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A31 183�.�n�ii�'tion �ate: 7 �`3 -G � �,o�� - �� : - � � �pas�n� Cacar�iv �iea�4h �3e�artrr�en# � - � � � ;�dir�nr¢��ntai Health Section �� T�x �lla� � ��,.T � ��3 � . . ' '"'s:. i4PQL'lCAT10N FaR SEi�VIC�3 � 1F TNE 1NFaRMA7TON (N THE APP�1CATtON FOR AN IMPROVE�AE�Ii' PERAAR (S FALSiF9ED. C�lANG�. OR THE 51TE 1S ALTE�iE�. THE�1 THE IMPROVE3VIE�IT PERMIT AND AUTHORIZATION TO CDNSTRUCT SHALL BE�OME INVALID. 1) Permitrequesbed by: ��agendprospecSve owree�: �.S"co, G'• �/�.��.'F s � Home Phone: 33� - v �7sx � Address: � A I ��„ :,� r � �,� .., �/.?� 8usiness Phone: ,� ,, . H J,�J l� �-r, ;/ i� ��c_ �� s�/ 2) Name and add� af cumerrt owner !�rl.� �', ��a��/�.•rs . � � .�l1cW,�., c. �a,.c� .c� Q� � �l-f��lc. vr.� �/s ..�/G o27;c1/ 3) Property Description: Lot sizs: �<<��.Townshl� �� c Directions to the property (lnduding raad�names an—�d rYumbers): ___.2 �' � � .�;� �� ►- .� _ _...,. 7, .. � , �.� �,�? �/,,,/ /�. , �• 4) Proposed Use and Structurs Oescri�ition: answer earh af the follawing questions: � a) Praposed 4 Existing � ' . b) Stldc 8wlt e�Mnduiar q Stngle Wtde a. Double �de � � c� Num6er of 8edrooms:�� Number of occvparsts or peopie to be senred: 3 � e). ..Basera7er� : Y�es�Q Nc��lf yes. #�of basemerrt fndures: . . . . . . . . .. ��--- � = . .. � . _ � � • Gariaage.Disp�,a1: Yes � iY�i.�". ..:_".• ..., ... r . �•.� . `. �.. _ . • ..... � . _... . � Dimensions of Proposed Struct�: Width: �% Depih�.� ��J C�GS�� C�,Y0. � � � � Water Su�ply Type; Private 0'(new � or existin9 �j, Pubiic a, Community �. Spring ❑ . • Are acry weils cn adjoiniag prope�iyt Yes Ef No Q If yes, lo�ation . S) P�ease Indicaie Desired System Type: (systems can �e ranked in order of ycur prefeiencs) Conve�rtianal _Baodifled Ccnve�tional _, Altemative. Innovativa Other (specifyj: CL�ARLY STAKIE ALL CORNE3iS AND UNE� OF THE PROPE�t?Y. STAKE THE CaRNERS OF A�LI. PROPOSED STRUCTl1RES. PLE�SE ATTACH SURVEY PLAT OR SiTE PL4N TO THIS APPUCATION 1 hereby make appiir.atian to the Perscn Cowdy Heaith Deparimerrt for a siie evaluation fcc the on-si�e sewage disposai system for the above-descxibed property. I agree that the ca�rterrts of this appiicatlon are trve and repceserit' the maximum fari�ties to be placad on the property. I understand if the site is aRered or the ir�tended use ct�anges, the permit shall became imraiid. I understand that as appiicarrt, 1 am responsible for ider�tifying and mar�ng property lines, camers and maidng the siie �ssibie for the persannei af the Persan Courrty Health Departrnertt to candud thear evaluatians. I understand that I am respons�ble for notiiying the Heaith Departmerrt ii my propesty caritains arty wetlands as designated by the Army Corps af Engineers. iG,ti. -�/�„ _/ � ' Owner or Legal Representative r �_;- PCt-iD, re+r. 10!'12199 Person County Heai�h Oepartment Existing Sec+aqe System Report For: _f�iobile Home Replacement �� Addition Requestee: Ke� �-` �'�<<'ns a`� 1 �.l /l l D n � r�c v c C� urc.� �' d� �I,�L� f�n i I Is �►, n�� s 4� Location�Qirections: �u��i It (1'1 � � �-5 i��YT � %i r5-� ��rh� an (L 0 Original Permit Located � Septic System D signed Eor: Kesidential Business � E3edrooms `� # Employees .- Eiome Phone#3�D�I'-11Sip Business� �3 ''Pax Maprt J � - ;)�,ln i On (� r� J c. .. Other (specifyl _ Other Uate Installed � ( � Wa�+er sup�ly Type ot 5ystem v ✓ Nitrification Line �� t 1`� r r .__ 1 .. Tank Size Certified Operatcr Required � � � On site wastewater dispasal system sl2owes nc visually apparent malfunction on C,� [. �`�/ � Yermission is granted to: �� tl - According to the attached site plan. Comments: Environmental Health �'�C.. ' �3�a � D TE --t---' .. . • � �� G � Y -e.�� -'� � Person -County Health. Department Sewage System Improvements Permit �ate: This Permit Void After 5.Years f' �-' �vme��i� �r ��-� SR# r ___'"__.M.�- ____' 1-K ... I � - ` / C�( f; vJr:�C.F',N/jl!) �Jt-C i.:��,:. Subdivisiort Name: ` �1�+ Lot # r Lot �ize: � � � Type of Dwelling: Water Supply: Private: � Public: Community: . Bedrooms: �- Gazbage Disposal � � Basement Basement Fixtures Ilv�ORMA D Y" � 1�' l�iv 5��: owner or rep�esentative � REPAIR: ALUATION: Size of Septic �c� all�� o� Pu Nitrif'xeation Line: / � ��' :j Depth of Stone: 12 inc 1V1a�c Depth of Trenches: Altemative System: Conv.