A40 218' Person County Health Department
° -Sewage Systerri Improvements Permit
Date: " �` � ' Permit Void After Yeazs Permit # �y � � ��
Owner _�,,,2„ r� v� ,� Y/it A vr �R# _�
Location/Directions: � _ --� "�'
Subdivision Name: '' � ' ""'� �� � �-�
Lot Size: �' � � Type of Dwelling:
Water Supply: Private: ✓ Public: Community:
Bedrooms: 3 Gazbage Disposal
Basement Basement Fixtures
INFORMATION CERTIFIED BY
Environmental Heal[h Specialist: e r res 've
REPAIR; REEV ATION:
Size of Septic Tank: � gallons Size of Pump Tank:
NitrificaUon Line: /� �� � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks:
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Date Well Approved: Well should be 100 ft from any sewer system
gy Environ ental H�alth Specialist
Date S� ge y ppmv _
gy Environmental Health Specialist
TI - ATE OF OMPLETIO i ,..�
Coniractor. � c' � �x
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazazd. Septic tank and
nitrification line must be inspected and approved by a member of the Person County �'
Health Department before any portion of the installation is covered and put into use. If ...p,
the site plans or intended use change t}ris permit is subject to revocation. �
(G.S. 130 A-335F) �
I.ocation of sewage disposal sewage system sketched on back. �
(OVER)
, NQTE: Make s 'of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. No�ecial problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
1
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�TCUG 1d�C� Y�ZU.N
- -.�erson County Health Department
Well P�rmit -
Owner.`"'?�� �i$ Pern}it Void Afte Years �/
bc ✓t� � � mc�� �.�
Location/Directions: _ _ �'� .1�,
Subdivision Name: ,
Drilling Contractor:
Distance from Nearest Property Line Distance from Source of
Pollution��
Total Depth:� L- FG Yield: �� GPM Static Water Level Ft
Water Bearing Zones: Dept Ft F`C:,t(„s_�t
Casing: Depth: From to Ft. Diam�: �D�Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve�tNo
Weight: Thickness: l Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountezed in Setting the Casing? Yes No
If "yes" give reason•
Grout: Type: Neat S�n$/Cement" Concrete
Annular Space Width 1�---� Inches
Water in Annular Space: Yes No
Method: Pumped Pres Poured`�
Depth: From �to Ft.
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes � No
4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN A ORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HE AR ENT.
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Sig re of Contr tor Date
(a :� -
anitarian's -gnature Date Issued
, Sanitarian's Signature Date Completed
s
Sketch well location on reverse side.
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I'10TE: Make sketch of instal atio showing lot size and shape, location of hou , se�tic tanks, privies, wa
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations be
l�cated �t later date. Note location of water supplies on adjacent lots. �vo�l��•�
,. �.
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FROM : D HUNT�2iP DORR
PHONE N0. : 9199671F3683 Jun. 27 1994 08:29AM P01
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�}-t.�C�.r-�-G� �S , - 7 r � � ,�� .
Site �valu�tian Application •Date: _�_
Fee Col�eeteci XES „� 1�0 _ _ _
�-1-�`� �.
APPLIGATIQN FOIt IiS�''FtQV�E19T$ �+�RHI�
�� �105 °� �
1. Fer.mi.t r.equ�s#ed by: ownerJpraspecti.ve owsier: '������• --
a�ent: �� -------_._. ._��
Atidxess: �5' 3 �
Home Phon� ��: r
2. I�ama and addresa o�' cux�ent awner.:
Busir���s phone ��.
3. psoperty Descrigtioti�: Lot s�xei .��
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= 4�.:. , . . . .. . . , .
4. Tax snun #: � � l� t Township: T��-11iGr.
SUbdivisi�n Name: �../�-� l�t tl?=-�. �ti'�}''C7p�1 I.at #�: .....
5. pfr.�ctS.Qns tta pra�erty: St te Ro�d �f S� �iazd Names, etc.
'� l 'S -7 . 1�- �. �Cc-�t:w f'�Z . _ �" �
6. Yermit requested for: -NeW Ix�stsil�t�c�n: 1�` �� . Ttepair: �
Additional. Re�tovation r.e�vsing present system�
, . :. . �-�•:_�.<.- ..
7. Nvmbe� of- occupants.ur people to Ue se�ved: ,�„
8. Uimensions p� I���pOseci �tructure: ,Widtti: '� d n4pth= ��'{
9. Wha� tiy�e (�� any3 �t�diti.ans, expartsions� or repiacament is antic:ipated to the Btruc-
tuxe nr. f'�ci.li.ty that this sewa�ge diapdsal $ystem ig int�nded ta serve?
. -�
ltl.
W�ter suliply private? _��
�tber saurce? (S,peci�y}:
... Are there any, w�13a oz�,.2�dj.p
publ�c? � camnuni�y? spring7
in� pr,Rp�rtY;_,,.��--::r:.,�,.�;., ..;�..
�2.ru_._
11, Tyge af �truatur� c�r f�ai7.ity: Proposed: � Exiating:
Typa nt dwe7.li.ng: Iaau�e: Mobile Hoznes � an�inoes:
Type oi businesss ��' Numbe� df E�ploy�es:
Number af bedroams: Garbage Disposa.l? Y�s �d� tf`
�aaement? �es � Nb ''�s' T,� so, nunaber of ba�ement_ffxtuxes:
�.^" r _"_' �
1_2, C;�Rrly et.ake a1'!. oornert� ai the p'�coptrYy and the carners af a1Z proposed st�uctures.
