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. Person County Health Department �
Sewage System improvements Permit
Date:�� This Permit Void After 5 Years Permit #—�F�
Ovmer: �-��ye Q�� vh�/p Yc%� SR# - f?�
LocatiOn/DirectiOns:
�.
�._
Subdivision Name: + I,ot,.��'J� __
Lot Size: —�L���w� T of Dwelling: `� -_.} i
�
Water Supply: �rivate: —�_ Public: Community: _. _ _r_.:. _. .
Bedrooms: -j Garbage Disposal '
Basement Basement Fixtures
INFORMA D
Sanitarian: wn or repres�,tau�
REPAIIt: REEVALUATION:
Size of Septic Tank: ���� gallons Size of Pump Tank: ,�
Nitrification Line: � � ' �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: _ ► _ . l , . .. , i� i
-------------------------
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
�CERTIFTCATE OF COMPLETTON r„3
Contractor. �� t �—e�J;��' �
------------------------- �
�
Sewage System location, installarion, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrifcation line must be inspecteci and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this perrrut is subject to revceation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
Site Evaluation Application
Fee Collected
YES�
P� � f.;-=
Date: � ' � O l I �
NO
APPLICATION FOR IMPROVIIiENTS PERHIT
1. Permit requested by: owner/prospective owner:
h2�/ agent:
Address: I�-�' � r>C�(�32-�
2.
Home Phone ��: G �q _1� �� �('';�� �
Name and address of current owner:
Business Phone ��:
3. Property Description: Lot size: i 0
4. Tax map ��: �� �.bTownship: C���
Subdivision Name:
S. Directions to property: State Road �� & Road Names, etc.
%f � c�
Lot ��:
;^ � m
6. Permit requested for: New Installatio�_ Repair:
Additional Renovation re-using present system:
7. Number o£ occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: Depth: ` i
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10.
11,
�
m
H
w
�
�
w
Water supply private. public? community? spring? .�
Other source? (Specify): �
Are there any wells on adjoining property? If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: Housei�_ Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No�If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
�
Signed er or Authorize Agent
Ir
0
rt
a
Permit Issue�l +
Permit D�enied ,
Plat Obse�rved
��� � - �D D � x 3 �
�
�� S ���
% '�
j �
� �
7'{�� l S.� u � � -
�
- SITE EV,
1. SLOPE (X)
2. S�IL TEXTURE (i2=36 i.n.)
(Saady, loamy, clayey,
Note 2:1 clay)
?.. SOIL STRUCTURE <12-36 i.n.
(Clayey soils)
4 . SOIL DEPTH (in. )
5• RESTRICTIVE HORIZONS (in.
(Ia�ervious Strata� rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
S
'U
S�
S
�
U
$
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AREA 1 AREA 2
. S
U
S
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U
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U
U
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U
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ARF.A 3
S
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U
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PS
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S
PS
U
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P$
U
$
PS
U
S
PS
U
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PS
U
S
PS
U
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,
AREA 4
�
$. OTHER (specify) PS PS PS PS �
U II U U
9. SITE CLASSIFICATION , _
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOI�4fEPIDATIONS /COt IIIIIdTS :
S�TE CLASSZFICATION DIAGRAM (Include: Soil areas, property lines, roads. streams, gullies,
aet areas, fill areas. wells, �aater bodies, slope patterns, etc.)
• -� -- -- _— _ _- , . �-
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. cor a� `
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.. AT SFaTlC DRAIIffELD A.�,l aA9 .0�. � . ,�
� . . 4%y� ~ :. i0R l07 C OF •iEA1TAGE N�tt�U2• � . .
�.. PLAT Ca8 S PACE 620 �
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NYCO LAKE
QPPROXIMATE WATER.��
i
N40'If10"W
25.00'
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57a��2� ��28� `
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GILFORD R. CIARK
D8. 12� P.236
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CNEFiYL BAF2lCFS2 MOOE2£
o�. �69, P. ss�
PERSON COUNTY HEALTH DEPARTMENT �
. WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # Parcel #
' Zoning Townshi " C
Owner/Contractor Dat -
. Location/Address r� �' � ,s- s'�j�j _ _
Subdivis,�
Layout
c
— — �wvy � �cj-� _ \
. nS � ► � - �N` o�
� z�, ; � ,'"M �,� , � �
�� ( ��o
.R.# 122 I
Lot#
-� (�'.� c�
I�a.s' �_�o
�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area l�, �i�{iu'r Size of Tank .�
SFD Mobile Home Size of Pump Tank
Business # of Bedroom� Nitrification Line l ��
Max Depth Trenches �l�
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' te e use changed.
