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A30 123Amount paid Receipt fl V� ��ao% ' 176 11767 %/ 9� Date i Improvements Permit.(Established/Recorded Lot) _ Reinspeceion of Existing System (Loan Closing) �pxovements Permit (Un�ecorded Lot) _ Repair/Replace existing Septic System Improvements PeRni[ (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well � 0 ��. n �.� �'� � ��;�� »a�er�S�''m� � Ie f ,edi ��° _ ' '�� a � _ Bacteria _ Chemical _ Petroleum _ Pesticide � w U � z 1. Permit requested by: Phone #: -s/%— usiness Phone #: �S'�9 �� I�Iame and 7. Dimensions or Proposed Structure: W idth: _ Lead 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? ,..s.99 �y.sy. - _ - . of current owner. 9. Water suppl y pe: �- -� �i�,vf�4 � private ublic ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No [�. If so, identify location: . Property Description: L,ot size: Tax Map#: � Parcel#: � Directions to property: State Road #& Road Number of occuaants or neonle to be secved: I0. Type of stcucture/facility: Proposed: DExisting: Q Type of dwelling: House: 0 Mobile Home: usiness: ❑ �ie of business• Number of Employees: umber of bedrooms: �_ Garbage Disposal? Yes ❑ No Basement? Yes ❑ No so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY A1�ID THE CORI�IERS OF ALL PROPOSED STRUCJ'URES. �I hereby make application to the Person Coun�y T3e2tlth Uepartment for a site evaluation foc the on-sitF sewage disposal system for the above described propercy. 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 E issued, I must present a survey plat of the propercy to the Healch Dept. I understand that in the event I have no� delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of thcsite by the Health Dept., this application shall become void and all fees paid forfeited. SiQncc� Owaer or Authorized Agent � a w � a e . � • • •� ' 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. Ta�c Map # � 3 (� Parcel # � 7i� _ _ Zoning Township � a�1�,�� pf �L Owner/Contractor �� oQ �; �r-c.� - EE Date (- 2�- 9 Q Location/Address QS � L 0..-�-e(� O no�5 L?e_,I __ ---- S.R.# Subdivision Name ��, ��t � (St.�� Lot# �� SFD �� SEWAGE SYSTEM SPECIFICATIONS Lot Area o7 . � ( �r G Mobile Home ✓ # of Bedrooms�-� Permits may be voided if site is Well and Septic �yout by� = 4 9 Installed by ell Permit Paid Size of Tank ��1 Size of Pump Tank_ Nitrification Line Max Depth Trenches, Cl--�—�+—�v� • r i �— a WELL SYSTEM SPECIFICATIONS VSemi-Public Site Approved Well Head Approved Grouting Approved_ Comments: �� '�� 8-9 q " Inst'�lled by Required Slab _ Air Vent Required Well Log Well �'ag � 0 � � 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 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. c:�amipro\permit.sam O1/95 rev.l.l AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DATE: �-a 8- 4 q IMPROVEMENT PERNIIT #: oZ (� TAX MAP #: ��_ PARCEL #: } � � � OWNER/OWNER'S REPRESENTATIVE: �1� (�GZ,�Q� � � � C�2 LOCATION/ADDRESS: SUBDIVISION NAME: �� ) ��.�Q LOT #: SECTION OR BLOCK: . AUTHORIZATION FOR CONSTRUCTION ISS AUTHORIZATION CONDITIONS 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifications as set forth in Improvements Pernut #�ab . The construction and installation must also meet all applicable rules and laws. 2. No portion of the Wastewater system shall be covered or placed into use until inspected and approved by the Person County Health Department. 3. Any alterations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specified in the associated improvement permit and application, may void this authorization and associated permits. 4. Conditions: � �n � Person Requesting: `e i �� o �a 'r' � � � � U ; � � o� v� �' �, � � � tn y � � �°' ` v � � � � �� i R � � U � x � . � � � � 'o� �"- � ., °d � 1 � �`A , � • �t � � a�: �r- l� ,' O ''''p N , �/ � t� - _ � � � b � � �. � � � dL..Bb,,GZ.6lS � _ " � � � •'�'4 U�' , 88'�yS - ''°�°'� _ - � � � ��► � ,88'ZS ;. .