Loading...
A31 80_ � � ..... . " .. ... ,r. ., .. . .. .:i � N v �yz �� � w 'd, � �, K ' �n a. � � � � � x z `° ��� p R7 CY � �� M o "' p b �. � � � � � � w w °'. •* o y �p ''� 'b �, O b � � oa y � �A OA � � � �� � w � �. � � w � fD, � •- � y � A7 w �g �' SD � o.r 0 � � �. � � o � � a. � � o er V A7 � � � 5' � �� w � w �* o �, yVJ � � a� � fD y O � n N p� � � ¢. K �\ Q �� `�'ry � J_ r�{�'ue 1�'f _...5�- l,t' -� ��� The District� fieolth Department Orange, Person. Caawell, Chatham, Lee Counties Water Supply and Sewage Disposal IMPRQVEMENTS 8 e R�i�T �Tq•� 't y • � Owner• .1 �Es .�'!i' :'.i��...., ,�_. ,,�n-�. ,,. Location• `' , !` , i � . i � . , Gi�`� �� � f � . � � \. ..i i� ,1� 1 r � � � � �,,; Contractor: 1 `, : i� �7 . : � �ti .. � _,��t� •, ti Water Supplp: Private � ' Public 7`, �� ��...�, �, j..,�.: j'' �, � � , �'"�� �` t �f r ,� �tj �f"'�r 1'.,�r -�;�,': ._c�C' �f, r � (. .t: r f ' i •,ti � � � j Sewage Disposal�Facilitiess No. liedrooms�' , F'�' Dishwashei�, Disposal,�{� washing machin ot er autom t3c appliances Size oi tank: � �� �� � � U ��= � �NitriBcati � line: '? �� �,• '��''r + � , �`U�i.'� � � �D ��.� ` , —_ Other disposal facility: ,��� 3 %►�y� !'�u.; �' ' �� �}%� � t r _3..��... <. f �r � r,{ � i�'1 F�'� ��+t�.�'!'� % Water supply and� sewage disposa� facilities loca�ion, installation an !.. protection must meet state and local regulations. ��•�:� Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a gublic health hazard. Septic tank and nitri8cation line MUST BE INSPECTFI3 AND AP- PR.OVEB BY A MEMBEft OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY POftTION OF THE INSTALLATION IS COV- ERED ANB PUT INTO USE. Date approved• �� �� �' �j �� Well: �-..' Sewage Disposal• L- �� " 'i Signe .�, r l,L ��.., t:�,tr �.�,� � � Sanitaria ' . '' Counter- signeci (Owner or his representative) . Certi.6cate of Complefion ' , 4 � Date Apprnved• f � �_ �,�? • . l �l�By. �� t_ - r_, � �-... t:) � �rx. '.`. . � � 5a�%arian ` ( (OVEft) ' Location of well and sewage disposal facilities sketched on back. ,. . .. _•: _' .,:� _..-. ..__ , r r '__-._-_-.'. � .': . ..�. . .� -.: . ;. .. . . . : . . �. .� '.. .; .� ,... . .',:� . ��::•.. .��.:.,, ... .,_`'. ..i,i�.,r.rr�...t�..�.:i.x.- �' �::.i .. . . .. .... ... ......... .. ... ... r.. .. r .. . .i . y.� .. t `� , .' Application Date: j'�1 "�� Amount Paid: 02 00 . U(� � Zy, �ja ��"�v Receipt#: ��3 9 3.2 _,�����1 C��✓'r� q �� � �---.`'—�� S f ���� �� �p � � = �� ����°�� � 7� :rn.-e.� n ��: .r:a ir�..:sa�a � a-n. 2an. ]l. 7�-�I .co � T2. �.fhi Application for Services (Sentic Svstems and Wells) Services �mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: � 3 / Parcel #: �_ ❑ Construction Authorization (Fee is dependent on the type of sy: ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No CharQe Important: If tlee information in tlte application for an Improvement Permit is incorrect, falsified, or the site is altered, then tJte Improvement Per»iit and tl:e Authorization to Construct shal! become invalid. 1) Services Requested b,� Name: /1'ir'e,f��e�. � %��"w� wter — Address: 2 ► D / �or'n.o1Gx �7�` �a+�. Ffvr�� /tlll.