Well and Septic Layout by _
Comments: ,� f -�`'^�;� ' , ,qQ 6Q 4���,'2
�
� ' � Installed by �`.�. A .. ��
Well Permit Paid
Individual
Public
Site Approved�
Well Head Approve
Grouting Approved_
-.....,..., e.,. � .—l�
by
7�_�{.Lv ° - K--'�- �-j (� U�
�ELL SYSTEM SPECIFICATIONS
-Public Required Slab _
cement Air Vent
Required Well Log
Well Tag
n
� � v �--., � r-- ,.
Date 1�-�-q�l nstalled by Approved by
This ceport is based in part on information provided the homeowner or his/her representative in the application s bmitted for this permit. 'The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided ro him in the application. Neither Person County nor the environmental health specialist warrants that the septic
tank system wili continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permitsam O1/95 rev.1.0
��
/'� y'"��'
�
P�RSON COUN"TY I;NVIRONP�;;NTI�[, [�LALTH
. . .,
, .Da te: . = 3 � ��j
Owner: ��� ��,: 1�;� r�
Location/Directions: �r
�ub'ivisi�n Name:
Drilling Contractor:�
�ai:r.r T,oc
!� : .
1
.•
—__-_ Lo t #
^--� - - -�----�.
. '.i'.,'._✓,=s'+r✓��.;
� <:,5;,;;�:�o w�•.
;�; �„,;�
_,5 �+.:
, T..
�Y
�.
'� ::�}:
. :{;
�,-
WEL.I, CnNSTRUCTION -�,��-�
Distance from Nearest Property Luic l� ��_ llistance from Source of ' �'��``�:
Pollution o b � �f . � ��.�.
��;
,,; �, :�`
Total.Dep.th: Ft. Yicld:—� GPM �':�~`�
Static Water Level Z `
Water B�earing Zones: Depth �{�__I= t. Ft. Ft. �Ft. .....�=':i,;,.
Q ��t. f r :.
C7 � 6 `��, P � �4♦
Casin Depth: � From�_to 3 � _ � �x,:.
TYPE: Steel - ---2--Ft. Diameter: � Inches .�;. r-.
Galv�inized Steel �--- . '��'`''�
If St `�1 ��-��T
eel, does owner approvc: Yes No ;��`�,°;�:
----- ,��s 6 =
� Weight:-� ��'�'}���ess: � eight Above Ground:___�(_`_L ��hes �.�°� ,
r,
Drive Shoe: Yes No - � '�'
r ::: A,r:.::
Were Problems Encounterul in Setting the Casing? Yes �� � jvo ���� �i ;:
If "yes" ' �f � �
give reason: , , ,�r;7 �
W';�'k- S r
rout: Type: Neat Sand/Ccment �• � ' W;=��''�' �:
Coricrete �� 4��..; �, ;
Annular. Space Wi�th 3 Inches 'y �`���`
: �� :
Water in A,nnular Spacc: Ycs T10 �$f` .
,t.
Mec�oa: Pum � ;� . :: s�` �
� �__ I'ressurc Paurecl . . .
Dcpth: From_____� �c� �v Ft. r
Materials Useci: No. Bags Portland Cement Weigllt of .l ba � �� lbs `
If mixture (sand, gravcl; ct�ttinbs) - Ratio: �� �:``£ '
:�,
ID Plates: Yes � No - � � :. : �
4 x 4 slab Xes_�� N�� - ,: ,
DRIL,LING LOC; �
De th 1��;
Fram To Formation Descri tion
� a<,;;.
. _ . - ;t7,,�
. � � .,
a--- - . , - ,..
. \�. �
.c_
z HEREBY CERTIFY THAT THE AI3UVE 1NFORMATION IS CORRECT AND THAT'�
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITN REGULATIONS �SET�°
FORTH By-THE P�RSON COUNZ'X I-ILALTH DEPARTMEN"I'. �
,. .
------���� _ , � 6 - �
Sibnaturc of Contractor Date i
'�
�
g1585
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) %r Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � 3 Parcel # %3 �
Zoning Township � �
Owner/Contractor �} D e�{- 3-`i 7
Location/Address
S.R.# 13z/
Subdivision Name vi -P� . ,s/ ��� Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area .'► � Size of Tank ��
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Ntrification Line �,��.
