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A24 124Type III @) System Inspection Checalist Tax Map �� Parcel #: o? PIN Owner: 6'.4 �, Subdivision: p�� o,i, s'o Address: a�1.� rG,' ,-�� iLC` Ph/Sec/Lot: !�,-��g Location: 1) Establishment a) type, size and sewage flow in accordance with permit 2� Tanks a) tank risers accessible and surface water diverted b) tanks and access manholes structurally sound, waterkight c) sanitary tee(s) in good working condition d) tanks pumped, cleaned out as needed 3) Effluent Dosin� System a) effiuent appears clear, free of excess solids b) required pumps present, operating properly 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, operati.ng properiy 4) Ground Asorption Field(s) a) no evidence of eftluent reaching surface or surface waters b) surface water �:.ing effect:: �l� d:v..rted away from drainfield c) diversion ditches, swales, tile drains are well maintained d) soil cover, vegetation adequate and maintained as needed e) protected from traffic and destructive uses � distribution devices in good condition, working properly g) repair area properly reserved, maintained h) pressure head properly adjusted YES NO Remazks [l 5�-��=-�� i . o?�' �c� s � , � 9r,�-�� J �� ;,��1 � .�s��.�,� 1 Authorized Agent Date �—.•Z 5'�- �/ aaL � . � . „ e �r erlc �': �v� � � �,,. �,a� e �-, � " �z �� R � i� (p .. "'I y w ;: � . � n X � o � � �o � b x . , � � o, � o . I � o y � S. " � �. � � � w '': �* o � � a y k w � �; O �b 5 � a� y � � � � � � �.�y ' w � �� " � a ' � O � ]�y ry w i y � � � � �. y � .. 5 a O �+ a � x ti � � A w er y � � . N � '► � m, n w �+ o � `.� y , N � , � b ' � � � m v�, � g w w '. r. �. ti :�� ` ,. Person County Health Department Sewage System improvements Permit o �"i Date: �"' " is Permit Void After 5 Years Owne*' �T� 1--�� ►� SR# I3 � Location/Directians: _— f, , � - Subdivision Name: —Q !'L i C� ! ✓1- C% ' Lot Sizc: —�� ..� ��_L.��-T Type of Dwelling: Water Supply: Private: —t� Public: Community: Bedrooms: -� Garbage Disposal Basement Basement Fixtures - INF�RMA n�,�771 Ir' BY „ ow�ner or representative Lot # � � REPAIR: � — — — � '�tEEVALUATION— — — — — — — — — — Size of Septic Tank: �d da gallo� S�� of Pump Tank: Nitrification Line: � Depth of Stone: 1? �nches �— Max Depth of Trenches: � vj� 7�� Altemative System: Conv. Pump _� I�'P PumP �'� �f��`��"�'`'-7 KMII ) Remarks: J Date Well Approved: Well should be 100 ft from any sewer system BY Sanitarian , Date S e ste A roved: � ��' �'� gy Sanitarian TIFTCATE OF COMPLETION Contractor. _ � --------------------- ¢, Sewage System location, installation, and protection must meet state and local '� regularions. Septic tank should be pumped out every 3 to 5 years and shall be maintained � by owner in such manner as not to create a public health hazard. Septic tank and � nitrification line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covezed and put into use. If the site plans or intended use change this pennit is subject to revocarion. (G.S. 130 A-335F) L.ocation of sewage disposal sewage system sketched on back. (OVER) _ • 1'I{Iz:�;ON COUN'I'1' I�:NVI.IZ!)Nh11iN'L'A[, III,ALTI�1 ' . IJI{I,I. I,OG Date: 2, �--2 �.G Owner: �rz �� d.� _ .. SR# � �-z Location - . .. .. . .._.. -. -- _ .___ �lI'C 10115: --��-----�_�...h��-- ,u1;;�:V1S10I] N�lllll; `--- - .. ......- --_ --------- . Drillin� Contractc�r: -� ` --.� .. . - Lot �� —��':t�-��fa..� .._%�--,UU_�%--'-----------____ WF_ONS"f'RUCI'I N Distance from Ncarest Pi�o��., iy �Li„��._/..� �,.s llist:inc� from So Pollu[ion o � �,��, . ��--- urce of Total Dep.th: �� F�. `� icld: �� Water Bearing �Lones: Dcpt�� -�� .�— c�M Static Water L,evel Ft. --�–�--�--- �-��_I'�-.____.--�F�.�_�t. TYP �; Dep�i: From p_to`.� .� Stccl -��• ll��I�icter: �.; Inches Galv:tilircd ,Stccl .� � I.f Steel, docs ownc�- ;�p��rovc: �`c:;__No_______. � Wei�ht:__f,�__'1',licknc:s:;:��Iciglit A�vc Gro Drivc Shoc: Ycs � Nc� �?�:� Inches - Were I'robleil�s En�.;oiintcrcd in Sc:tting thc Crlsing? Xes r I�� .