�S �1�C'. sZ,2s�f/ Phone # (home): ��(,-36�-g31� (work/cell): � 36 —��D� - �%C 7 7 _ 2)Name and address of current owner (if different than applicant): Name: Address: O�iV1, (, 3) Property Description: Lot Size: ��j, ftGSubdivision: Lot #: Address and/or directions to Property: /S''1.� f3''r►t��e� �v /�oi-��°ex�� Q� oy. ✓z�l�.f''— /.+1��e. #� box on R�" Af' 4) Proposed Use and Type of Structure: Residential �_ Business/Type: ,z���L�Cl1fv.�� Other Number of bedrooms 3 / Number of people served (seats/employees): ;2 Basement: Yes _ No i�(with plumbing: Yes _ No � Garbage disposal: Yes _ No �/' Approximate size of building foundation: Length Width 5) Water Supply: Private Well � (Proposed ✓' Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes i/' (please show location on site plan) Note: A completed application must also include: ➢ A pladsite plan of t/:e property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of tl:e `Lot Preparation' form ver�ing that the prvperry is ready to be evaluated I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): /u,�.�;�� ^ Date: /- �'—o$ 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) i ��,� �� ; �II`_' l� 1 � �.� � -l. \`� I �_ � � 1 � � -��' � `�J � b '�i � � . �.➢�.."�i �O -n-� -rn-n «7LZ.¢.�..11 .14_ J3.. � �C.�',�� �li��t: �j; cl�a-� t ���ie,� . . �az�t ��lad �sar � Type of Fac�i�ty: — # of Oc�ants�Lta�, Proposed Wastewa Prop�sed Repair: � �� II �1 ������ �, o a �'� a o � ��r��e�e�� ��a� e � � _ �% �a�ton � '> . . l�e� �, Asidiii�n . . '��� ���p�y -w r.1— �� � f B�rooms Proje�ted Daily Flow 3� g.p.d. ,O t e � � Type: /� � TyP�: '_,..� .�.�R... _�' �..�:�•i'` Owner or Legal Re�nese Aut�orized Stat.� Age� 7�a#.�: Dat�: The ;ssu�,�� of tiris p�it lsy �e Heal#h Deparlmesrt in daes nat guara�es the issuan�a oi other pernrii:s. If is t�e �espons�iiity of the aFPli�oP�Y o�vner t� in sure that aIl Persan. Couaty P3aunin.g a�3 Z�g an� Bu�ing �nsge�tians re� �e me�. �'his �a��v��ent �'e�a$ i� saabj� tm re��ation ii #�e sn� pi�; �pl'�f'�'t�e �n►��snde� �as� e�gts. '�e �g��effie� �°�t is sa��t ���9ae� la� � c�s in r����ip o� #he �nropertg►. T�s �n�s�i# �aas i�n�ed a� c+��lia�sr �� tdne p�visa�� mf the l�oa� ��1��, - '�ass�s aaad I�rales f�� ��vac...�e i're�aesa� ased 1�is�osal ,�`vstes�as' (�,��i lYC�� 1�A .1900�. I��si3a�x 3'2�n ���aaa�i�:�ame";t.�r.�.`'= �a�v�rm�nt� �ea1� Sge�iag'sst �►as-r.�i� ti�� t.�ae segs#ic � sy�ma � c�n�aue t� f��on s��i��ri$y in t� f�at�re��r:#��� t�a�wa�rs sn��Ci� waIl re�aaia� �a��aie. � • • • �uatinoa-��t�ii�sa t� �ons�s� ���� S�� ('.�.�s�.� ��� ��a� ���'� � *. Ses szte plar� r�d additianad attac3�men�r (_). � Z Fln� � � . -. . � '. . Frop�sed �Tastewa.#er Syst�m: C! �� ' C�'�"• � Ty-p�Bi � Wastewater �low� �6o g.p.d. . New i� Re�air E�ansio � .- S�� I,�� . 27 S g.�.dJ $ 2 . Type of Fact`li1y: 3$� S • � Baseimeat �C Yes _ No ����E��.��' �'�$�� ���'����� �� �: ��� ��:� �0�0 �� � �� l00 0 � �� ���: � - � '�', n��: 'Tm� A,t-„a: Q�� sq � ��� Le�g#�a �30 �g ' ' �s ��-��s�a ��a�a�2-/8`'� a�n �re��3a �a�a � f� 1 S�afl �n�er: � 3� � 'Y'���a �e����o �I' � D. C , �a�'s�u�son: 3��i��a�,¢�a� ��a iC Sea� ��n��� �r��� ��o�d. 5n�ffi�atio . .2 . ��'/ �►�d�� . Cnv-2,� .