-Pump LPP Pump.- �„ ,,�� Remarks: �,�j,�.-� _ Il vl �a.Y1 �o �i� Date Well Appcoved: Well should be l00 f� from any sew� BY $8I111aT18I1 Date e ag S pro U� � BY � anitarian , .� � � Contractor. - ' ---- ---- ------------- ''3 Sewage System location, installation, and protection must meet state and local � regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained � by owner in such manner as not to creaze a public health hazard. Septic tank and�d nitrification line must be inspected and. approved by a member of the Person Counry � Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this pennit is subjecrto revocarion. (G.S. 130 A-335F� Location of sewage disposal sewage sys.tem sketched on back. (OVER) G r�, v�yx 00 w 'o H � � t� "7 y w ;: � � � � zy o ° � � (D fD R �° '� K p�� M a b � �,�.° � � w m �: m � M �p � k b * o b�E. y' � � � .r � � � �. I� V. y �' w � n � � � � v o �• a �V~i � ]' � � � � � � � N O ... � � o � M a � ;; o c � A w er y �� N � w � w .+ N � � � e' m y � w r. � � � � PERSON COUNTY HEALTH DEPA�2TNIENT 3�5�, SOUTH MADISON BLVD. RO:YBORO, NORTH CAROLINA 27573 BACTERIDLOGICAL tVATER SANIPLEANALYSIS Name of Owner or Tenant�n� ��' Address oi�c'i( l.l��,,r. —c�� Ch d� _ County P2f<�.r, Collected By �' or�n r � �'(��- Date Collected (l��3�� Time Collected /� � �SL Source: L� Well O Spring � Other Location: ❑ House Tap �VVell Tap ❑ Other pNo Charge QC:harge ��*�****�***�***�****,��*�*�*��**�*��****�*'**�*�*��*�*�*��*�*,�***�**�***�**** ***��**�**��****��*�*��**�*�*��***,��*�**�*��****�*�*******�**�r�***��**�**�** Total Coliform FecaVE. Coli Resu[ts Present � ❑■ Absent O � Reported By � .r��h�) MT �p��; e� ��I��t� . bactreport PERSON COUNTY HEALTH DEPARTNIENT 35�� SOUTH NIADISON BLVD. ROYBORO, NORTH CAROLIN � 27573 BACTERIDLOGICAL WATER SANIPLEANALYSIS Name of Owner or Tenant Jari�rrc �en�zsa.n� Address ,( �%rZi�i FtYZ,�re �%�c� County P�,%S��r-� Collected By r�n�P F�l�- D1te Collected ► a�� Time Collected �-t-" �� 5ource: �Well ❑ Spring O Other Location: �House Tap �Well Tap � Other " �'�mP�� . C�d%Io Charge �Charge, - *�******�*�*�**�,��**�**��**��*�****�*********�*,�******�***��*��***��*�**��* _ �**��**��*�*�**�*�*��***�*�c*�*****��*�**�*�**��*�**�*��*�*�t*****x�***�t*.** Total Coliform FecaVE. Coli Results Present� Absent � � ❑ GY Reported By �,.J -� 1��°-� , G1'1�"" bactreport N��i�e� �a�5�� ee�i -f� chl�� r�-f-e PERSON COUNTY HEALTH DEPARTIVIENT 35��, SOUTH NI.�DISON BLVD. ROYBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAtLIPLEANALYSIS Name of Owner or Tenant �C�r�in ��rrizc�n� Address a�l L1ul� c�r� Fr�c �.re ��% County ��r� Collected By �r-, �-e �--Q- D1te Collected �01 �-7 �� Time Collected � O�' v� Source: C�'Well ❑ Spring ❑ Other Location: �House Tap Owell Tap O Other _ � -�'�O/� . �No Charge ❑Charge � ***�**�*�***�***��**�******�**��***��,�**�****�*��**�***,��*��****�*****�� :�*�***��*****��**��*****��*��*�*�****�*****�*��***�***�*�*****�**�**��* Total Coliform FecaUE. Coli Reported By, bactreport � Resu[ts Present Abse ❑ ❑ �� o��h�, m-r- North Carolina S�st� ��boratory 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: Jen�ino, Janine Address: 281 Union Grove Church Rd. Hurdle Mills, NC Zip: 27541 County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street (336) 597-2371 Roxboro, NC 27523 Courier: 02-33-15 Collected By: B. HOLT Date: 11/13/2006 Location of sampling point: Outside Spigot Remarks: Source of Water: Ground Source of Sample: Type of Sample: Raw Type of Treatment: None Type of Analysis Private Time: �11:2U:00 AM Parameters Results Units Date Analyzed: Alkalinity as CaCO3 16 mg/I 11/14/2006 Arsenic <0.001 mg/I 11 /14/2006 Calcium 6.1 mg/I 11/14/2006 �� Chloride IC 8 mg/I 11/14/2006 � Copper 0.11 mg/I 11/14/2006 `rjn� Fluoride <0.20 mg/I 11/14/2006 ` � I ron 0.13 mg/I 11 /14/2006 Hardness as CaCO3 (Ca,Mg) 23 mg/I 11/14/2006 Magnesium 2.0 mg/l 11/14/2006 Manganese <0.03 mg/I 11 /14/2006 Lead <0.005 .`?'`- 1 rrig/I 11/14/2006 pH 5.9 - Std. unit 11/14/2006 "Linc 0.31 mg/l 11 /14/2006 Date Received: 11/14/2006 Today's Date: 11/29/2006 Report Date: 11/28/2006 Ref: 14728 Login Batch: Re orted B : �'�'�`"- ` p Y ��I �"^' Sample Number: AB49527 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. 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