A40 298�
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32� S. �'.o.►r,2n Strept � � �,
�+oxcoro. N.C. 2: �?u a,' %��' �- � �
'�C::"er �"?2-�3-15 D a t e
T.T( _ATinN F(�R SF.RViCFS
Improveme;its Permit.(Established/Recorded Lo[) I_ Reinspection of Exiscing System (Loan Closing)
Imci:ovements Permit (Unrecorded Lot)
Improveme�ts Permic (Mobile F-iome Replace)
Improvements Permit (Addition)
Re�air/Replace existing Septic System
_ Permit for New Well
_ Re�lace Existing Weil
l. Permit :equested by: . � "", ,,,' • . ",
owner/p; ospeccive owner/agent:
Address: � .�� s� . v�' /J h �
� A� �60/PO �1/'� �
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� Home P� ene =� • 3 �.�6 �-
¢ usiness Phone �:
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7. Dimensions or Proposed Structure:
�Victh: � �'
De�ch: %�
8. What type (if any, additions, expansions, or
repl2cement is anticipated to the structure or =acility ,
that this sewa�e disposal system is intended :o set-�e? �
2. Name and address of current owner: 9. Wacer suoply c}•pe:
_ ' t _ priva[e �public ❑ community ❑ spring L
Are any wells on adjoining property?Yes ❑ No (�
Ir so, identify Iocation:
3. Prope:ty Description: Lot size: �� ��C
. Tax Ma�• � `� � �
ParceIz: � `� 8
Township: � A'1` . �l v �' 'P
. Direccions to property: State Road �& Road
ames,�tc� � �� � �
10. Type of structurelfaciliry: Proposed: �Existing: Ci
Type of dwelling:
House: ❑ Mobile .Home: C� Business: ❑
Tyge of business: T R��< �= W�.��'
Number of Employees: �
I�Iumber of bedrooms: � �
', Garbage Disposal? Yes � No ���
� B asement? Yes ❑ No �If so, � of basement fixcures:
6. Number of occupants or people to be secved: a- �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI`iERS OF ALL
PROPOSED STRUCTURES.
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 propeccy. I agree that the concents 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 pecmit shali become invalid. I undecstand that before an Improvements Pecmit can be
issued, I must present a survey plat of the propeRy to the Health Dept. I understand that in the event I have not
delivered a survey pia[ of the property to the HeaIth Dept. wi[hin 60 DAYS aftec the date oE the evatuation of
the site by the Health Dept., this a�plication shall become void and all fees paid forfeited.
�:�,/�--�
Sign Owner or Authorized Agent
< �t� PERSON COUNTY ENVIRONMENTAL HEALTH
'�. �:��►SE SEE ATTACHED PLA�V �OR SOIL �►REA AND SYST�EM l
Tax Map #: � � � � Parcet # K L� �
Zoning Township �LL3.�f�=-�it�-C _
:,ppiicant: •
Location: �i%� /5� _
/ /��
Subdivision: �Gl� i Sec:�on:
�
Lot �_
Im�� �v�rrrant Permit
A buii�irq permii carnoi be issueci wich oniv an Improvement rermit
New ✓ Repair Addition _� Type of Structure Water Supply
# of Occupants ? # of Bedrooms � Other
Basement? �!o Basement Fixtures? �1'0
Projected Daily Flow: � g.p.d. Permit
Proposed Wastewater System Ty e:�
Pump Required? Yes �No
Prop�sed Repair �i�,,��, ' �_
Permit Conditions: i �� �6�ta�. n�uv� /
Fory�Five Years O No Expiration
Owner or Legal Representative Signature: �'7z`�� � v��`�'i^ Date: 'Z /� av
Authorized State Agent: (��,.� �,G�%�c2� Date: j� 3iJ -�
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 goveming 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 System (Required for Building Permitl
Type of Wastewater System _�� Wastewater Flow: ��g.p.d.
Facility Type: D- 1'►'� f� New�epair OExpansion ❑
Basement? O Yes o Basement Fixtures? 0 Yes _ No
Wastewater System Requirements �c.d�►t�
,��t�Ccd � I ��'� �, rr r
0
Septic Tank Size: -oUv gallons Pump Tank Size: _� {�' g Ilons , c�5
Tn5-�,.ticd qoo' .�� a_t5-c�o .�,�,,,5 �A
C�0.r�td Total Trench Length: � feet Maximum Trench Depth:�� inches Aggregate Depth:LZin.
�<<tn it Maximum Soil Cover: � inches Trench Separation: � Feet on Center
Other:
Permit Expiration Date: / � ���-6 �
Authorized State Agent: ��1'.t�� � ��_.� Date:�l�
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: �� 16�0 a
��� ���o � PCHD, rev. 11/18/99
• •t , .
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Appiication #: �_
Tax Map #: �-/�
Parcel #: �q�
Person County Health Departrnent
Environmental Health Section
5 r_=�
Ap icant's Name
��� �
- Authorized State Agent
SITE SKETCH
% '� ��v Qu.� `�� _
Subdiv sion/Section/Lot#
,�/: � 3� -��
Date
System components represent approzimate contou�s only. The contractor must flag the system
to beQinnin� t/:e installation to insure that proper grade is maintainer�
Scale: i� D Iv�
r _ _ _ � _ � l
�� 75 ���(
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PCHD, rev. 10/12/99
��
Person County Health Department
Environmentai Health Sectiona � �
Tax Map #: n 4� Parcel #:
Zoning: Township: i" ��f ���� r
Subdivision: � aKr� d k c� � C r� Section: Lot: ��
Applicant: �lC� m n'`� � Q W ��� n's
Location• �� F � ���
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
AUT RIZATION.
