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F�dsitnA _, �1'�Ipe cri S�aC � � �____M pepih -..� b) Ntrt�6er � 8sdraatt� _„ (�mbar c�( o�rp� a people io be �erve� c) ' 8ar�emenk Yas • Nn _ lA�t tt�r�e bs ptc��bbsg (n ttta b�asraant? • .. d) C�rt�pe Df�tk Yes ,_, i�n _ . :�} lili�t �'�YPx FrivaOe �. i� .._. d�' eod�tt$ �. P�udic_, �..,..� sWr� _ . �'�Y ��� p�v�sriy� Yos._ No ,.,, IlYe� t'�k�e �� �+ap� � an tt� ac't� pie�e. �p � tl�. p�op�' coo4la� pit,.�y I�i�d i��ott�i wa�? Yas _ rto r�,/ t. D� A PI.AY OF TF� �� g�T.E PU�N YU�i' AC �T7� WITi�i 'iHIS APPLIGATIDI�L y�,o�tnr ta� �t� c� �r ee c�.�.� �. �� et�oPos� �or�►�a ar� n�.,�.. �-r��� ��� cu�t r�.v►c�. � � T�1E �'T� 1�q,J8i' E�: RE�G�,Y i�l� ��►N gl/ALl1A'T'➢i0N 8Y TfiE tgALTN DR�IIR77E�.'T giy1FF. �' �Seb�t Reslo� � tio ttie P�aa C°uMY H�h De�rtrn�tt 1bt a si� � fi�c 11t� c�be - � �Y�rn 1br tt� ab�� pR;p�, ��� tlteat th� c�a af tftbs a�c�tlon ar+e hus and represer�the ma�rnrKtm �come t�v�iid. �� p . 1�ticber� ii tha � ia a� at tha i�herideQ t�e �1g� � p�� � '� `�' �"Ql+�Lt'�T�V� _ •7 .;Zc•—G,'� � � PI::tD. taM�.lOtt?101 � � ������' �'��..��� �___-. -. --,` � � � � � � I����a-��-,-,.-„ ��.�.�.IL IL-���.Il�� Applicant: Location: il ,� .—� �'�rffiit qlalad �or �iv� Y�ars Type of Facility: S :��� # of Occupants���of Be� Proposed Wastewater System: Proposed Repair: ��r, �%_' Permit Conditions: �x , �p . � ��r�:.� �# � � S�ubd,iv �ion ! � � h;as= Sect;ion:Lot r _ � � ��apra����e�t �er�t G�� G-�. �{ ►� � 3�u.1 iadoExpara4aon � o"t��^v�. r�:'�,�.,,�,l�z ��s;�1�P�:.r��:_ New�'Addition Wate� Su��i� z.��i/ s���� Projected Daily Flow �z^ g.p.d. , Owner or Legal Representative Signature: x Authorized State Agent: Type: �'.� Type: ��'� � Date: a - /6 � � s Date: �- �"'� � The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibiliry of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. 'This Improvement Permit is subject to revocation if the site plan, plat or the intended use ehanges. The Improveffient Permit is not affected by a change in ownership of the property. 'This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Systems' (15A NCAC 1��. .1900). Neither Person Countg� nor the Environmental �ealth Specialist svarrants that the septic tank system will continue to function satisf�ctorily in the future or that the water supply will remain potable. Aut�or�aiion to ���s�ra�ct �asge�a�e� Syste�a (�2equired for �uilding Permit) * See site plan and additional attachments (�. Proposed Wastewater System: ( �.���-�.�'��a�;.� New � Repair Expansion T e of Facili � �' YP tY� ��/" S:ie�:� /�_ ����-, � �• ��s� ���:.e1� 3� a- ��s- Type � Wastewater Flow �g.p.d. , Soil I�T�: �.3 g.p.d./ ft 2 Basement _ Yes �-No Wastewater System Requir��ents Tank Size: Septic Tank: ' c�'Ca gafl Pu��s T��: �- gafl Grease Trap: �— ga1 Drainfield: Total Area: '�.sq ft Total I.eng� .� ft 10�Iagimuan'I'�encfla I3ep�n 36 an g'reaach �'ad�► �_ �t l�anaianuffi �oi� Cove�: 6' an I)ist�abut�on: ✓ Distribution Box Serial Distribution Specafications: S rA Minimum Trench Separation: � ft Pressure Manifold Autho�nzesi State Agent: ���l���-� , 4��5'• � Permit Expiration Date: � � Date: � 5%' 03 The type of system permitted is � orlventional Innovative Alternative. I accept the specifications of the pernut. �Owner/�egal ���resentative: Date: �-/.