� - � o ,. — �� +� � a' w 1 � ; � �� L�� - � � - �� O � � �y�r � E � L-] � Oj� � � � ` ' � .�,a � Z� � �� 1 � O � 1� .� � \ I ��o� � I � � , 86 �o« , 62"ozz � � • � B0.8ES__ / w � � .i�� I \ ��9s O o �� a,� � r , l� I� � Z� nt /n � � �� • - r r �i � , , �-k ,.,�r'" - � I o ' °' °j o � �' � � � � -� �`� o I � �zT �#� �d P10 , �6'�5� :, � - -------- - --►----- .` , � �.ss, so.8cs � ,.��,. �� I `� C� � � I � I I � � � � . � I , i � �� . ��/ � � . � � - � p �.-Q�� . � � � � ' � � � I � I � � � � � �` � � / P��`� � � .� y.f�� i �� -+� �� io' ��,H � � �� .a �� / ' � � �� N � �� t�� ._ °' o �.! p � _ �-- ' � � v` ,�� 4 I w � �w ^ _— � � �I � I � I�y� � E-, �i o I rn � .� � �' \ � � I I r.� ; � , 1 co �Z� I �, , � � � � a , �� I �i � �;' � � „i•,� ��,� j _ _ � � �� r ,.' � _ �- � ,� �,?9' ' ci f � _ _ �� .. rf `, 4 � - � � r __� _ ti �- '�-`' I _ � - 1 . � % � z ' �" � , �f-� v N09 09'4�'.E ;148• za f- ' � _-�- �� --_. Date� 3-�'9�' ' Owner. " S � Location/Directions: _ Subdivisibn Name: Drilling Contractor: . . " . .. . . ... ..... _. _ _. . .. PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG . . .- _ ..... . _ • <�� f •• �. r, a� ra , : �: � !.. - . -, �. . ; � . Distance from Nearest Property Line �O Distance from Source of Pollution /�d ` Total Dep.th:�_ Ft. Yield:�_ GPM Static Water L,evel o?�— Ft. Water Bearing Zones: Depth �ac� Ft.J�o_F� � F� ��, Casing: Depth: From O to�1�Ft. Diameter: Inches TYPE: Steel � Galvanized Steel / If Steel, does owner approve: Yes No � Weight: � Thickness: /� Height`Above Ground: 6 t% Inches Drive Shoe: Yes ✓ No • Were Problems Encountered in Setting the Casing? Yes No � � If "yes" gir•e reason: Grout: Type: Neat Sand/Cement ,/ Concre[e � Annular. Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped . . . . Pr:ssure � � Poureci_,/ � �- �. � � • �. - : - Depth: From O to �. �- Ft. . . Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixture (sand, gravel; cuttings) - Ratio: to :ID Plates: Yes ✓ No � ' � ��' . "� 4 x 4 slab Yes�—No I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERS0�1 C�Ui�ITY HEALTH DEPARTMENT. � ..� �3 -1-� `1'-- �Signature of Contractor Datc � 05/14/2008 14:56 3365382233 KEVIN COGGINS PAGE 02/04 05/B5/2H08 12:55 3365977809 P�RSON COUNTY ENVIRD �s.�,plicanoz� iJate; 5 /ylv3 Amount Paid: � C �� .eccipi�#: �� .-,`�-�,`?.�...�"� .I��,� � � ��T��lf�y� �+5�"7.^� ]Z.A�.+4. ..�OiAilT.l�i`9�T.N� TA.RR.Y'IL�:IR App�ic.�fiio�t f,ox Serv�ces _ (Scpt;c Sy,^t8ms �ttd Wc11.*�l PAGE e1 Tax �p: �3D Paxcel #: 133 ovement Pe�rmit (5ite Evaluatlon) � Coa.�ructtea A,uthorization $z00,p0/S306.D0 (!f T 600 d (Fee is de end�nt bn t�e o af ��( Il�a �ame �2splacement oc SniIding ,A,ddFtio�l ❑ P�rmk Reviafoe , . StcvaSit� uu�d $�$.00 Parm�t (New/Rc�lacemcnt) G Re�air af �xisting Scptic Systcm 5225.OQ1$T,�S,pp No C a int: lftJ�@ �iniformalion p�e ti�e a�pl��tlo�tJ�ir an lmprnv¢menf Permii Is incorrect, falsr'J'�d, 8r fJ�a sirc is alrered� then th� �ttl Psrmlt Qhd fhe��iorixatio�r ta Cn,rslract s7�dli Lervme fnvalld I � ' • � � : � , ' � � :� • ��,� ��— ,L�r..r � f = � • �' . . � � r�.� �'� RY� .. r��j��f;�F+��1C:�� M �, . � , '.` � �i��rAl�\t[� _� .� �s�r � � r� : �� :�. r:�i i •� i• �• r -� i� � s _ •. � � ,� . ,. - �.�Tfi�►.�•:��'r _r.!i�. �� ` �- _ �� 3) P'['ope�t�y Da�crAFtiQu; I.o1' S +�Lddress s�nd/or directions to Properiy: � 4) 1'roposed U5e and 1�pe of Structu ; SWtiY1YY1tr1 ��1 Residential �_ BusinessJTyp • � P,.