�'� ���/1 �in� �o�� o � �'Ap Ol�v- Pi-t �--� -S - S .A�m�9aaaa�e�i S�-� .P�g�a�. -� P�t E�ira.tion Date: Z�e tyne of system per�it�a is P�- ��1� �� �2�a��������; � Conven�ionai ' � Ac:,�tea ,�'/, �Gf�vc-•�, Date: A.ltsrn�.�.ve. 1 a��ti�t *.i�e �erificati�ns of the Date: 1'2 S'' - d g' r'�"� �'�. � � r iV���•- � �• .. � . ���.sf 1��I�..��I� �+ cou���1 lUl1TITOIl1t1B21�a.1 �OA.I�II SITB SSBTCH � � �,�t- '►����1 s�k� �ur, ,,u� a,,�Q;�,��. � ��rs�, �1 �n c��� Name/ "1 / C � �'P/ ` 1� 11 �'II "f"U Tag Ma #/ � /i . Patcel # �0 In `l �( Yv ff a *� p �.✓1�a%���r �P � ' Sub vi o ,.,r_ Section/I.ot# C�� 1 a C/�� ' l� 6�- vv�-� 2�(:� 0 p Authorized State tlgent Dat � 11 �►1;�4 ( �� � �,�Q,{- �QA� � tf�.er i � � -7 ,,�,- - System components represent apprnxemate rnntours only. Tbe rnntractor mrut flag tbe �� q,�� /� system prlor to beRtnninR tbe tnstallation to Inssrre tbat properxrade is malntatned. � Q� a(�Q� 17 a . .}.� �Cav�� � ,��������✓��• � 12�—�1��� T�c� o������ H -� ..�� �. � + ,.�� � V -�- � 137 p � p 232 . 56 ' — - --_. cZn ` " ` ---- _ 6 ' `i / � , S06°59'44��yy 1-'`�--_ -_'�-- cn � � �' '�— - .� —. --�� Q -- "��� � Z �� � " � .�_ � � �._ ,� ���� N C2 � — . O (� _` —.�� _ _Y r-•� "�--- - N �,, — — � � H j � � � � . '�:ai• 0 m rm— • pp m �� �� N � r :� � � � Z ���: � l''_ ��� .�{ • 1: ". v t� �t��"'��i��t��_ , r/��i ` f �F" f'� v� C+� N N c0 � t0 J � N _ -P� --I � O D m r �- �OL��O� cn _ _a_ �+� � (Jt � � � w� � N V r - o � � -, � m O --1 n r --� � �� ... � � �. � � � � ��, 0 ' �� `� ''.- � '� � °:;� ����� �� vGi � �. ��,,. -� r` . �rr �1 1�'�/• �;� N04 ° 19' 40"E ,� � �S �» H 113.41' � � � _.. _�,. _ .. .. �--.. ..._. l � _.w..._ Z i r' w �Gy � �e � w ' t o - N .,-�m.�R),..:.,�_�.�J ' .__:� .�.. � J 1' _ f'rl r!)r. � � � � r�:.:�' ; ���-,->��� � �� e� �;�, 2>�f1�Fr� • � t���...... � � � ����.�� �� �c�� , �,8;..�-,:�.� � �`t, � '�i,.-�-,v�'��., V.=��4i Vy�F � z � � 440. 0� � rn,-�o S09 ° 06' 00 �� w �d r , H � NEMA 4X Simplex Cox�tmlPanel . � I� 4" X 4" Prns�ate Tretted Post j Sbped To Shed Water „ 12 Sepuatmn Electmcal Cox�4 6" Covu •. ' � Acce» Cov�en � • . • ; � + t . , I � � � � ` � �' ' i 'r• �� � � r 1 • �-�� •. . V . i �� • . �,. O4ening Filled With Anti Siphott Hole Inlet Fmm Septic Tank Portland Cem�ssi Gsaat �� � � d" SCH d0 PP� Pipa 'a �� Valw �P� F7nat Wue� < � High Water Alarnt Lav�l ' .� • (8" Separatmn) . . ;,,', Hi�t Level- PamP Oa ; � � � � �9apor Lock Floats �, 7 � � � Dra�xdotv:t Hole ♦ ... � ,' �P � � r�..R.emovable '. • ' ' � Float Txae �. � . Law Lavel -Pomp Off , �•: • •ti ' �►P .• . ' P�emt Coz�crete Taxik 4' Conezpte � '�' ; : cre :•; MateriaiStre h}3SOOP �lock r I :: � � '�,.; . .• � • . . ' � � ' ' . . .% ' , : . � '� � • ♦ • `' t . � • • � . Duci Seal Hoth'! Endi Of Thn Condait --- 24" M� = Coxicrate Rises x cra � � � � ' ' 6" Separati,on Tlmeaded Gat� Yalve ; �x[ . . , • �r ,. . , ..rl'.or ;�,�r-Portluid Coxucreta Grout • s� �3l�1C • ' � . .