� -o S PCHD 1/17/200a ���. � 11 Ji.a�� �Jl �1 . ^- ������ �c���-��.�.,a:��.ffi.n �.��.Il��. � SITE PL�iN. Name �i �s es' Tas Viap #�� Patcel # 3 9� Subdivision Section/Lot# /O� c g,� _�3 / Authorized State Agent Date System campoaents represent appmadmate conmurs on/y. The contrrctacmustllag tfie system prior to beginrting the iasrall�tion to insure thatpmpugrade is marataiaed i.:. "�: ' , � .�: YELL! � �T4� DR! V� i � 5t� R�1�' ._ � , - � $ �o, �� ��° �� L`� we�� � 73—�y ; �p� ' '' . �¢ l'?D IJD � � �ial2 f%m� _ , � � %�%d �� � v. f ia G � �S/ �� % �/t?.S . . � L�-� / Gi �o;C, c.� .�s slr.OcJr w �o - s,7; � � ..� b� � � - :k.s�� 4 1 � ak- � � � fl ��j ' i � ��. w �u, � � , � .. W � . �-��c � � . : v , � C� �-1?-05 �. .A n o .. � �e�u�:r r�/'ea � . • � �— ' . . 535 � �`oNv �%ne � 30 �'.yi�;�;Gt�rfo�ti : ��� � . ��� 3 b�- :''� � �`�`v � � . � . �,S 1�/a7� r� � � - - � � � ,�✓�a , r� ��j �a � { ' �.���� � '+J� � i��. , . . . . ��a Scale: I �� 5 � � PCHD, rev. 09/IZ/Ol ���� �� ���� �� `�.. � ' � � � �� Jl 1L � �n.� a- � � a� � � ��.11. I�—� � �n.11. �1�n. T�x M�p � / � Parcel # � � Subc{livision / ' ! �. � Ph�s•e Sect�i�on Lot # I � # of Bedrooms �, �'� =.�: ' �° : : : :.' " ',�� : � System Type (in Accordance With Table Va): 1�4 THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLtPlA GENERP►L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND COi�lSTRUCTION AUTHORIZATION. , . 3�zr /�S Autho d tat Agent Date I nstalled By: ���i -� Date: �/Zl �b S io,7a 10.7 ' � ►O,i�• � - ��6i , ,. , 4��„ ._ T ���--s `�� ='-'Gc�K. � �-� � �. a" <L . �� � � I�t�Y1 u 4.G l �- yp - p,,,4 � /�" t'�'� � l DO p /� 6 � `��"T r � `} Z O. �� PCHD, rev. 07/29/Q4 �E�TBG TAiVK IRISP���'aORI C�iECKLlST (TyPe. ll - I!/� Tax Map #_� Parcel # Sysiem Type (Tabte Va) Owner/Applicant Subdivision Address/Location Sec/Phase Lot # State ID/date ��� l�Z Capacity � /��, c Tee and Filter Baff1e Sealant Riser (if applicable) Tank Outlet Seal Permanent Marker Pump Tank t,ct ctt:lty t�a�. Water roof /Seaiant � Riser Water Ti ht Pump Check Valve/Gate Valve Ant�-si on o e Floats/Switches �11arm visable and audible Electrical Com onents � � Rate m A roved Pum Model Block Under Pum Pum Removal Ro e/Chain ��Distribution. System � Serial Distribution ressure ani o Low Pressure Pi e A r. Pi e Maieriai. and Grade Valves - z� ; �z Trench Width -� ft. � Trench De �th 2- o in. T,rench Len th do �- Trench Grade - Trench S acin � � Rock De th and Quaiii / Dams/Ste downs etc. � Pressure Laterals � ,� Hole Spacinq Sleeve Required� Setbacks From Welis - From Property lines � Surface Waters Public Water Suppl Vertical Cuts (>2 ft. Water Lines Vehicle �Traffic Easements/Righf.of W Other Easements Recorded e e perator on Tri-Partaie Agreement Comments � pct�d rev. 3/13/01 : ���.��' ������ ._...—�=�,� c� � �J���" ������� ���.�� ���.���. w���. ���� 1���� ��� ��"�'AG��D �'�l� ��� �I.I. SI'�E ����J'�' 'Tax 1@ida� #: � �' C Pa�c�i # J � �' '�owns�aip ���. �� .�i�'vr>r Applaca�at: .�� s3� �:i � ��u�.��i � Subs�vd�noaa: � r� ;^,'cf�• � h`t.'r'��: Se�tloIIa• I.mt• �� 6 �ca�ioaa• . Qo-• �nS�o..