� Other � Nwnber of. badroo�s JNumber pcople scrvod (s s/employees):� Baseznent: Yes No _, {with plurnbing: Y�s _No Giarbage disposaI- Ye�s No ApproxRbuate sazc o . : Z,en�#h� Widtl� �� Watcr Sap ly• �rivate Well� (Propas�d Exfstir�,�� Community'Netl_ Public W�ter Sysbem; ,�,� Are there wells o;a the adjoining properties7 No 'Y�s �(pleese show location on site plan) e: ,4 ,� lgt�d a l�Cltt�On Hi�[3'f �[190 t'PtC i' r•1 plar/sttQ plet�,e of tha pra,rrarty thar show�F�ppB�j, atirrter�s+s'�or�s uct�d th� size ar�d loeatxon of 4�i propossd srruc�rrres 3> .� s�gned copy o,�'th�'Lot Prepar,��s'form ver�ing tlsut the,�rop�r�y is reaajy to be �u�IuatQd x am �ubmict;ung this applica�ton tn reque5t serv4ce� froua tb� p�z�pp Coun.ty Health Dcpar�lZ�Qt The �nfarmat�on pr"dvid�d fr accurate. I naders�nd t�at if a�ty site ix a�t�red or the is��ded use chan��es, a�[t per�a�tts shatl become invaGd. a Signatare (OWnerILE�aI Re�resentat�v�): Da�tG: FPr �Lsr 8 �r�✓ 1• 1/07 Person County �z�vironmeata�l F�eakth, �2S 5. Morgari St., suite C, Roxboro, NC 27573 (33G-597-1746) 05/14/2668 14:56 3365382233 KEVIN COGGINS PAGE 04/64 � � �� h � � � �..r�•. ti . �' t� - � �l./ � � � �1..J ..tL:�!]C11,'�4'73.1L'�,7rli„7t31C11.�7CIl'1�.�.,'I.JL J.L �.LtLa�4.1i.t�� 3aai�ding Addi�ao�as/ 19�o�iie �ome Rep�ace�ent� Tax Map #:� Approval Requested for: Parcel#: ��3 Mobile Home Replacement o Building Addition � Applicant Na.me: L mn;� k Ls�r� -1 TPr��u�e��► Address: " 51 rC �,-�c k�ra Nc �6� Phone #'s: ��-l-��oo '��-�",� t�e�n �g�s Permit Lacated: ✓ Yes No Installation Date: 31� �qq . Design flow: 3l _(gpd) Current Contract with Certified Operator on file (if required): NI� Water Supply: _� Well Public or Community Wastewater system shows no visual evidence of failure on: X OS- Z2- v g (date (Applicant's signature if site visit is not required) Comments: .A�dd�tioa�eplac�ment Appr�ved `�.�m� �,-�- Environmental Health Specialist 11/15/OS 511S1�� Date � PERSON COUNTY HEALTH DEPARTMEIVT SUBSUR�ACE WASTE�]VATER SYSTEIV� Nd01�TITORING REPORT �� a -,� .�._�� b �� !1- �- Date of Inspection System Iastallatton Date Type Tax Map Parcel # �7�sr r��(r�%� I�-� Property S Instructions: Check yes or no for appropriate items and explain ins�ace 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. Nate that this monitoring for�n is not totalIy inclusive for all systems. All maintenance and monitoring items specified in t�e permit aze to be carried out. INSPECTION RESULTS �OLLECTION SYSTEM: Evidence of loaks ? Tank risers accessible, free of infilttation and surface water diverted ? �eptic tank needs pumping ? �nches of solids: Septic tank filter cleaned 7 .F,FFLUENT DOSING 3YSTFM: Required pumps preseat & fucctional ? High water alarm operating properly ? Floats, valves, etc. in good c�ndition ? Control panel & components in good condition 7 Effluent free of excess solids ? Inches of sblids(pump/dose tank):� Elapsed time readings ? Counter readings ? Drawdown rate: YES / NO ❑ / ❑ p ; ❑ ST" �- ❑ � ❑ ❑ � � — � .. _ ■ /:' ■ ►: ■ ►: ■ DISPOSAL FIELD: Evidence af effiuent swfacing 7 ❑/� Evidence of eftluent ponding in trenches ?❑ ! Surface «ater e�ecdvely diverted ? � / ❑ Dit��rs�oas/swal?s �ropsrly mai.ntained ? / ❑ Vegetative cover mainiained 7 � / ❑ Protected from trafiic/unauthurized uses ? / ❑ Distribution devices in good coadition ? /❑ Field free of settied or low areas ? /❑ PRESSURE DISTRIBUTION SYSTENI: Tumups/cleanoutslvalves/taps intact & accessible ? ❑ Pressure head properly adjusted ? ❑ COMPLIANCE: Compliant Non-compliant Needs 1Vlainter.ance ��7iTi0NtiL COM � �� d� �� o < � o �o�uc'� EHS �"'� REMARKS a (�Cessi b i� ��,f � (a►-� �P�' ��Z -- ao�c�.e� �- �. ( � �� s ��- C�,,,�Q�^�'f . w��,' `7� �� ' �c�vv i'r� . � L(. Q . .J �� 'el� t vl �j �c�.� �r �'F► �''1 �. c(...�n�.�-- ,,� lo e� ��Q i o v�q � t/to es'S�,cre__ 1't-�,?_.�� ❑ . ❑ -s: l�►^��e.� �� c(-.e.��.�..� � 1�-�,-e�, 0. ��,' ,� _ � C.�u �t_.9'4' n_c�t. �e —c (�-e�.�...�{- - �.✓°1S � �