�y�s" givc rc,isol�• ---____ No Grout: Type; Ncat ��111c1 ,�- /Cc,ncnt Concrc[e Arulular..Spacc `Nic:tl1 3 II�c11�1 - WatcrinAni�ul:u-,>'pacc: �'cs ` Mct�iod. __ N�__ ' �'tzm�x:cl-.. -- �'I�au��_____— l�ouc�i ,�-- � . ` Dcpch: Fr�m C � ---- �.. lu _ U t.L � Matcrials Uscci: N�,. �3a�s ,('�rtl;ui�l Cemcn[ If mixturc (sand r�ivcl cuttin��: --�— Weigh[ of .1 bag�_lbs. �ID Plates: Xes � g�� - �tatio: �.. t� I No . . �4x4s�ab Ycs �'� Nc� � -�: . , -- �---=-----________- 1)RILI.,I NG i .CX: _ From � To Fozmation Descrintion �, _ 0 � -- .�..__....._.. I . Z �EREBY CERT'IF�'" T�-IAT'I`IIE �A.].�OVL 1�NF �- – .�:" T�S WELL WAS C ONSTR UCTCI� 1N ,�,CCO D�C O� rS CORRECT AND THAT�: "°.';};� _ FORTH BX�T�-IE P,E(�SON COUNZ'�:' I-I1�,AI.TI-� DEPAR'TM �T REGULATIONS'SET� �i;°�r� ------��- �� , . Si�;naturc: �f (.'orltractur ._. . �� . Datc .� � � � «i a PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # fio� `� Parcel # %o� y Zoning Township ;u/1ni��u M Owner/Contractor. nf�n Zat�r'�-f , Date i Location/Address �� ( A�i« �� Q�`�'}` `�n vy`C Gi-HF(= s Iv�i � i y� � i .��, S.R.#—� Subdivision Name �+r�' _ Lot# �� Layout ��'e a�fucH �d Pe rM; f�o r �ra�+n�i�t°G, S�ci�+Ca�onS, L`l r'�'S i n S�a. � �F� �^�' ` I`�P�� t,�'�J' D n 71j��9D� �� 5 Pe �� r T�n K ��, v9-�� %ho�, . As Installed • �� 0704 � ��.� . r �� ► � � , � -T.. � M , , •--- .- �G �. h2f� l ` SEWAGE SYSTEM SPECIFICATIONS /�S yin�(e� �' ?�s s� t✓� Repair Lot Area Q.y3 Size of Tank /D00 SFD ✓ Mobile Home Size of Pump Tank /OCO �'�� Business # of Bedrooms�_ Nitrification Line .ins}�Il�c� u�� vfz�E Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is a tered or inten e u chang d. Well and Septic Layout by � � 0� a� �.._..._.,....,.. � ► _� J ,. : . ,1. � _ -t�: ,�._ . , s : �-, .', L,zJ/ � ,�f � /-„ �, �,.� /, � o.�' z✓� i �,L� Wks �r-�'�,siz�f'e� vuev Date �-10- �� Installed by : ., � .. ,� by Well Permit Paid C1�' WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab _ Public Replace ent Air Vent Site Approved Required Well Log Well Head Approved „. Well Tag /�:- �6y R. B 6�ti 7% ��l0 This report is based in part on information provided the homeowner or his/her repcesentative 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 in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person Counry nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam O1/95 rev.1.0 North Carolina State Laboratory of Public Health Department of�-lealth and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTE Name of System: Zandt, Tara Address: 372 Glennie Irvin Rd. Semora, NC Zip: 27343 County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street (336) 597-2371 Roxboro, NC 27523 Courier: 02-33-15 Collected By: JS Date: 1/24/2007 Location of sampling point: Kitchen Sink Remarks: � �-q--� 2� 7 Source of Water: Ground Source of Sample: Type of Sample: Raw Type of Treatment: None Type of Analysis Private Time: 10:37:00 AM Parameters Results Units Date Analyzed: Alkalinity as CaCO3 110 mg/I 1/25/2007 Arsenic <0.001 mg/I 1/25/2007 Calcium 34.4 mg/I 1 /25/2007 Chloride IC <5.0 mg/I 1/25/2007 Copper <0.05 mg/I 1/25/2007 Fluoride 1.27 mg/I 1 /25/2007 Iron <0.05 mg/I 1/25/2007 Hardness as CaCO3 (Ca,Mg) 104 . , � mg/I 1/25/2007 Magnesium 4.4 mg/I 1/25/2007 Manganese <0.03 mg/I 1/25/2007 Lead <0.005 mg/I 1 /25/2007 pH 7.6 Std. unit 1/25/2007 Sulfate 14 mg/I 1 /25/2007 Zinc <0.05 mg/I 1 /25/2007 s Date Received: 1/25/2007 Report Date: 2/12/2007 Reported By: �J�`��-�„�� Today's Date: 2/12/2007 Ref: 1186 Login Batch: 07010052 Sample Number: AB52259 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 0 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 ,, � �.��' Z� PERSON COUNTY HEALTH DEPARTMENT 325 SOUTH MORGAN STREET ROXBORO; NORTFi CAROLINA 27573 BACTERIOI.00ICAI. WATER SAMPI.E ANAI.Y.SI.S N1me of Owner or Tenant_ �xa� _ Address ��j2 C�,I��r1�P_ "T�j,r, County p76 � J��-0 J Collected By �� Date Collected 1 Time Coliected ��-� ;��( Source: �7We11 ❑ Spring ❑ Other � / Location: ❑ House Tap ❑ Wcll Tap ❑ Other ❑No Charge �harge �v ****************x*********,�n,�*�****x**�*�*x�******x******x,�************�****�* *�*********�*�*********�**********t**xx******x*****x*****xx,�***x****x****x**** Total Co(iform Fecal/E. Coli Present ❑ ❑� R�rults Abse�t �� Reported B � 2�Z /o �'1,? J bactreport � �