� . . ry� � � Zip Cord ' OpeningF�lled With ' Ties � s�� �• . Portland Cament Gmat � � t Oatkt To Diitzbutioa �,�y�A 2" SCH40PVC Pipe . � GAI.Lt]N' PTJ1V�.' TANK �. �`��,�� ���� �� �-, � �., � � �U � 11 1!. 'i T"�'�'a�^��e''��'„'r �9� ��.� �aBa�O.�� �� ,■ • �i'iiLLVlai Pl[..EASE S�E A'I']CACHED P�.AN FOR WELL SITE LAYOU7C Tax ldiap #: ✓�`3 I 1'arcPd #�O Townshig APp�,� (C Sul�divisiori: Sec�ion: I.o� �-� S � L��ow'�f �G�P� ` C'� c�i`c�� � Qo��c������ ,,�, - r �'� • . � Requirements: Individ�tal Community Public . Site App=oved by �� w �c7 7��}.S�c� � Grouting Approved by % Well Log J �ell i �5 � Air Vent � 6 - 22 -oii Hose Bib Coacrete Slab Well Driller.: �`� `� � S�� e I 1 �r i� � 1��'. Well Approve:d �-, - 2 2 -� �°�'See At�ttached Site Sketch'� Wells must be 10 feet from propertp liaes. Wells must he 100 feet from septic systems. Wells must be at least 25 feet from aap building foundation. Odier conditions• � PC�-ID, nev 09/07/01 b � < O � N � � � � � � �m � N Q Gz �n �a i� �� � �. � � L 1 '�...w. ,� '�^ � � �1.1 � � � I7 �3L'S1.tiY71a"�D31=L.IC�C�.�.'1171..�a�.U.� ��3:�I1.��� Building Additions/ l�dobile Home Replacements Tax Map #:� Approval Requested for: Applicant Name: Address: Phone #'s: Parcel#: �� Mobile Home Replacement � Building Addi�ion � �y ✓�o��e Permit Located: �` Yes Installation Date: �/1C ���;, Design flow: 3� (gpd) i�s� °e Current Contract with Certified Op ator on file (if required): � � � Water Supply: �� %C Well Public or Community � � QVastewater system shows no visual evidence of failure on: � l7 � 0 (date) (Applicant's signature if site visit is not required) X Comments: �►, ss;��, � ��; l�C' .� ����' 0 ' ` Addition/Replacement Approved _ �-,. C� � o�` En ' onmental Health Specialist Date 11/15/OS � � ���,� �� � 1�. `' -_ �' � ! ��` _ ��y=-_ � �.-��---�- �� � � �,���' ! �s 'T-.�� �.Q.--��-�o -_--� -*-�--s-�� ��.1I. �S � �..���. ,',p P �]C2 LOC�IiO V'a� �� �_ s�uC�� � ' 80 �, �e o �ac� l�J ^�U7l7lLlJL1L}I�JIS N � . � ot� o. a� a o r� 3 � . � . �� �� � � • �� . �� . _ � . S�fst�m Ty�e (in Ac ;ordanc� With T�le Va): � Z TH1S �Y5 i�� ��� �E.=� i1��T,�L.L�i� 1t� Gt3�i1F'��lC� 1�tT� �P�LICA�L� .�I�RTH G'AROLIN� G�i��3�AL STATiJTc�, ��Ut��S FOR Sc'�i1.�4�� TR�ZiiflEi� i�l�D DtS�OSAL, ,�.RI�D • ALi CONF�[T1C3i�S �F ' TI-3� lI1�FRGl����T P��UiI i Ai4lD GDhlS'� RUCTIOf� �IiT�O�i�+Tie3N. . . . �.� fQ-2�2'a8 � utho�� Stats Ag�rtt Daie � nstalie� 8��: � co��;�e . '� Liate: . 8 =s— os� � � � 9 9 � � ! � ab' � �D ' �'�tl �,l,$ �, . G 0 ' . " 1�+ S0� �`-°" �-' . - . . 33b'. . �2 ; �• 5 I � �f' `� ,�C�;� . r=l�. u�l2�i��'. �. , i' � ����� �.�+.c�it� ��5��� � "s�� d����i��S a � � ;.��e �9 a ��� Ta; Nia� i'� �_ P2�'C2� =��'� Sys�e: r� Type (Tabde V2) C�z O���erlA�pii�t � � � S��division AddresslLfl��tion Sec; i'i�as2 Lct � � Sta#e-ID/date S�- 2�1/ S-IL- Capaci�ty pr5- I000 3a�- Tee and Filter � � Baffie Sealant Riser (ifi apQiicable) �2t1�C OU�iE� SBa� � Peiz�nan�nt iViarkes- Pum� �'an� State ida#e - -a Ca�acitv P; s_ �ve o qaL Ris��' Water�Tight � . � P��a� Checfc ValvelGate 1Jaive Alarm visable and audible �3ectrical Com onen�s � Rate m , . A