A40 287�
Amount paid �.SJO.Uv ��i �vts
Rece i�p [ 1� � �20( 1 �
,� � �$� Ibll�l �aA� L
�
�
�
3-/5-9�1
Da ce
�..;.:T.. . -:i::;:;;•-,a�..;r-
:•.��"�' . . '•� r�.>>.. '�:'.:.L..• ..
Zmprovemcncs Pecr;�ic ("rstabiishcd/Reeorded Lot) _ Reinscec:ion o� Eziscing System (Lo�n Closir
Imasovements Permit (Unrecorded Lot) _,,,_ ReaaidRcpiace existing Se�cie Systcm
[mp�o�emcics Permit (Ivtabile Hame Replace) � Pecrait foc New Watl
Improvemcncs Permic (Addition) � _ Replac:. Existing Well
w i�.1'.. '�'n'd�.►���i�:t�w,.yN.s:; � n,,;. ;z� {, �. i,1. . ,u; •,;w-� � ., Z �„�,,.. ..: �y•�:r ...�:a►;•.,• �?a�"`:'�..%�++"*i�
•.B["::A��...>. .:�����• ��"• �ri•eat �`t`.L.�.,�,,,...:.y;,;%;� .Zi.'''ali
��•?x;;.,:..,,�,� ,,� � �:;�Y.�� :�: aEes'� tripl'e�o�be��oll��ted_;,:�,�-.:�'��.-r�M,...,....:�3•:��. �
,......� :�..._
_ $acceria _Chemicat _k'etroleum � J Pcsticidc ._..Lcad
1. , it ceques:ed by: .
�wner pcospective ownc:
ress: � '� � � i���
�
�
�. �
,� Hamc Phonc �: �. �/ �/- �.�-� �
� usiness ?hone R:
a
z
7. Dimensians or P:o�oscd Stn:ccurc:
W icth: _ _
Deach:
8. Whac tycc (if any, additions, cxpansions, or
reoiaee:nenc is anticiaaced to the structure or facility
that chis sc�va;e discesal system is inteade� co serve
I /�n,�IF
Nanmc and address ot,c::rrent ownc� 9. Water sug.oly ty pe:
�) �d� /Yj�% ,���u��C //15 PfIYS[CyQ public❑ communiryQ s�ring❑
�?-�/�� ��—!�u r�llr' /n �/( 5/c� Are any wells on adjoining pcoper.y?Yes 0 No �'
�'r� �bore /Y � �� �03 _ If so, idencify locatioa:
. Pro
n: Lot siu:
. Tax Map#: 0 �vZ� 9
Parcel#: � �
TowttshiP: F�,� �� r
.� Dircctians to pcoperty: State Road #& Raad
�a1iCS r�'+LC. , , 1 n i. � /
0
0
IQ. Tyge of struccurelfaciliry: Proposed: (�Exisdng: (
Tyge aE dwelisng:
House: �'Mobii� Heme: Q Business: ❑
Typc of busincss:
Number of EmQloyees:
Nurtiber af bcdrooms: �
G�rbage Disposal? Yes ❑ No �1
;Basement? Ycs ❑ No� If so, # oF basement fixtur�
6. Number of occupants or peoplc ta be s�rved:
CLEARLY STA� ALL CO�NERS OF THE PROPERTY AI�ID THE CO�IERS �� ALL
PR�POSED STRUCTURES.
I hcreby makc applicatian to the Pei'SOA COUAtj� ��Ith Department fvc a sitG evaluation for thc on•s
sewage disposal syscem for the gbove describod property. I agrce that the coR�eacs of this application ata ttuc
and cepresent the maxirnum facilities to be placcti on the propeccy. I uaderstand if the site is� altered or the
intended use changes. the pernut shall become invaIid. I undetstattd that bcfore an Imgrovcmcnts P��<< �n
issued, I must present a survey pl�t of the progerty to the Health Dept. I undersca�d that in the evcnt I hava n
deliveced a survty plat of the pcopercy to tha HeaSeh Dept, within 60 DAYS aPter thc datc of thc evaluation ol
the sita by thc Hcalth Dcpc.. thj,� application shalt becomc void and all fccs paid forfcitcd.
te 3�dd
�
• � �cghcd pwner er Authorized Agcn�
9NINl�Z QNd �NINN7�d 6ELTL6S
6V�Ei 666I/80/Z0
- ` ''. Am�un t
'� '__Receipt
�.cf �
�
H
O
-`" QO�.�p-q � ?Fr.s�.r c;�urry =�sith ��:::
p a i d`.<^,`��� =l C a 32� S. �v'.or,2n Street
;� . _ j3 �oxcoro. N.C. Zi57�
� —�{�' 10 C�C:t.^er '��i�..:3-15
Ic�. I J`'O�C�J
� �� � ��
� .s :.c �-Y � ,.:.
s
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1 v�-0 " / �
Da te
_ . ' _ . > . -. � K!;. J.. .. ,
Improveme;�ts Permit.(Established/Recorded Lot) �_ Reinspection of Exiscing System (Loan Closing)
Imaovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Eacteria � _Chemical
RepaidReplace existing Sepcic System
_ Permit for New Weli
�_ Re�lace Existing Wetl
�mplewto �be Collected t X `' "`
.���: � w
_ Petroleum _ Pesticide
l. Perr•tit :equested by: . S�n'�' y��'9"`"�'��' 7. Dimensions or Proposed Structure:
owner/prosgeccive ownedagent: ��licth: � g
Address: �_YSS� �i�.�.p�j /liif�`s/�p, De�th: �° .
