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A40 38The District Health Deparfinent Orange, Person, Chatham, Lee Counties SEPTIC TANK PERMIT DatP l � � ��,�t,� ame of owner —*� �� " � � "� �� 1' %' �. . 1 � ` �:� � ,. � �+ and Directions �� -�:�a� �' '',•' ;��`- {-" `` ,.�- _ �_ 1 .;r�` .�� *r � . �r".-�— � P , Person or firm doing installation: �� . t� ��, ►t, .+� ..� f f . Address �� .r,�a� t:',rJ� l�r*•.,� . No. of persons to be served —g�� bedrooms 1,�2; 3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine Minimum Requirements: Septic tank �Y � ' _ ' � ::.;ti �� z` it � . J .,,r� ; , i, , ., f i Nitrification line: ! Septic tank and nitrification line must be inspected and approved by a member of the Health Department staff before any portion of the installation is covered. Date Approved: ! By. _ � � � Countersigned (Over) r ]A �� `� - �' �v� } �j � ti i' .,� �� t r.. P , r �:. �ni rian � �� O. David Garvin, M.D., M.P.H. District Health Officer �VOTE: Make sketch of installation :showing location of house, septic tanks, privies, water supplies on � adjacent property, etc. Write in measurements in order that installations may be located at later date. � : ... � ,� �' �� . ,_a,, ,...... ._ ..,�...�.9.� �,._...,� . _.�.. ,,, . „�... ,.... _.�... _--a' - ,. .. . ._.. ..._- -. � � . 00 �� ,/� �i �� c � � �� a � � Application Date: O" ��'6 �-- � Tax Ma #: � � Amount Paid: __� �j �4 �e Rec�ipt #: ��_ � Parcai �: � �� ..� �� , ! 6 3 � = --� cC � �LS1� �" �Y � 2'� �aa�-aa-oaa�-� �aa�a� g-�om��71.a � � Y APPLlCATION FOR SERVIC�S IF THE INFORMATION IN THE APPl.ICATIOiV FOR AN IMPROVEMENT PERMIT IS INCORREC�', F�,LSIFIED� CHANGED OR iH� SITE IS ALTERED THE,� THE IMPROVEiIAENT PERMIT AiVD AUTHORIZATI�Id TO COMSTRUCT SHALL BECOME INVALlD. �� .3�� 1} Permit requested by: (Own agent/prospective owner): �• "'� J �j �1 Home Phone: (�G li � 3€- l0 3( Address: � c-� Business Phone: � 1 -�Fi-�q � 2) Name and address of current owne�: SrQ _ 4 '�z q• r��r 3) Property Description: Lot size: � Township: ��_ Subdivision: Lot # Directions to the property (Including road names and numbers): �� 4 1 f-� �-��' 4) Proposed Use and Structure Description: answer each of the followin- g��stt�ns: a) Proposed _, Existing �, Type of Structure: �-(o�� Width: Depth: b) Number of Bedrooms: 3 Number of occupants or people to be served: _�_ c) Basement: Yes� No Will there be plumbing in the basement? d) Garbage Disposal: Yes , NoDC 5) Water Supply Type: Private �, (new � or existing�, Public , Community_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site plan. � 6) Does your properly contain_previously identified jurisdictional wetlands? Yes_ Ido� PLEASE iVOTE TFIE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PL.a►iV NIUST BE SUBMITTED WITH THIS APPLlCAYIOM. ➢ PROP�RTV L1NES �4iVD CORNERS MUST BE CLEARLY MAR6CED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST.4KED OR FLAGGED. 9 THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE liEALTH DEPARTMEfVT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. Cwner or 2 ZdoZ ate PCHD, rev. 06/27/02 �� 7� )'� �� l � . � �� ]E��s-��.�•��¢.�.]L IE7T��.Il�1}a SITE SI�TCI� N e c C�M � -- Sub ' ion Authorized State Agent Tax Map #.