ravet9 Pum iVioded 81oc� Unde� Pump � Pur�z Removai �Ro elC�ai . �•��s�ba��soe�:��t�� � Se�ial �isinbution ress�re anna Lnv� Fressure Pi � A� r. Pip� 111�ttate�ia� �nd G� i/alves " a � rer�ct� �dah 3 fr. Trenci� Des��h /Z'JX in. T.renci� Len9� 330 �. Trenct� G�ac�e � Tr��c� Spac�ng� Rcc:� D��ti� and Qualizy Darn�/S���down� �#c. PI'2SSl,]iG L3fE!""cIS ' Hole St�acin� � . Slesve ��ud�d� Se��� From� VVelis � �rom Prapertv lines Surfa� Waters Fublic 1�14aier ��ppi 1/.e�#icai Cuis (>Z �t. 1Itlater Lines �e�iici� �Traf�c � , ��asernee�tc.JlRi hf of V� . O�er' . �as�m�ni� R��ded e � e �erator i �ri-�ae�ta#e A�ar��nes� �c7d r��. �I��IG � PERSON COUNTY HEALTH DEPARTMENT SIJBSURFACE WASTEWATER SYSTEM MONITORING REPORT q-q-13 g-5-08 �q^ �31_ �_ Date of Inspection System Installation Date Type-� Tax Map Parcel # Property Instructions: Check yes or no for appropriat„ iter.is aad explain in space 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. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? YES / NO ❑�❑ . ❑ � ❑ f" ❑ � ❑ ❑ � ❑ EFFLUENT DOSING SYSTEM: —/ Required pumps g:esen: & functional ? [��j" ! High water alarm operating properly ? �iQ, � Floats, valves, etc. in good condition ? [j Control panel & components in good condition ? � � Effluent free of excess solids 7 �� �/ Inches of solids(pump/dose t ):�_ Elapsed time readings 7 Counter readings ? Drawdown rate: DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ / Evidence of effluent ponding in trenches ?❑ / Surface water effectively diverted ? � / Diversions/swales properly maintained ? ❑,_,/ � Vegeta!ive cover maintaired ? 13� ! Protected from tr�c/unauthorized uses ? [� / Distribution devices in good condition " �,_,// Field free of settled or low areas ? l!� / ��� ■ �i ■ I�� � L� ❑t�}�A ❑ ❑ REMARKS 5,:o�;c. `�anK b�lo� �� g���� na�' access�ble PRESSURE DISTRIBUTIOi�i SYSTEI�L• `. 1 Tumups/cleanouts/valves/taps intact & � �, r�U �e m p n f���/SP �Q5 R accessible ? ❑ � ❑ k P Pressure head properly adjusted ? ❑ /❑ j� COMPLIANCE: Compliant Non-compliant Needs Maintenance AvLiTitiivr�L i:viviivic,iVTS: EHS n ■ ■ box i n s+ea� � ; Report To: North Carolina State Laboratory of Public Health 3�12 Dist�ct Drve Environmental Sciences Raleigh, NC 27611-8047 htt�://slah.ncpublichealth.com Inorganic Chemistry F�ne� 919-715-86�$ Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: MICHAEL RIMMER 2103 POINDEXTER RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES120215-0001001 Date Collected: 12/01/15 Time Collected: 09:30 AM Date Received: 12/02/15 Collected By: J Smith Sample Type: Raw Sampling Point: Inside spigot Well Permit #: Sample Source: Well Temp. at Receipt: GPS #: Sample Description: Comment: Inorganic Chemical I (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 36 m Chloride 10.00 25o mgi� Chromium < 0.01 0.10 mg/L < 0.05 uoride < 0.20 4.00 Iron Lead m < 0.10 < 0.00: 0.30 0.015 pH 7.8 N/A Selenium < 0.005 0.05 mg/L r < 0.05 0.10 m Sodium Sulfate ; Total Alkaliniry Total Hardness ✓ Zinc Report Date:12/10/2015 16.00 7. < 0.05 Page 1 of 1 r_kz�. 5.00 Reported By: ����a