A30 9he Distri�t H.�alfh Deparfinent
Orange, Person�,,Caswell, Chatham, Lee Counties
�
Date � �" � � ✓ `� �
Name of owner: � Q �'�?' L.�/'! ��g j�-
!i
Name of contractor:
Address and Directions ; -t
M � J� �. . 1 � � . i �., �, .�
No. of persons to be
Bedrooms 1, 2,�4.
Additional appliances to be used: Disposal, dishwasher, washing
machine � �L.�"� ��
Recommended: Septic ta �
Nitrification line: � {' �' � �'
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the District Health Department sfaff before
any portion of the installation is covered:
Date Approved:' �- �rj"
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
` (Over)
�NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
� adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ) FINAL INSTALLATION (Date �„
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Tax Map #�D parcel # 6Q �
Existing Sewage� System Report For: Mobile Home Replacement
� Addition Type• �� �
Requester. �„�j _A�r�� f���'1%%L Home Phone# .�g5�-�� �fj
Business #
Original Permit Located: � Water Supply: ���j.�'
Septic System Designed For: V Residential Business Other
# Bedrooms -3 # Employees Other
System Type: �o�✓ Tank Size: 9D0 Nitrification Line: '�"Lo t�l z'
Date Installed: 5`�� /rv ��S Certified Operator Required: �o
On-site wastewater disposal system shows no visual signs of malfunction on
Perniission is granted to:
Comments: ��.� ���v�ll�S �'/a�r,� t�fLs/ ,,i�a✓Za ����
90�?�� ��x ;�a.t�-
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Environmental Health Specialist Date: fD'la "0 �'
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JOY HORTON HILL �
TERRY L. HILL �
D.B. 339, P. 457 I•
�
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� PERSON COUNTY HEALTH DEPA�tT1YIENT
35�� SOUTH NI.ADISON BLVD.
_ _ _ _ _.. ___ ._._ _ . ___ _._--- - --- _ ._. _ --- .....____. _ _ _
ROYBORO, NORTH CAROLYN.� 27�73
BACTERIOLOGICAL WATER SAMPLEA.NALYSIS
�
Name of Owner or Tenant � V � ��Y���
Address � � J / ����p� / l�" � �d County /�'v�
Collected By��—
Date Collected c�. (�I�� Time Collected /f-� �
Source: C�'�ell ❑ Spring � Other
Location: C�ouse Tap �Well Tap ❑ Other -
DNo Charge C�tiarge
********�*�********��***�**�**�*****�**�**�***��*��********�**�***********,�**�
�******�******************�************�****�******************�*****,��****�.**
Resulls
Present Absen
Total Coliform ❑
FecaVE. Coli ❑ � �
Re orted By ���' j'mT
P �
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bactreport
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: Lawrence, Carl
Address: 1359 Hassell Horton Rd
Hurdle Mills, NC
County: PERSON
Report To: Person Ca Health Dept.
, 325 South Morgan Street
Roxboro, NC 27523
Courier: 02-33-15
Zip: 27541
ATTN:
Source of Water: Ground
nurce of Sample:
t�.�� `�,
Type of Sample: Raw
1.00� ��� 7�pe o�' Treatment: None
� Type of Analysis Private
Collected By: BH Date: 2/5/2007 iime: � 0:59:00 AM
Location of sampling point: kitchen sink
Remarks
Parameters "` Results Units Date Analyzed:
Alkalinity as CaCO3 26 mg/I 2/7/2007
Arsenic <0.001 mg/I 2/7/2007
Calcium 4.8 mg/I ; 2/7/2007
Chloride IC <5A mgA 2/7/2007
Copper 0.08 mg/I ; : 2/7/2007
Fluoride <0.20 mg/I 2/7/2007
Iron 0.11 mg/I 2/7/2007
Hardness as CaCO3 (Ca,Mg) 20 mg/I 2/7I2007
Magnesium 2.0 mg/I 2/7/2007
Manganese <0.03 mg/I 2/7/2007
Lead <0.005 � �,.mg/I 2/7/2007
pH 6.6 Std. unit 2/7/2007 -
�in� �u.u5 rrig/1 ti7i�OG7 '
. � . � . � r . .� . .. . .. .
Date Received: 2/7/2007
Today's Date: 2/22/2007
Report Date: 2/22/2007
Ref: 1810 Login Batch:
Reported By: � �
Sample Number: A65285
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.
s �1
Inorganic Analysis:
Recominended limits for drinking water. Sample should not exceed levels listed
below. � �►
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limit�
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 mgll
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
Application Date: _�'1
Amount Paid: 1571,
Receipt #: \ rl�-k�1 "'S
Tax Maa #: 1'1 � l7
ParcEl #: �3U �l
����1���� ���� ��
- --,:_ � � ��� � �
1�s�_vaa-amaa��• .eaa�mll. �E—�mm]L�ZLa.
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IIMPROVEMENT PERIIAIT IS INCORRECT. FALSIFIED.