���
J
w
� Home P� cne =;: 3 �`� �r��
¢ usiness Phone �: '�
a
w
�
z
_ Lead
� s 8. What type (if any, additions, expansions, or
replzceme�[ is anticipated to the structure or `acility ;
t�at chis sewa;e disposai system is intended :� se��e? �
.� Name and address ot.current owner: 9. Water suoply type:
C� Pr/� %� � A G F�i. �C !�i �S 1-�- � privace t`-'�. public ❑ community ❑ spring `
N � r- F 1� D r�1re any weils on adjoining property?Yes ❑ No L.�
Ii so, identify location:
. Prope�y Description: Lot size: I, 0 O.4 �.
. Tax Ma�": .� � � �
ParceI� 02 8%
Township: ��'� 7 ' � � v � �
. Directions to property: State Road n& Road
iames,gtc.. , _
v/-/
Number of occuoants or
ys
to be secved: �
I0. Type of stcucture/faciiity: Proposed: �Existing: G
Type of dwelling:
House: ❑ Mobiie Home: C] Business: ❑
Tyge of business: � o � s�- G W% p�
�lumber of Employees:
I�Iumber of bedrooms: ��`'�'
Garbage Disposal? Yes �No
Basement? Yes ❑ NoQ'If so, � oE basement fixcures:
CLEARLIT STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOII COUTIty Health Department for a site evaluation foc the on-site
sewage disposal system for the above described property. I agree that the contencs 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. I understand that before an Improvements Pecmit can be
issued, I must present a survey plat of the propec[y to the Health Dept. I understand that in the even[ I have not
delivered a survey plat of the propecty to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shail become void and all fees paid forfeited.
S
r or Authorized Agent
��.� /h � P �3 -- �{o
•'�
'' - PERSON COUNTY ENVIRONMENTAL HEALTH
F�E��� �EE ATTACHED PLAN FOR SOIL Ai�EA APVD SYST�IVI LAYOUT
Tax Map #: �" �f 0 Parcel # ��
Zoning _ Township f/
Applicant: � ��1 �1( e.l �-. ,�d �ls`t-i AJ
LocaUon: /��� '
8ubdivisio.^.: _ Section:
Let: ,�
�riprovement Permit
� buildi�q p�r��i car�r�ot be issued rvith onlv �n imprdvernent �ermit
New �Repair Addition __ Type of Structure Water Suoplv
# ot Occupants # of Bedrooms t1�' Other
Basement? _� Basement Fixtures? _�
Projected Daily Flow: � g.p.d.
Proposed Wastewater System Typ
Pump Required? Yes s/
Proposed Repair : CtltnV�llTlc
Permit Conditions: T_NS�1,G sV
Valid For: ive Years ❑ No Expiration
Owner or Legal Representative Signature: 1� e..., ; 1t �1��.✓�� Date: ( 2' 3d ' R�(
. . 2 -�v v
Authorized State Agent: -S�'��/�_D��� Date: / �1
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permit)
Type of Wastewater System (.C�h,�By►�i�rlcP �p, Wastewater Flow: -�� g.p.d.
Facility Type: �Gp -ih!¢ New �' Repair OExpansion ❑
Basement? 0 Yes �No Basement Fixtures? 0 Yes� No
Wastewater Svstem Requirements
Septic Tank Size: �DV� gallons Pump Tank Size: N� gallons
Total Trench Length: .�3,� feet Maximum Trench Depth: Z'� inches Aggregate Depth: f� in.