�.� � 2 - Q '�'�e of'Water Su��l� �ndiv�idual Re��aia�e�ne�t�• Site Approved bp � S � -7 -05 Grouting Apptoved bp �S 3-`7 -05 Well Log �S �-9-0� Well T � 3 21 a� Air Vent Hos� Bib Concrete Slab i� 3 -7' � _ Community IL:) Ab We�fl Drayfler.�crncZ�� 1�s�9.� �.\ W�ll Approves� � . Da$e: � ' '�Se� Ai��es� Site Sketc9g� Wells must be 10 feet from propertp lines. Wells must be 100 feet from septic systems. WelLs must be at least 25 feet from any building foundation. Other conditi .p �r p� �, I�y (., � PCi-ID, rev. 09/07/01 Barnette Well Drilling Inc �36 598 9275 03/08/05 06:23P P.001 ��� S . � � OD � �l' � ...��,.4 � . ����� o fl c�Qt�,� �� - - � �� : � �� ��� � � a� ]F.rsh�vu�-�.s.a�rna��cn.�{o.A' ��a��l[�Ila � ��� � � ���i� Grout X.og Owner: ,��C�.�kl1'I�l, �l'' �C—r��u� � Tax Map, f/U Parcei #� c�� Locaaon• Subdivisian• �� t �t � `/C' G� Well Construetiou I�istancc �rom nearest �'xoperty Litte {Minimum l0 feet) l U Distattce from S tic System (Minimum 60 feet) U Total Depth: �� Yield: .��G� GPM Static Water Le�eX: �S � ft Water Bearing Zones: Depth��� ft ft f� ft Casfng: Dcpth: From ��� to ��� ft. Diameter: � in Type:�Cr.tiva�ized Steel .�/ � Weigh� Thickness: ��Ieight above Ground: 1�� in ririve Shoc: Yes No �1ny proi�lems encountezed wk�ile setting casing? _Yes /No If "yes" givc rc350ri' � Gmat: Neat: Sand/Ccmcnt Cor�c;rete GravellCemerxt � •. Annular Space Width inches Watcr in Annular Sp�ct Yes No Mzthod of Crrout: Pumped �'ressurc .Ipoured DepCh _� to ,�_ k't 1V��texials Uscd: , No. Bags Yortland cemen.t � Weight af 1 Bag Pounds If mixtiu�e (sand, gravel, cuttings) -- Racio to A� plates: �,,,�es � No � a 4 slab l'Ycs _ No Liner: .. Depth: Date �itstalled: � Crrout: � Installed by: _ Drilling Lo� �.ocAtion �rawxng J�rom To Form�tio `'� ' , L _. . � t �P. � C ��f=' 7� Q �• � � O t^ `� cy . �J�, � Gi � '-�J� � '��y�� w U � . � � ��� I hereby certify that the abovc: information is earreet and that this well was construeted in accordance with rcgul�tions s�t forth by the Person Co�mty I�calth Aepartment� ��' . Si�natnrc of YD # �� Dute :�� � yC� S Pnmp xns#allment �P lnstallation C;ontractor_ �LyL�.�� ���=� State Rcgisiration Numher: l�° y pu.mp. Depth: � U ft S'c W�ter Levei: �� S ft Pump Make & Model: - 1 Pump Size and Rating: �_hp � gpm I hereby cCrCii'y that this pump was installcd and thc well read complcicd accordin� to the Person County Well Rules in effect on this date and th�t a� of th;s rPcnr has been pro ' ed to the wcll owner. . �'umu �stali�r Si�naiu� � ', .� . � " Datc: � � 7'C� � PCE�D revQl/�7/04 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant rJ�►'��� ►'Q %-� Ur/�u� Address J�� ��/����� 1��Y� Lf'� County �'c5C71 Collected By�1� '�; , Date Collected o1 �4� � ��, Time Collected / 1' I"7 C��� Source: C�Well ❑ Spring � Other Location: ❑ House Tap �IWell Tap . �No Char e ar e g g ❑ Other /(�, � 3 ! co V �., **���****�*�***����**��**�����**��**�����*�***���*�*�****���******�****�*��*�* �*������**��*�������**�****���*�*�*�*���*�**�*���*****���***����**���**���**�� Total Coliform FecaUE. Coli Results Present Absen ❑ p � Reported By ��1�� ���.J, rYl 1 bactreport 1�� ��. ����$ Q� .