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERIVIIT AND AUTHORIZATIOId TO
CONSTRUCT SHALL BECOME INVALID. -
�1) �ermit requested by: Owner/agent/prospective owner): ��1` �r" r1 %� �!.�/I" �1C �.
U/Home Phone: 33� -�`� 9- 7�3 0 Address �3 S' S5 e o r �--, ,e.�Q .
Business Phone: Gc r � r .0 •�-.'ZS'��,t/ •
�2j�ldame and address of current owner. �A.w��
3) Property Description: Lot size: Townshlp: Subdivision: � Lot #
Direetions to the property (Inciuding road names and numbers):
4) P'roposed Use a, Structure Description: answer each of the following questions:
a) Propased Existing , Type of Structure: S� t� IQ_,�.�(�/� Width: � Depth:
b) Number df Bedrooms: �.� Number of occupants or peopie 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_, Community_, Spring _
Are any wells on adjoining property? Yes_ No _, If yes, piease indicate approximate location on the
'site pian. � . � . ,
6) Does your property contain previously identified jurisdlctional wetlands? Yes_ No_
,
PLEASE PIOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTI( OR SITE PLAN MUST BE SUBM1TfED WITH THIS APPUCATION. .
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. �, -
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAIT
STAFF: �
I hereby make application to the Person County Heaith 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.
�° �/- 3 - �'� 7
Owner or Legal Representative � Date
PCHD, rev. 06127/02
�� �
�, a �
'-...�.. ,r l � � � �1.J ��� � �
�71�.'ki�'71.7L"�CbIm.7C�lCIl.a�'7�ll..��II.� ���i.Jl'�Jt73.
Building Additions/ Mobile Home Replacements
Tax Map #:�_
Approval Requested for:
Parcel#: a o 9
Mobile Home Replacement
✓ Buildi.ng Addition
Applicant Name: %�� i�+��% -�T - � ���
Address:
Z /
Phone #'s: �9 � 77 30
Permit Located: ✓ Yes
Installation Date: �
No
Design flow: (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: 3�S�o 7 (date)
(Applicant's signature if site visit is not required)
,
' = Addition/Replacement Approved
Environmental Health p ' ist
11/15/OS
,3lS�o 7
Date
� l•} 1 � � � . l•1 \ T�'X M:�p ! � � F�,rcei # �� '
SThcllivis�ion
< <�� � � I � Fh:as�e SecGion' ot #
t � �.. . , � , , � - f 1 1 <- - I � I ,
Applicani
Location:
Permit Valici for _ Five Years
Type of Facility:
Ia�proveffient Permit
No Ezpiration
# of Occupants # of Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Owner or Lega1 Representative
Authorized State Agent: _�
New _ Addition _ Water Supply
� aily Flow g.p.d.. �
Type:
Type:
Date:
Date:
The issuance of this pernut b the Healtfi Department in does not guarantee the issuance.of other pemuts. It is the responsibility of the
applicant/property owner t in sure that a11 Person County. Planniug and Zoning and Building Inspections requirements are met 'This
Improvement Permit is bject to revocation if the site plan, piat or the intended use changes. The Improvement Permit is not affecfed
by a change in owne 'p of the property. Tlus permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules or S'ewa e eatment and Dis osal S stems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warran that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
A�uthorization to Const�uct dVaStewater System �Required for Building Permit) �
* See site plan and additional attachments (_�.
Proposed Wastewater System:
New Repair Expansion
Type of Facility: �
Type Wastewater Flow g.p.d. ,
5oil LTAR• g.p.dJ ft 2
Basement Yes No
�� �� 1� \ Wastewater System Requirements
Size: Septic Tank: (aoa gal Puanp Tan�: gal Grease Trap: ga1
field: Total Area: sq ft Total ength .- ft ' um Trench Depth in
:h Width ft Minimum Sovl Coover:��� in Minimum Trench Se aration: ft
P
Distribution Box Serial Distribution Pressure Manifold
Specifications:
Authorized State Agent:
Permit Exp:
Date: 3 D
The type of system permitted is Conventional . Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: � ����,T , _ Date:-, 3 - /�v - � �%
PCHD7/30/2002
.���.�� �1�' �����
_ � . � `l.J' ���
1� sa�nro,•,� ,,,,,, ��aa�m.11 IC��.�.7L�ll,a
5���. ��.���.
l A�t 1�.
�..1 t�A�GC M 1G��
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�� System cos�bonents r�iirreserat a�roxiaatate�tant�urs on1y. T ne caniractor �nu '•, fTag t3ie .r++s�ean pri�r to
begenning tlie rnstallatza9s to insure tdaatproj�ergrrrde i.r �saintairsed :
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S1TE PLAN .
Name � ' � I-Q.W YeV l i� / Taz Map #� P�cd #�_
S • • a � oY � • C � ( ��1 � se�riou/I.or# �
•S. 3-3n —d7
' ed State Ageat Date
Sysrrm campoaencs �ear appcu�vasre conmraa acly. TLe canuactormusrtla� rhe ryarempaiar m begran�g rhelna�doa m
lasvrrr6�rpunFergadelamariarained • .
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