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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: z � � -------------------------- 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 ---------- -------------- � � 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 ' �1) � f r.� i2) �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$/Cement" Concrete Annular Space Width 1�---� Inches Water in Annular Space: Yes No Method: Pumped Pres Poured`� Depth: From �to Ft. Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes � No 4 x 4 slab Yes � No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN A ORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HE AR ENT. � Z qy Sig re of Contr tor Date (a :� - anitarian's -gnature Date Issued , Sanitarian's Signature Date Completed s Sketch well location on reverse side. `d � z ��� � �' � �� �^�'w' �' n� S'e �t c � �o�t�+ M I'10TE: Make sketch of instal atio showing lot size and shape, location of hou , se�tic tanks, privies, wa supplies, etc. Note special problems existing on lot. Write in measurements in order that installations be l�cated �t later date. Note location of water supplies on adjacent lots. �vo�l��•� ,. �. :, � :'. . ,.,. . . I r.-f FROM : D HUNT�2iP DORR PHONE N0. : 9199671F3683 Jun. 27 1994 08:29AM P01 � ��I�� �3��t� �}-t.�C�.r-�-G� �S , - 7 r � � ,�� . Site �valu�tian Application •Date: _�_ Fee Col�eeteci XES „� 1�0 _ _ _ �-1-�`� �. APPLIGATIQN FOIt IiS�''FtQV�E19T$ �+�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 .�� � - - ---�- - - ---._... --- -.. ...__ .._.�..; .::...-:..r.--..-�-�.....:� �. - . �.. ...�,,- . . . - : .. -. ::;:�� = 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) � � � � � � _ - .�_.__-�-- .�iannri Rwe] . A� Aiithnri�Pli J��P.nt �I �,ao1f�.� ��q -�� � � � ,�92�Z ��� G y l � �L,��. � 1E�1�1t�.� �1� - _� � � ��,-�-�- ��-��-4--- ----- _�..�.....b ��e�-�� pAobi� Flort� ) ;.:�.____ r,• , -•.: =:u��� - a�u � � � ..,..� � �.� � � � r�:" � • . ._:. . ` l �. _ �� :.. � I � " ;1_. � li�t. • �: • I� 13 ;Z�:!_�l j ..- !,:1��1� �� - _i�.. ��..:�s • G la :ll.. t i '� i � .:rwtll� • ?►I i�.3i+..� ►[' ! G� � �L l� � `:�i � ��a_�... = t�a.__ �►}, � � � -, i� i - . . • �. . , �� \ ���L. • : • �,..� ��� :� • - - - �■ � • - • ,( • � i - ��� r _ ����.� � �L�� �SoS�`!%� /�/1.�� �- 3} Pr�partp D�sip�ic Dire�crions to the {xo � ��s� ��c�rc� i� r ie� �a. t�•ic� r�=w c3 �ti]:���`L�3�/5�7'�l�..�_ .• �. " - - � - _ - � - •. . . .� , .. � ..r�� _ � �.:•ii • • _ • � :�� F► 1 � b 1� � 1 .• 1 I \ �:.� 1 • � 1 ■ 1.�� • �� I • 1 •• • F• H•-� • • +�'�� 1 �• ra - ' = G �� � _ • _ • • .• 1 •'. _ • L.- 1•"..� : � .: � �.•�� � ' � 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 �s� pfan. . . . , .. r �' ..�ll 1 i . •�. . �i � ! a � ➢ 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 STAF�. _ - • - ._ .�.. .- � . �. � �:: - o : : � � _:.� � •• � '�- - ._.�.. . � . _���. :..�_ .�•:�.._—: :.�; ., � _ _..`_ .�.,« ..:. . ..� _.� __ � -� � _ .... �_. � .� � �.. _... .r��.� _ � .. _•. _-:.� , .-... .�.� � _ �. . - .,.-...:.. . '� - . .. _: . _ � - - �� .•. . � _ � ��- . : • - - « ., , � . _ � ._,: ' _ ..• ti� • , ' �' ••" — � Ii�� • .: -..: - �.� � _ ,.-:� : � _��- �„•'- �.r� .• t/l 808LL659EE 41�caH �eluawuo��nu3 0� uos�ad WV iL�80 YOOZ/£0/ll � � ' € j.•� ' �a � 4 :�, \� � F ; � (� � .�``� � i � �li _ c r � r. u� c�. u t� r c c�G t. �� 1: .�i. (�'. �� �s — ..�u �� li I��i r �'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: ,� � '�'�►. � Y� 015 �- �rts.,.. wcQ.1 c,.i ��. Iw u� C1�1)Q OJpl �Cis �n �nvixonmental �ealth I�ate: " 3" C7� � �� � � � ►,a� �,�y^ , �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 :���;�� �� � �� � �' ��� ---.� �o�+�^��- �� Ji�_7m.�3T�tJTrn �rmn ��`y�.�.�.� JL �1.���,:t.Z. �� 3 A'•` J����. . 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 : �,�.. S c.�."L '� �Gc.+� ...-. G� r�Ga.a r"�O� 0 � �ic 15�'tr SI�rC.t. • %� � 7i..z U �J� -. . r — ...� _ �� Sy. - °� � I CY��n I � � ` � �v � . _ _ � .� r �1 ��' � CnC7 �'- -�Y`'^ � ��,g _ �/„ . .. �.S -} �. �,.-,.. c.�e�l ( w `�"''` �_��� rv,,,� L.a...�s.� , � �� v /f I�,ve o �- e�'s�'�, �� � .. . �, l, �� �.p�-,'�. 0 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 � v-fsl��� S��o �- ***����*�*������������*�*�����������*�*����*�*�����****��*��*���**�*�*���*���* *����*��****x�**����t�*�������������������*�*�*������*����t���*����*�������*���* Total Coliform FecaVE. Coli Present ❑ n Results Ab� C�' Reported By � ���tLL.��� (Y1T bactreport ,