 HESTER'S STORE RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES030111-0003001 Date Collected: 02/28/11
Date Received: 03/01/11
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 10:00 AM
Collected By: H Kelly
Well Permit #:
GPS #:
Inorganic Chemical 1(Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium < 0.1 2.00 mg/L
Cadmium < 0.001 0.005 mg/L
Calcium 10 mg/L
Chloride < 5.00 500 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 0.27 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 4 mg/L
Manganese < 0.03 0.05 mg/L
pH 6.3 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 6.40 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 52 mg/L
Total Hardness 40 mg/L
Zinc 0.95 5.00 mg/L
Report Date: 03/08/2011
Page 1 of 1
Reported By: �e�ic %%lo�c�l
. • �• • .
Date: � -- -S �
Owner: �
Location irections:
PERSON COUNTY ENVIRONM�NTAL HEALTH
WELL LOG
�
s �. �1, ii� —�
SR#
d
��b�'=vision Namc: Lot #
Drilling Contractor: _ ,� �-� � I,J� // C�
WELL CONSTRUCTION
Distance from Nearest Property Line ' �.s Distance from Source of
Pollution�/���/�s
Total Dep.th: � Z Ft. Yield:�_ GPM Static Water Level Ft.
Water Bearing Zones: Depth 6 � Ft. J�/.� Ft. /`3 v- Ft. �t.
Casing: Depth: From�_to��Ft. Diameter: � Inches
TYPE: Steel - Galvanized Steel �—
If Steel, does owner app��ve: Yes No
� Weight: ,1 3 Thickness:,�_f�Height Above Ground: � Y Inches
Drive Shoe: Yes No -
i
Were Problems Encountered in Setting the Casing? Yes No
Tr �t
lr yes" give reason:
Grout: Type: Neat Sand/Cement `� Concrete
Annular Space Width 3 Inches
Water in Annular Space: Yes No �
Method: Pumped Pressure PoLred �–
Dep[h: Fr�m D to d r t.
Matenals Used: No. Bags Portland Cement � Weig}it of .1 bag�lbs.
If mixture (sand, gravel, cuttinas) - Ratio: � to
ID Plates: Yes 1/ No � � ����
4 x 4 slab Yes�No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED ]N ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEF�LTH DEPARTMENT.
--����— ��rL�C�- ti -�d � 6
S�gnature of Contractor Date
�
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant C.�1%�1�
� �� . I
Address � County��'�u�0 f�
K� ,
Collected By �_ j�C����
Date Collected Z- � Time Collected � 0= � Q
Source: �Well ❑ Spring ❑ Other
Location: C5/House Tap
�To Charge ❑ Charge
❑ Well Tap ❑ Other
........................................................................�
*********************************************************�**************
Results
Total Coliform
FecaUE. Coli
Present
❑
�l
Reported By , ``"
Date Reported �-ti � � � �
A s nt