Maximum Soil Cover: l� inches Trench Separation: � Feet on Center
Other:
Permit Expiration Date: /7 � 3v -��f
Authorized State Agent: ������� Date;%�'3v`I'%
The type of system permitted ❑ does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signature:�� Date: � ' -3� - � �
PCHD, rev. 11/18/99
Application #: .�����
Tax Map #: —���
Parcel #: ��7
Person County Health Department
Environmental Health Section
SITE SKETCH
�c� � ,�i,��� .���, ��� �` �
Applicant's Name Sub ivision/Section/Lot#
,
/� "�k�� %�/����`✓ ��— a�
Authorized State Agent Date
System components represent approzimate contours only. The contractor must flag the system
to bePinnin� the installation to insure that proper grade �.s matnta�ner�
Scale: % � �%/Ob �
,�2�;
�
,
;
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section��� 2� vc�
Zoning: Township:
Subdivision: �aKr� �aC i�"C ie S Section: Lot: 9
Applicant:
Location: �-uF� �0�` d
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements ✓
B) Distance from system to any wells ' I�� (,wetc not dr� ��td �t ���rnr. oF � nspz�-����')
C) Distance from septic tank to foundation 1 O
D) Distance from system to prope�ty lines 10'
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank �
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outle ��
C) Date of tank manufacture ���
D) Tank serial number S TI.� I Y a
E) Liquid capacity of tank �O(� O gallons
3. SUPPLY LINE TO TRENCHES
A) Grade ✓ (1/8 inch per foot minimum)
B) Material supply line is constructed from .�� 40 P��
C) Diameter � �
D) Length
E) Distance from tank to drainfield/distribution device N�f}
4. DISTRIBUTION DEVICE(S)
A) Type N / �'
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth �_ inches
B) Trench width �Cs inches �
C) Distance between trenche �
D) Number of trenches
E) Length(s) of trenches �� `I� 1�S`i� I`� s
. F) Aggregate depth 1 a inches
G) Aggregate material and size �J1
H) Record septic tank outle elevation
I) Trench grade (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed arth N�R
b. Proper rise over step down �h_
c. Solid pipe used N/A
d. Elevations of step downs //} (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Tax Map #: � 4'� Parcel #• ��T �
Zoning: Township: ���t �� Jc r
Subdivision: ��r�C�G� I �Cr� Section: Lot: �
Applicant• VC �"1 � e f Z-' ►'i Lis�'��l _
Location• �rI.�FF 20� `�
Operation Permit
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
��,,�,� a a �-ao� �
Authorized State Agent Date
Tax Map #: Parcel #:
O� �� � ���� PCHD, rev. 10/12/99
Iv
Tax Map #:
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Parcel #
2oning __ Township
Applicant
LocaUon•
Subdivision• SecUon• �O�
Tvpe of Water Supplv:
Reauirements:
Well Permit
individual Community Public
Site Approved by ��S 3� �' 0O
Grouting Approved by
Well Log
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller: 1�-D • � �hh�,`�
Weil Approved By: Date:
**See Attached Site Sketch**
Welis 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.
Other conditions:
PCHD, rev. 11/29/99
�� �
� �t� �
`�'+ � �� � ���'�
J.ir:�']IlZL�''ll<La�CD]Ch7t'II�i1�sRT1t�,t�..�� �L: �l�£+�s.11�;.��il
Date: �/ � �� /�
Name: J�sSi('� 4/�`�Su�� �12•e9,��v,��
Address: `3 l ��E �,,,,,,�► � r ,
e r�-, � S_�
Re: Bacteriological Test Results
Dear Well Owner:
Tax Map: �� Parcel: �_�
Your well water was sampled on (�/ lZ/ l�, and tested for both total and fecal coliform bacteria.
Your water sample test results are noted betow:
No coliform bacteria were detected in the sample. Your well waier is safe to use for drinking,
cooking, washing dishes, bathing and showering, based on the bacteriological results only.
� Total coliform 6acteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliforrr bacteria are naturally found in the �oii. Fecal colif�rm bacteria are associated with
animnal and/or human waste. The presence of either total or fecal coliform bacteria in well water may
indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated
groundwater may be entering the well. If coliform bacteria are present in your water sample, the water
snay rot be safe for use. Young child: en, tl:e elde�•ly, and the individuals with compromised immune
system.s are especially vulnerable and their physicians should be notified of the test results.
A well that tests positive or total or fecal coliform bacteria should be properlv disinfected and retested
prior to resumin,� normal use. The well may be disinfected using the enclosed disinfection procedure. A
weil contractor or plumber can assist you if needed. Once the chlorinated water has 6een thoroughly
flushed out of the system, please contact the Health Department to request a re-sample.
For additional information, please feel free to contact Environmental health at 336-597-1790. Our office
hours are 8:30 to 5:00, Monday through Friday.
Sincerely,
� ���
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Perso� Counry Environmerrtal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fac 336-597-7808
�
�
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �` �� � p�s� �"� ��`'P�
Address ��� c�5 �-��n�.� h• County � �e
Coliected By
� / f
Date Collected �l 2� Time Collected l Q`��
Source:`�Well ❑ Spring ❑ Other
Location: ❑ House Tap �llleil Tap ❑ Other
❑ No Charge �Charge
�3�
�`�0 °�� �
..............................................................................�
*******�********************************************************************
Totai Coliform
Results
Present
Fecal/E. Coli ❑
Reported B
Date Reported �• / 3" � �
Report Called YES ❑ NO
Called To � �" �i � , %�-ei?!l�
Absent