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Person Co'unt��ieait De artment
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Sewage System Impr�o�ements Permit
D„a •'� ' rThis it i After 5�ears P�#�
� r� -- SR#
Locaaon/Directions: � _ _ c . ,� � _ .
Subdivisio�i Name�% _ _ �, �t,� ",,�,_�p
Lot Size: Type Of Dwelling: '' kta.
Water Supply: Private: Public: Community:
Bedrooms: Gazbage Disposal �
Basement �► Basement Fixtures `
------�-� r--------------- �
Size of Sepuc Tank• gallons S' of Pum ank: T�
Nitritication Line: � �- �
Depth of Stone: 12 inches 1/ `
Max Depth of Trenches:
Alternative System: Conv. Pump LPP Pump �
Remarks:
-------------------------
Date Well Approved•�:��� Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sew�ge S stem Approveti: S'—� $-9'/
BY GU� �.�'-�-K. Sanitarian
CERTIFICATE OF COMPLETION
Contracwr. � �^=1 y►�.-,-z. 02�--...�-�'�.
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Sewage System location, installation, and protection must meet state and local
regulations. Sepdc 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
niuification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this penrut is subject to revocation.
(G.S.130 A-335F)
L,ocation of sewage disposal sewage system sketched on back. ,
(OVER)
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
� __ ROXBORQ, NQRTH CARQLINA 27573_
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
�
Name of Owner or Tenant � Gt '�
Address ��� S�ot"Z� �G�reS �, County
Collected By �� �
Date Collected 7�1 S—l.� Time Collected �%�S
Source: �'Well ❑ Spring ❑ Other
Location: O House Tap ❑ Well Tap a0ther
❑ No Charge �'Charge
..............................................................................�
***************�***************************�******,�*************************
Results
Present Absent
Total Coliform ❑ �
Fecal/E. Coli ❑ �
Reported B
Date Reported � �� � � �
Report Called o YES o NO
Calied To _
�,�� J ��
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�.Ld�rn�v-�ia a��t�n:tan�c:un.iL.�n.11 IE-�J[��:..r:n,lI1LIEn
Date: 7 / ZD l�
Tax Map: Parcel: 34
Name: � � �
Address: " ��,����ifL•
���—tl��- �� �
Re: Bacteriological Test Results
Your well water was sampled on 7/�/�; and tested by the Person County Health Department for
biological contaminants (total coliform and fecal coliform bacteria).
The results of your water sample are noted below:
� No coliform bacteria were detected in the sample. Your well water is safe for normal use.
Total coliform bacteria were detected in the sample.
_ Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are naturally found in the soil. Fecal coliform bacteria are associated with animal
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 may not be safe for
crse. Young children, the elderly, and individuals with compromised immune systems are especially
varinerable and their physicians should be notified of the test results.
A well that tests positive for total or fecal coliform bacteria should be properl disinfected and retested
prior to resumin� normal use. The well may be disinfected using the enclosed disinfection procedure. A
well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly
flushed out of the system, please contact the Health Department (597-1790) 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
Person Counry Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808
(revised 07/29/13)
Application Date: �� S� ������ Taz Map: '-(
Amount Paid: �-t� �.� • �l- Parcel#:
Receipt #: �'1lQ`�°l�o � � ����
�Yavaa-aDaaIIanouad:ing 7Hlcaeall��a
___ __ ___ _ __.._ _.___ _____
ct�. s3- i��i
Services
❑ Improvement Permit (5ite Evaluation)
$200.00/$300.00 (if > 600 gpd)
❑ Mobile Home Replacement or Buildiag Addition
$150.00 (if site visit required) __
Well Permit (Nt
$300.00/$200
1) Applicant Ic
Name: �
Address:
for Services
❑ Construction Authorization
(Fee is dependent on the tyve of
❑ Permit Revision
$75.00
❑ Repair of Ezisting Septic System
Annlication: No Charse/ CA $150.00 or $300.00
Phone (home): �� - '—
(work/cell): 336 - 5 8r� �n .
2) Name and address of current o er (if different than applicant):
Name: � Phone:
Address:
3) Property DescripNon: Lot Size: _l_ Subdivision:
Address and/or directions to Property: ��{ � i10� �L�(2_�.�
.�
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
0 yes ❑ no Does the site contain any existing wastewater systems?
� yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: C�rrent number of bedrooms: •
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Malcimum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
'�-( �/J�-._� 3oz�l -A-
Signa re (Owner/ Legal Representative*)
* Supporting documentation required.
j�,Q-2�-i�
Date
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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I���s���m���.Il ]F][��.��1�
WELL PERMIT �
(New_ Repair i� ) ��'��
Tax Map: � Parcel: �_
Subdivision: Lot:
Applicant's Narae: i C�U�C ��`'15e,�i �o �l%a�r U/� �"�S
Mailing Address:
Phone Numbers:
Location of Property:
U T ,S►�l Qr� 7/��►''�S �✓'• \ ��*�- ,J " ' a r"� 1'� (.0 �
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable �tate ard Couytty regulaiiorrs g�vernir�g c�nstructi�n and setbacks apply.
3.) 1'ermits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�lYevv Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Wel1 Drillsr:
Pump Installer:
Approved by:
Addiliona! Comments:
Daie Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxooro, NC 275i3
Date: 1 � rZ 61t �P
C�rtificat� of �'om�lehon
� iner:
EHS/Date
Depth:
Grout:
DAbandonment:
D�te:
Method/Materials:
License #:
License #:
Date:
Date Results l�Iaiied:
C'o.✓�iic{a�
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Fhone:336-597-1790 fax:3j6-597-7808
11J26/13