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i� �iE INFd�RRflATI�R! 3N T�E v�P��9CFs'�OP! F�t� �iV 16lA�6aOa/E3�iENT PE'R�Iflll' �S i�C0i�4ilE�'i FALSiF�Ei�
�1�9�9dG�� O0� T9-iE SiT� !S ,4�TEH�Ei) �i-9ES!! �E l�fi�'ROb'E3ltiE,�l�' F'4E�i1liBT.�ND �IdTN�I�tZd�'a��� 7'd�
CONSTQaUCT SHALL, �E�OnAE INVA�.1�. .
�,��s��A �`k.d �esse RLt � ��f�'
9) Per�vnii requ�ted b:(Owrnerlagen pros eciive c�wrae . C3� P�,cGrl`f'
Home Phone: 7'��70.3 Address: l:'� �.c, v l
Business Phone: �,?,L� ���-57�Ui �chr_no �]G c��.�?Lj
2) �aevo� and as9dr�s o� c�ra�nt owreae�: C
r?
. }� rn n K- �s`� �-
3) �raperty i�esc�g�i6on: Lot size: Township: i�I���,�,Subdivision:
Directions to the property (!ncluding road names and numbers): (�� n�,t,r(' �.�I�
G1Q�•�n i-%11_ ����„� c.lu.1�..5�,.,,l�.hc�,�.��. i-, r rn m-, /y'
a I I'tfti ��i 'N e
�n c ��„av Wi,;-t� �
Lot #
t�c•J
4) �ro�osed 4D�e an�i �ge�uc$ur� �es�riptaon: answer each of the following questions:
a) Proposed � Existing T_ype�of Structure: _}�o�5e. Width:� Depth:�
b) Number of Bedrooms: ��v Number of occupants or people to be served: �
c) Basement Yes_, No ✓Will there be plumbing.in the basement?
d) �arbage Disposal: Yes , No � �
5) �Bate� Suppiy T�pe; Private ✓(new _ or �xisting�, Public_, Community , Spring _
Are any welis on adjoining property? Yes No _ If yes, piease indicate approximate location on the
P'a� •�sit pian.
ce! Il Nt,�.,� t�k�.Q �'c�-�s�t,r�� Comrnun,� we.�.Q ? in P l��
6) Daes yo�ar pa�oper�y ��ra�an p�vaoaasBy 3c9es�t6fsed juacsa�ictionai wet9and�? Yes_ i�o�
Pl.�SE i�0�'� THE FOLLOliVING: .
9,a� P�T �� T�9E �ROP�3�iY OR SOTE FL4f� i�fll9Si BE SUBAflIi'TE� liVl'�4�9 THBS .9►PPL�C�'e�'9Q(�.
9 4�ROP��� L9iVES AP�D COaiNERS MUST �E CL�RLY MARKED... , �
9 T9�IE P�dOP�S�D L�C.4T1Oi� OF A►L� STRUCTURES 6ViUST BE ST.�4�� 01� �LAGGE�.
� T9-iE �IT'� MUST �E �DILY .,�►C��SSi�L� �'t�R A�N EVALUA�'iON $'f 'i9-iE �l�►LTi-1 �3E��RT�iE�IT
SiAFF.
I hereby make applicatio� to the Person Caunty Health Department for a siie evaluation for the on-siie sewage dis{�osal
system for the above-described properry. I agree that the cantents of this appiication are true and rzpresent the ma;cimum
facilities to be place�i on the property. I understand ifi the site is altered or the. intended us� ct�ang�s, the permii shall
oecame-tti�alid.
���
Cwner or L�Gi Represzntative
����� ��n��
Daie
PCND, rev. 06/27/02
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. Authorized Stax Agmt Date
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T�x M�p : Pa�rcel # �
Subdivi:sion
Ph�se'Sect�ion Lot #
Applicant: ��C�S�2 f�,�TZ����
V
Loca i n:
C� -�'I S Q e-�' �!' c�l.✓ -3i� �
Improvement Permit
Permit Valid for %� Five Years No Expiration
Type of Facility: � Nla � 'G�P New � Addition Water Supply jAfl°�c
# of Occupants �'Lt�1C� # of Bedrooms Projected Daily Flow � C� g.p.d.
Proposed Wastewater.System: ' Type:
Proposed Repair: P �P Type:
Permit Conditions:
Owner or Legal
Authorized State
Date: Z — — O �
Date: ^ �
The issuance of this pernut by the Health Deparhnent in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for Sewa,ee Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* 3ee site plan and additional attachments (
�i�� S� :vt 'Q�G�
Proposed Wastewater System. S Gu Typ� Wastewater Flow ��Dg.p.d.