a a� �oa�
Authorized State Agent Date
N
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Tax Map #: Parcel #:
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c�` pESAc
, rev. 10/12/99
Person County Health Department
Environmentai Health Sectionr
Townshi /" ���� �I'V c �
Zoning: p�
Subdivision: �aKridqr /'�C�cS Section: Lot: �
Applicant:
Location:
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �_ �,� n ccE�or)
B) Distance from system to any wells 0 lus w�i i nDt d r� �<<d at �` �°�' SP
C) Distance from septic tank to foundation 1 U '
D) Distance from system to property lines 10 '
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank ✓
B) Visually inspect the interior walls, ba le, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture 1'�3'`J9
D) Tank serial number ,.57�3 /'la
E) Liquid capacity of tank 10�� gallons
3. SUPPLY LINE TO TR CHES
A) Grade � (1/8 inch per foot minimum)
B) Material supply line is constructed from ���� 40 P✓C
C) Diameter 4"
D) Length ,�-�"'
E) Distance from tank to drainfield/distribution device �1 �A� .
4. DISTRIBUTION DEVICE(S� /�
A) Type
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 o�`'r inches
B) Trench width � inches � �
C) Distance between trenches
D) Number of trenches 4'
E) Length(s) of trenche � 1`I � I �� I I,S`i 7 5—
F) Aggregate depth � � inches
G) Aggregate material and size �' S7
H) Record septic tank outl i elevation
I) Trench grade � (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step own �
c. Solid pipe used
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 ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �r �`�' Parcel # �� �
Zoning Township ��� /,��
e �
Applicant:
Location:
Subdivision:
Type of Water SupplY:
Requirements:
�
Lot: '"
Well Permit
Individual Community Public
Site Approved by ✓`J+�� 3'a3-oo
Grouting Appr9ved b� K -a,f'� o�
Well Log _ �
Well Tag 3 a3-�o
Air Vent �a3-oo
Hose Bib � � "a�
Concrete Slab � a3-��
Well Driller: �X�`�'
Well Approved By:
Date: ��a��� -
**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.
Other conditions:
PCHD, rev. 11/29/99
. . • • '
..,. `�,
Date: oo '
Owner. ��}MN
Location/Directions:
Subdivision N�une:
Drilling Contractor:
PERSON COUNTY ENVZRONMENTAL HEALTH
'� �41
WELL LOG
SR#
Lot # --�
�
�
WELL CONSTRUCTION ` --
Distance from Nearest Properry Lin� lU Distance from Source of
Pollution �C�b '
Total Dep.th: 1�O Ft. Yield: SCS____ GPM Static VVater Level Z�_}=�.
Water Bearing Zones: Depth �__rt._� F��_Ft�_C�`� _�t, q=].�-j-
Casing: Dept}l: From � to L�'�Ft. Diameter: Inch�s
TYPE: Steel � �GzlvaniZed Sceel ��
If Steel, does ownerapp:ove: Yes No
� Weighc: Thic�;ness: 1�_ Height Above Ground: l� Inches
Drive Shoe: Yes �No
Were Problems Encounterc:d in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement / Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . Pressure � Pourzei ./ . . . . ,. .
Depth: From_ � to 2-� Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
T.f mixture (sand, gr�l; cuttings) - Ratio: to
�ID Plates: Yes No � � .� �
�� 4 x 4 slab Yes / No �
►..
I HEREBY CERTIFY THAT THE ABOVE INFORM�'IZON IS CORRECT AND THAT
THIS WELL WAS CONS3'RUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERS0�1 C�LidTY HEALTH DEPARTMENT.
. Z �1 �
ignaturc of Contractor atc
North Carolina State Laboratory of Public Heaith
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: Austin, AI & June
Address: 189 Autumn Drive
Roxboro, NC
county:
Report To
�T=r:��•P
Person Co. Health Dept.
325 South Morgan Street
Roxboro, NC 27523
Courier: 02-33-15
Collected By: JOEL HICKS
Location of sampling point: well tap
Remarks:
Zip: 27574 $ QEC ,0 � �0V
Y �3
ATTN:
(336) 597-2371
Date: 11 /20/03
Source of Water: Ground
urce of Sample:
of Sample: Raw
of Treatment: None
�e of Analysis Private
Time: 1:30:00 PM
Parameters Resuits Units Date Analyzed:
Alkalinity as CaCO3 12 mg/I 11/21/03
Arsenic <0.001 mg/I : 11/21 /03
Calcium <0.5 ` mg/I 11/21/03
Chloride <5A mg/l . 11/21/03
Copper <0.05 " mg/I` 11/21/03
Fluoride <020' mg!( 11/21/03
Iron 2.62 - mg/I 11/21/03
Hardness as CaCO3 (Ca,Mg) <2 mg/I 11/21/03
Magnesium <0.10 mg/I 11/21/03
Manganese 0.03 - ' -:ng/I 11/21/03
Lead <0.005 mg/I 11 /21 /03
pH --- -- 6.3 � Std. unit 11/21/03
Zinc 1.4.1 mg/I 11 /21 /03
Date Received: 11/21/03
Today's Date: 12/1/03
Report Date: 12/1 /03
Ref: 16503 Login Batch: 03110045
Reported By: ��
Sample Number: A604061
�
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinkin� purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking putposes.
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 �vater supply.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below. •
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hazdness
No established limits
0.01 mg�l
No established limits
250 mg/1
13 mg/1
4 mg/1
No established limits
Iron
Lead
Ma�esium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mQ'1
0.015 m��l
No established limits
0.05 m��l
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1