��,.Parcel # �� Section/Lot# -1 -� Z Date System components represent approximate�contours only. The contractor must, flag the system prior to beginning the installatio'n io insure that propergrade is maintained . ��pG p,,,�,�,,�,,� S �� C,�c��+ � %�n� �� f �elv w � � � �� S� �� '�` � _ � � , � Scale: Q � _. pGHD, rev. 09/12/Ol North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Huff, William Address: 1061 Huff Rd. Roxboro, NC County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27523 Courier: 02-33-15 Collected By: MERLE TERRY Location of sampling point: Remarks: Zip: 27574 ATTN: (336) 597-2371 Date: 2/19/2007 Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: Type of Analysis Private Time: 11:05:00 AM Parameters Results Units Date Analyzed: Alkalinity as CaCO3 52 mg/I 2/20/2007 Arsenic <0.001 mg/I 2/20/2007 Calcium 19.4 mg/I 2/20/2007 Chloride IC <5.0 mg/I 2/20/2007 Copper <0.05 mg/I 2/20/2007 Fluoride <0.20 mg/I 2/20/2007 Iron 0.25 mg/I 2/20/2007 Hardness as CaCO3 (Ca,Mg) 52 mg/I 2/20/2007 Magnesium 0.9 mg/l 2/20/2007 Manganese 0.12 mg/I 2/20/2007 Lead <0.005 � � mg/I 2/20/2007 pH 7.1 Std. unit 2/20/2007 Sulfate 15 mg/I 2/20/2007 Zinc 0.78 mg/I 2/20/2007 r � � � � T `� _ _.: _.'� � .rP_ �i/ i ' MAt� � 3 2007 i3Y; Date Received: 2/20/2007 Report Date: 3/10/2007 Reported By: Today's Date: 3/10/2007 Ref: 2459 Login Batch: 07020038__ __ , Sample Number: A653342 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. _ Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 � PERSON COUNTY HEALTH DEPA�2TNIENT 3�Sa SOUTH NIADISON BLVD. . ._ ..__ _ __ _ _ ___ _ - -- - - .._ __...._._ _... . _ _ ROYBORO, NORTH CAROLTN:� 27573 - � � BACTERIDLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant �1V� ��Gc�v. /`� V7'� Address �� j � �vt� K�. County �C..ei�o,1 Collected By �,P/1 %rri/ Dzte Collected .2�L�7 Time Collected_ Source: Ly'Well ❑ Spring O Other Location: ' ouse Tap �Well Tap o Charge ❑Charge ❑ Other /: oS �***�********************�***�********************�**********�*****�******x*** ��t*�*******��*************************�t****�*�t**�**�****�****�******x***�**.** Total Coliform FecaUE. Coli Results Present Absent � � � �� Reported By c��1�' `n�� T bactreport � �' ` �� oo � 6 ��,5� ��.�� e . . , � :- . �--' � � � ��-� � ( � n p� a� � l I� �c11� 1,� L LL ��a�-.m�.,m„ ��.��.�. ��.a��. D�o Dr��(la�� /n - /� -a2 I, /.� Well Log Owner: i.-%� '►� i''� �'r u� Tax Mapf� ��a Location: Subdivision: Lot # Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: �_ ft Yield: s'O GPM Static Water Level: Water Bearing Zones: Depth 9 5 ft� lC� ft I lS ft ft Parcel # 3 � 0 Casing: � �% Depth: From -f � to �,� ft. Diameter: ��Y in Type: Galvanized Steel Weight: Thickness: Height above Ground: ��z in Drive Shoe: Yes � No Any problems encountered while setting casing? Yes liVo If "yes" g-ive reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ Materials Used: Concrete GraveUCement inches Water in Annular Space Yes Pressure Poured No. Bags Portland cement Weight of 1 Bag If mixture (sand, gravel, cutti.ngs) — Ratio to ID plates: Yes _ No 4 x 4 slab _ Yes __ No Drilling Log �� Depth to Ft. Pounds I.ocation Drawing From To Formation � C� � � 'S��c�f.�,"l�s `Z � �3 , ` / �r �— � � 1/c(�vnCS g/`'�e"c X � I hereby certify that the above information is correct and that this well was constructed in �ccordance with regulations set forth by the Person County Heal Department. .t Signature of Contractor �a �� S ID #� 7� Date J� -� t( — D� PCHD rev O1/16J02 �� ` � � �J �� I��a-�� .�,Il ��.Il�. iW�LL PE�T� PF�ASE SEE A'I'I"�1�fiED PY.AN F�� WELL SI'� I.�YOUT TBx Map #: � Pazce1 # 3 v '��p �n�� `� ,i s�o�: s�o�: �� '�'y,�e of W�.t�r Su�ul�: � Iridividual Commttnitp Public Requirem�mmts: � Site Approved by E- Grouting A roved bp �� Well Log Well Tag; Air Vent � Hose Bib Concrete Sla� Wed� I)riller. �� Well Approved. �p: I}ate• '�°5ee Attaciied Site Sketch'� Wells must be 10 feet from properry lines. Wells must be 100 feet from septic systems. WeiLs must be ax least 25 feet from any building foundation. Other conditions: - PC��, =ev. 09/07/Ol