, , i , , Max Depth Trenches
� ��,� � �3v � � � �,�Zt
its may e voided if site is altered
Well and Septic Layout by
Comments:
Date
Installed by,
�Vetl Permit Paid ❑ W L SYSTEM
Individual Se '- ublic
PubIic R lacement
� Site Approved
VVell Head Appro d
Grouting Appro ed
Comments:
Date Installed by
use
Approved by,
TIONS
�tequired Slab
Air Vent
Required Wel
Well Tag ,�
Approved by
This report is based in part on information provided the homeowner or his/6er
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements ia this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily ia the future or that the water supply will remain potable.
c:�amipro\permit.sam O1/95 rev.l.l
�
9
� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
� (Void sixty (60) months from date of issuance)
DATE: `f - 3- � 2, IlvIPROVEMENT PERNIIT #: S.�
TAX MAP #: .3 PARCEL #: I.3 �
OWNER/OWNER'S REPRESENTATIVE: � �e- �'t �h h �Y��'
LOCATION/ADDRESS:
e�� .�f � � � � 3 2 ( ��c, C� �- � . �„ �
�
SUBDIVISION NAME:
SECTION OR BLOCK:
� Y�
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
r� LOT #:
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #� f,�,�'S� The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
�
r►1�� I , )Y
Person Requesting:
�
�
v� �i C-�-�-e--c-`
� f�,j t� �t 4
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0�.:-�b
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a2o' c.oH't°��
t{YCO L�
t�c�o
� !j0lj SET -
. �
. _ _.
� /; _ . � � . .--�
`fs � k `�"2 � , �
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'Q
RKER MOORE . - " �'- � ' �
....
._,...
CHERI(t. 9A , -- � -.: .: �.,��.. -:....-.- ... _ . ,
.1'ig.�f69: P::aS( ..�•�. .�. . ..
� / _
pPP�XWpIt �r.��..-� �
50' F
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I
PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant_ u��j�_�j 1QS-�'
Address 3� � l��l�{W�}�� Ln , County P�QYSO'
Collected By ��
Date Collected�� - i 2 Time Collected � Z:�
Source: IJ Well
CI No Charge
❑ Spring 0 Well Tap ❑ Other
[�'Charge
��*����������*�����*������**����x��*���*���*xx���x������**�*�*������*��x
��*����*�����*�����*���������������*���t*�*�������*��*����*�������**�����
Total Coliform
FecaVE. Coli.
Reported By
Results
Present Absent
❑ Ld'
� �
Date � I � (� (/1
Type III (b) System Inspection Checklist
s . _�. . TTax Map �olu� Parcel # : /,3 6 PI1V � . ;
_ Owner: S arn/icrr%fL Subdivision: e� '-.°�,. ���. o�—
Address: Ph/Sec ot:
Location: �
1) Establishment
a) type, size and sewage flow in
accordance with permit
z� Ta�
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good working condition
d) tanks pumped, cleaned out as needed
3) EfIIuent Dosin� System
a) effiuent appears clear, free of excess solids
b) required pumps present, operating properiy
c) high.water alarm present, operating
properly
_ d) floats, pipes, valves, disconnects in good
. + working condition, operating properly
e) control panel enclosure and components
in good condition, operating properiy
4) Ground Asorption Field(s)
a) no evidence of efIluent reaching surface
or surface waters
.._... ., _ . ..... ._. ._.._ . ..... .. ... . ��.... s;uf��c �: uter being effLct;vely diverted , .
away from drainfield
c) diversion ditches, swales, tile drains aze
well mainta.ined
d) soil cover, vegetation adequate and
maintained as needed
e) protected from haffic and destructive uses
fl distribution devices in good condition,
working properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted
Summary of
�a�/��, �,
.�
YES NO Remarks
� � T� d� �
�q► %Li'ser G'' asbo v e. 9/'0.��� `�a t�,1 �
�res¢��e�
�� Ta�z. .-,�,e�j he_ %a'�'ii..�
[ ] /�'�t �b.sev��-� .
fj4 l�,"l/� a�µ-���s��Q � �` ePss
so/; s�� Jr� � /.�ti;�/�/�,�/�
�cs5.'a/ . al�r�%`o v' 7�i; c� s/u,�g +�
[ ] � ;N R� .�-��..,�T
[ ] [ ] H�,�od.,s�e,-�Pa/ .
[� [ ] . � olr�
[►'� [ ] LaU9 .� .. s%�/s�
and/or Repairs Needed:
'e ' � �
, .
�.� s
,�
.� %� ,.,.,.._ ,_ ,,. ._ �,
[� [ l Floa�s S ir.�,�,��,� �u.�e�
- . _ _. . . _ . . . . �. c� � .rc�.?!' ���2.`�aSi�' (/o �i�zue
[-� [ l � Q ar �'���� �� L�"`e—
[ ] N/� L ]
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[� L l _/ /
� � L � /Ye'n2 �eS'i g/l-�t.�`'-Pc�.
L ] [ l `— ----� _ .
0
Authorized Agent i/ `'� : J1 S Date / D�.� /-- O�.