New � Repair � Expansion _ p �j Soil LTAR: �' c"� g.p.d./ ft 2
Type of Facility: �D1��KL' S' � Basement _ Yes SC No
Wastewater System Requirements
Tank Size: Septic Tank: �O gal Pump Tank: � gal Grease Trap: gal
Drainfield: Total Area: -eX • sq ft Total Length �X � ft Maaumum Trench Depth 'e%� • in
Trench Width �?� � ft Minimum Soil Cover: �_ in Minimum Trench Separation: �C • ft
Distribution: Distribution Box Serial Distribution k Pressure Manifold
Specifications: �_S� 'l� ��-e��`
Permit Exn.
Date: ` j�
The type of system permitted is � Conventional Accepted � Alternative. I accept the specifications of the
permit.�
Owner/Legal Representative: k �� Date: Z`�—� �
PCHD rev. 11/10/OS
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Tax Map: Parcel #: � � Date: � �
I�ine Tap Tap (Sch) Tap Flo�* Line I.ength Flow / foot
# Aiamete in) ( m) � ;. ft)
1 � �fc� - �s' �v ' . p SS
2 �� S• � lv��
3 Y � S• S • vv'
4 �
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7 �v ft of line x 65 per 100 ft= L Q S�o� �q�� ; 100 = 14' �gal
75% x� ga1= � S gal per dose o� � gal per minute (gpm) = I�'low Rate
�'TICtIOI} �� N h
I.osS: /• � ft per 100 ft of supply line x'V ��� ft of snpply. line ; 100 = 7 ft
�—ft x 1.2 =�� ft of friction head �.
Manifold Size: 3� " Force Main 5ize: � " PVC �f
TotaI Dynamic Head ="' 3sft of Elevation head +�o� ft of Pressnre head + ` ft of
Fricdon Head = ^' TDH
Pump Require�nent: � GPM @`v �• ft of Head
Arawdown: _ ��':S �al per dose : 21 gai per inch =.�_ inch drawdown per dose
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Applicant � �5�- ��� � lQ
Location: � � , t __, i
�
- _ .; �
� ',�� ' .: �: �
/ �
a�x Map I P�.rc�el .
S�u�b cili v i�s,i o n
Ph�se Sectio,n Lot �
� af 6edu Qoms �
System .Type (ln Acr.ordance Wifih Table Va): ���
THiS SYSTE3Vl H�+S BEFa� INSTALLED li�! COMPl.IANe� WtTH AP.PLICABLE . NORTH
C�4ROL1RIA GEi�ERAL STATUTES, �RUtES EOR SEiIUAGE TREATMENi'. AND DISPOSAL,
AND • ALL COPiDIT10iVS OF � THE lMPR�VEMEI�lT PERMIT Ai�D CONSTRUCTION
AllTHORIZATION. - .
. . - _ ��;��/� - .
.
uthorize Stat Agerrt � Date - �
�n By: �� �-�,�:v'3 . o��:. � �� �� � . .
/ � �t/` c�i,1� �,n;,� 'e��f ' � � ' . �.
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�
���� ��� ��5��'���� �:"�E��S� �'�� �� - �
Tax Ma� #_y�"_��Parc�l # 3 Sys�em Type (Tabie Va)
Owner/A�ip�icanf � � S�bdivision
Address/L�ca�ion � SecfPhas� LDt # '
pc3�d rev. 3l13/01
Application Date• T 2q''-j /
Amount Paid: . �
Receipt #:
Improvement 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/Repair)
$300.00/$200.00/$75.00
~�` Tax Map: � ��
`?,�� ������ Parcel#: �Q —
� � ���� �
lE��a-omm � ���.Il ]E-���Il¢]�
Services
for Services
Construction Aut6orization
(Fee is dependent on the type of
Permit Revision
pair of Ex�sting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information•
Name: �'C'r� 2,C-,"�"z,�.�f'�
,
Address: �3 3��-�-�• h�:rj H o I I ar ���C
� o�c ►� c3c�r� lUr.
