A31 93�
W
�
a
� �- . B 1262
PERS�N COUNTY HEALTH DEPARTMEN'�'
WELL AND SEWAGE SITE, LOCATION IlV�R�VEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued untii Authorization for waste water system construction
. has been issa�ed.
Tax Map # /-� . ) Parcel # �% �
ZO111I1g TOWriSlllp 1�v.�N Y to�Z k
Owner/Contractor ,qL �o� Date 9/-T /� �,
Location/Address ,�s� < 7/2 c� /N D c- k T�,� �t _r� _____ �o I
N►.�t T� ,aT r��a� � Z� .�d S.R.#,
5ubdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area �3. /�•q � Size of Tank � x �s i ��t 4-
SFD ✓ Mobile Home Size of Pump Tank �-^/'�
Business # of Bedrooms Nitrification Line � x � s r. �4-
Max I�epth Trenches
Permits may be voided if site is altered or intended use
Well and Septic Layout by ��%% � ����
Comments:
l.�1 A /J Lrt
: o _S C ' G SY —E
Date .- Installed by �-k ..� ? , �� 4 Approved by �� � �
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS EX i s r,,�- G-
te Approved,
'ell Head Ap�
Date Installed by,
Slab
r Vent
;quired Well og _
ell Tag
Approved by.
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 environmen�al 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 �ater supply will remain potable.
c:lamipro\permit.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: 9� E� IlVIPROVEMENT PERMIT #: /3 /z � Z-
TAX MAP #: A 3/ PARCEL #: �j3
OWNER/OWNER'S REPRESENTATIVE: /.� G � �
LOCATION/ADDRESS:
i/iz i o �.v o�xr�
�o % r-► , �t i,/L � r a3 cr � .T__ � Z o
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED
� �
�
CONDITIONS
LOT #:
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 Permit # . 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:
LI D D � N C�- �l �,k' Z y� ��4 �ZA- Crc �
�!o G�A N l� � -� S� r� i/ c S4� S Tc- D—�''(.
Person Requesting:
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �• �� �K ��!' .
Address ��� 1 c�r�x�� �� County -t'YSd-�-�
��'-�� � �l s ,Uc
Collected By
�
Date Collected S�Z���( Time Collected.
�—�
Source: �Well ❑ Spring 0 Other
Location: � House Tap
❑ No Charge �Charge
�Well Tap ❑ Other
�0<l ,�
/�3 � "� 3
........................................................................�
************�x***********************************************************
Total Coliform
FecaUE. Coli
Present
❑
u
Results
Abseiyt
Q�
�
Reported By
Date Reported � � 2� I 2�( �