I lycr[:Dy make applicatibn �to tt�o Per�on Ccrunty Health Department fc�r a sit�.e
evaluation o�� existing syr�tem evnlaatiun for the an-�ite aeuage disposal systcm far
the aUave desc�ibed propcsity. I a�raQ that the contentg af this applieation are true
and represenf tt�e maximus4 fa�ilifiies Yh �ie piaeod on the� p�apert•y. Y und2r�t�rid if
�th� site is a7.tc►r�d or the intenaed 'us�+ ehanges, the permit ahall beca�ue inVa? Xd.
P�r�its ar.e v�lid for 6fl mon�hs i�om date a£ i,ssue. Perm3�ssi,on ia lter�by grartted t�
entez� tha p�op�rty for.. tha evaluation. G:S. 130A-335(F) �
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� wa�r S�=PP�I TYP�= ��� (new _ cx �. Pul�C,,,., Carrtlflli[pijl' . S�[irlg _.
Are arty w�ells on adjoazing p�aperf7�T Yea_ Ptu � If Ye� Pie�e 1� ap�umdmaie location� an the
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➢ A PI.,AT OF THE PROP82TY OR SiTE PU1N �JST BE 9UB1@'FTF3� 1llf!'if{ TI-�g pppLJCq7�pN.
➢ Pf40P9�TY LlNE:� AI� CaRiVEti3 YUST BE CLF.�►RLY itARl�. . .
➢ TiiE PR� LDCATION OF ALL STRUCTURE3 �ll9T 8F STA� OR F�.AGG�.
➢ THE SffE 11U3T 8L READR.Y AC�.E FflR AN EYALt�ATWN 81i TH� liE�►LTH D�ARTY�IT
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�'ax 1V1ap # �� I'arc�l # � 18
�xisting Sewage System Re}�ort For. ✓ Mobile I�ome Iteplac�ment
- � tS.dditaon Type:
Requester. �t�wo� ��n "' I�a�a.k �'�"� I�ome I'hone#
,u , „ _ ����M f2Z _ Business # 594��51
�,.�.�T �vc ��s�3
Location: SZ� � S -� 'Fto..� � i2,'va. G.. � � �l �.�. �'.l� Yv.-� �a � �
n_,.� ��,x;� ca ���� � C^t� ��-k -�- � n,, i�,�.� ��„�.
�v►x M a� �1t.^Sa�e.. -f+. l �--�
priginal I'ermit I.ocated: na Water Su�pply: �VO-�-
Septic System Designed For. �/ IZesidential Business Other
# Bedrooms � # Emplopees Other
System Type: ���'+� �'� S�e� ��� Nitrif cation Yrine: ^' Y�' k 3�
Date Installed: �"� �- g7 Certified Operator J[�equired: t�a
�n-site wastewater clisposal system shows no visual signs of malfunction on �-��- u5
Pezmission is granted
Comments:
,� � '�'�►.
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Y� 015 �- �rts.,.. wcQ.1 c,.i ��. Iw u�
C1�1)Q OJpl �Cis �n
�nvixonmental �ealth
I�ate: " 3" C7�
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, �r� Y .r'"'� . � � � .b- V � Ji
-�� .�:��,���:�.�.���.�.�..�.11 �.��t�<,�II�t.J�.
��aH�c��a�b �d�atIl�a��/ l�fo��fl�e �o�a� R������a�a���5
Tax Map #:-���
Approval Requested for:
Parcel#: 7i��6
Mobile Home Replacement
_,� Building Addition
Applicant Name: �j � rn G �f i � � ��t q �Ci (� �. - �,c�o d � S
Address: �p'j 2p n�� �� y� ,�
�v }C� �,r v V� c�� 5 7�f
Phone #'s: 3 �� � SS� � 7� � �
Permit Located: � Yes No
Installation Date: 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: � , _(date)
(Applicant's signature if site visit is not required) �'-`�--�.
A��g�o�/R��iz�c�a�a�n� �p��-�ve�
�P /`d�
Environ.menta ealth S i list Date
11/15/OS
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Ji�_7m.�3T�tJTrn �rmn ��`y�.�.�.� JL �1.���,:t.Z.
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Name ��� 1-�•� - i�� ��•5�,�.�, Tag ylap #��0 Pascel #� 1�'
Su ' ion ���^�`^ � Se�tion/Lot# `�
g- 3-�
Autho ed S e Agent � . Date .
� Systeqn cv�onents r�h�eszra� up�ir�xis�rate��niaurs onl,y. The contractar maust, fdag �he syst�raa prs�r to
begzmznin� the installa�n ta insure tdratpro�iergrade is maintairsed :
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P�G�333, ae�. 09/12/�1
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant }l�.�r��� � et�-� �ov�( S
Address 6 � ,�� ee___� �� County ��SUrL
Collected By � ��-- / ��/
Date Collected �� !� j Time Collected // � y�
Source: L �'ell ❑ Spring ❑ Other
Location: ❑ House Tap ❑Well Tap C46"fher
ONo Charge G�harge
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Total Coliform
FecaVE. Coli
Present
❑
n
Results
Ab�
C�'
Reported By � ���tLL.��� (Y1T
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