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Ot C. Subdivision:
Address and/or directions to Property: ,, _
Phone (home): � - S q �j -3 � �3
(work/cell): �/3 y- 33 y- q 3 `t'
Phone:
Lot #:
❑ yes "�no Does the site contain any jurisdictional wetlands?
�s ❑ no Does the site contain any existing wastewater systems7
❑ yes �io Is any wastewater going to be generated on the site other than domestic sewage?
0 yes 'T�no Is the site subject to approval by any other public agency?
❑ yes �no Are there any easements or right of ways on this property? ���( C��� ���c,6ti
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: ��� d"� S�c7'� •
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
.�Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? � yes ❑ no
� ❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any ex�sting wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s): �
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other pny
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subse�rr ly altered, or the intended use changes, all permits and approvals shall be invalid.
$i'gnature (Owner/
* Supporting docume
ve*)
yz9/S
ate
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(1(1/11� PPrcnn C'nnnt��Fnvirnnmantal T-Taaltl� Z75 C A/Tnrrt�n Qt C,,;tol� n.,_.L_.._ wri,.,•,�.,� ...... _.._ .___.
����,s� ���.���
���.���
?.Lo �ra-Yn �z- � �ra :r�n � �n.-��.IL IF—� � �.11 �I�n
Taz Map: 3� Parcel: � �
Subdivision
Phase/Section/Lot #
�j �� t t
f' %�� A . ,. �
Improvement Permii
Permit Valid for: Five Years ___ Non-expirina
Type of Facility: New _ Addition _
Number of Bedrooms / Occupants / Employees / Seats:
Proposed Wastewater System:
Proposed Repair: , -
Permit Gonditions:
Authorized State Agent:
(X) Owncr or Legal Representative:
Vt�'ater Supply:
Projected Daily Flow: gallons/day
Type:
Type:
Date:
The issuan�e of this permit by the HealLh Department does not guazantee the issuance of other required permits. lt is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
improvement Perc►iit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is noc affected
by a change in ownership of the property. This permit was issued in c�mpliance with the provisions of the North Carolina �Luws
and Rules for Sef�ag� Trealment and Dis�osal Svstems'(15A I�TCAC 18A .19U0). Neither Person County nor the Environmental
Flealth Specialist iv�rrants that :he septic systcm rvill c�ntinue to fanciion satisfa�torily in the future, or ihat t�e water supply wiil
remain poia�]e.
Authorization to Construct VVaste�water �ystem
See site plan and additional attachments (_).
x
Proposed Wastewate.r System: �(,� yVt,p �pL(,tl�w �i e�r (*)Type � Design Flow 2��_ gal./day
New Repair� Expansion _ Soil L'Cf1R: �� gal./day/ft2
Type of Facilir�: ��12 S Bssement: _ Yes � No
(*) System 7'yp�s Illb, lilbg, IY, and V; require perioclic system inspections by the Ferson County Health Department.
Wastewater System Requirements
Tank Size: S�ptic Tank ��� gal.
Drainfield: Total Area �''' r4 �� sq. ft.
Trench Width�� `�ft�
Pump Tank � gal
�
'fotai Length a'x � �ft.
i1�i►�.Soil Cuver� in.
Distribuiion: Distribution Box / Serial Dish•i
s
�-
�uthoriz.,d atate
Grease Trap _ gal.
Max. Trench Dzpth2`� 3�n.
Min.Trench Separalion n / �t ft.
Z—
/ Pressure Manifoid �
.� ' "' �'� � P� �� _�1u��� �/�f2s
� J-c,�e�e c' s� l��x 1� o-
�re
■�■ �aoa s
� tssue Date: �! $
Permit Bxpiration Date: S—� rZ�
T'he system permitted is: Conventional �/Accepted / Alternative ( Innovative . I accept the cotiditions
and specifcations of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 32� S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Tag Map: �5 Parcel:�
Subdivision
Phase/Section/Lot #
Valid for: Five Years
Type of Fac� '
Number of: Bedrooms / Occupants
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Autherized State Agent: �_
(X) Owner or Legal Representative:
Irnprovement Permit
Non-expiring
New Addition _ V�'ater Supply:
/ Empioyees / Seats: Projected J
t�
gallons/day
Type:
Type:
Date:
The issuan�e of this permit by the HealLh Department does not guazantee the issuance c�f other required permits. It is the responsibility of
the applic�ndproperty owner to insure_that all. Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to� revocation if the site plan, plat or the intended use changes. The ImQrovement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the NoMh Carolina `Luws
��rd Rules for S`e►va�� Treatment and Disnosal Svstems'(15A NCAC l8A .19(i(1). Neither Person County nor the Environmental
Health Specialist ivarrants that :he segtic system will cantinue to fanciiaR satisfactorily in the future, or ihat t�e water supply wiil
remair potable.
Authorization to Construct Waste�vater System
See site plan and additional attaehn:ents �_).
il
Proposed Wastewater ystem: � d�X —�� �(*)Type �� Design Ftow 2�{a _ gal./day
New Repair � Expansion _ Soil L'ff�R: � 3� gal./day/ft�
Type of Facilit-�: 2��� S- Bsser�ent: _ Yes I`'o
(*) System� i'ya Illb, Illbg, IY, and i�, require periodic system inspections by rh.e Person Counly Health Department.
Wastewater System Requirements
Tank �ize: Septic Tank �_ gal. Pump Tank ��_ gal. Grease Trap gal.
Drainfield: Totai Area '�� ' sq. ft. "fotal Length � 0_ ft. Max. Trench Depth ZY-3{qn,
Trench Width � ft. Miii.Soil Cuver i� in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
r -2 ' ,S`� �� �t PS
Specifications: 5��� j� ��- R ' � � r x ?0 � �t �
Sei i �a S�s�A �i i.[e -���'4 �Pr�, rcL� �P•'z • �` V0� S l -PX � ✓��
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Authoriz:,d 'tate Agent: � Issue Date: �'�2�(' (�p
Permit Expiration Date: �-2�— 2 (
T'he system permitted is: Conventional /Accepted �/ Alterna ' e / Innovative . I accept the co�zditions
and specifications of this permit.
(X) Owner or Legal Representative: __�,__ Date: � C �
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12)
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- � � �.T�T'IC�`Y � A �..
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Owner:
Tax Map: 3 Parcel #: � 3 Date: S—� IS
�,ine Tap 'Tap (Sc�a) 'Tap �'lopv Line �,�ngth �'lodv / f�ot
# DiaYneter(ax�) ( m) �'. (ft)
1 3 �fo z. S o-a � . �z
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ft of line x 65 gal. per 100 ft=� : 100 = gal
75°Io x gal = gal per aiose gal per minute (gpm) _�ow ate
�'riction d
Loss: 00 ft of supply line x supply. line = 100 = ft
ft x 1.� __ ft of fricf ead
Manifold Size: " rce M ' e: � " PVC
�otal Dynamic �$ead — ft of Elevadon he _ft of Pr.essure head + ft of
Friction Head = TDH
cement: GPM @ • ft of Head
�al per dose : 21 gal per inch = inch drawdo er dose
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Size illcuerial FTow GPY!
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT --
Tax Map � �7�
Applicant:
Subdivision:
Location:
# �93 � �;�Tovwnslup:
��Z �t
Lot #
.��pe ater Supply: � Individual _ Community Public
,w'� �,` ✓ -
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g�� � R uirements: �
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0
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'L ite Approved By:� f� = 3�-��;lo.._ Lmer:
�A� Groutin A roved B >�+� �� �k� �"� �'# ,. � � las� �stalled b
g PP Y: .�_-, ' . � ___—�.Q� Y� -
Well Log: aS7 Depth set: _
Pump Tag: Grouted:
Well Tag: Date:
Air Vent:
Hose Bib: - Water Sample:
Casing Height:
Concrete Slab:
Well Driller: k-� n�`$�(� �,�5-E'�� �t�0 ���v.,,�
Well Approved by: Date: D z �
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
PCHD rev O1/27/04
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���* : 74�f ���� �� : � � l� n
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a a � _�4►�ne%t-� I,✓�l ( (�/' �
_� � � ����; .
��.�����.,.�,-,. ��.��� � ���.�.�.� D� D�SI .�-� - O U
.-- ;� Grout Log
Owner: ����7t/ 'cC�� I u� Tax Map ��� Parcel # C�
Location: �1��(nC� r�:I( �2�. 7 Ns�ssc) �/�c.�Fo�.K� �7 1�,a�Ctie� Nol�n�,.� 7 G�- P�`-�-
Subdivision: Lot #
• Well Constraction
Distance From nearest Property Line (Minimutn 10 feet) r�
Distance from Septic System (Minunum 60 feet)
Total Depth: 2 p�' ft Yield: �_ GPM � Static Water LeveL• �_ ft
Water Bearing Zones: Depth i On ft!H� ft ft ft
Casing: � C �/�
Depth: From .� to � ft. Diameter. � � in
Type: Galvanized Steel �
Weigh� Thiclrness: � R�. Height above Ground: ;��_ in
Drive Shoe: - Yes No Any problems encountered while setting casing? Yes �No
If "yes" give reason:
Grout: �
Neat: Sand/Cement Concrete GraveUCement
-. Annulaz Space Width � inches Water in Annul Space Yes No
�Method of Grou� Pumped Pressure Poured � Depth to Ft
Materials Used:
No.�Bags Portland cement � Weight of 1 Bag � Pounds
If mixture (sand, gravel, cuttings) - Ratio to-�--
ID plates: ✓ Yes _ No 4 x 4 slab ✓ Yes _ No
Liner: - .v
Depth: Date Installed: Grout: Installed by: _
Drilling Log
Location Drawing
From To Formation
r � P�
� P I,� G
� 0 iA ��� �� 'g„1-�„� _ N�s�f a�
o - i� �� °
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. . �7 ,�''' �,
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth
by the Person County Health Deparjx�y�x% _,� _ �
Signature of Contractor
ID#��/ y� Date c�- 30 �C
Pump Installment
Pump Installation Contractor. �(,�r(►e��C— ���� v�< <� •��P State Registrarion Number. 3��� �
Pump Depth: G C� ft Static Water Level: 2� ft
Pump Make & Model: �� Sc,G'�'e �- Pump Size and Rating: �%Z hp 1� gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to the well owner. .
Pump Installer Signature� �` Date: ����� 6 PG"��iD rev O1/27/04
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
q-ZR-tI 9-�5-U�e �], ..o' 0�.3
Date of Inspection System Installation Date Type Tax Map Parcel #
133 ���r �IIoW t�h,
Property Address
Instructions: Check yes or no for appropriate items and 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 ?
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose tank):
Elapsed time readings ?
Counter readings ?
Drawdown rate:
YES / NO
❑ � ❑
❑ � �
❑ i � �An�
❑ � ❑
❑ � ❑
❑ � ❑
❑ � ❑
�� ❑
❑ � ❑
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑�
Surface water effectively diverted ? Q
Diversions/swales properly maintained ? ❑/
Vegetative cover maintained ? �,.,_/
Protected from tra�c/unauthorized uses ? �
Distribution devices in good condition ? �
Field free of settled or low areas ?
�
Lld
°a,���
❑
❑
❑
i �K
i ��1�/_\:7:(.y
I�10�"
�i
PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? �j / ❑
Pressure head properly adjusted ? []" / ❑
COMPLIANCE:
Compliant ❑,_,(
Non-compliant Ll(J PuWIQ i"A n K�' i ser c ov e✓e�
Needs Maintenance ❑ �
aTli �iTi��ivAT. f'nl�flViF.NT1�
QCCeSSr�1�
aCc�.SSt���
EHS TS1.�171-�'�
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