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Person Co�nty .Health Department - -
Sewage System Impro�ements Permit
Date: -- • �ZThis Permit Void After 5 Years Permit #�
Cswner: �. A. VY�J [�j.-EL�/'��N SR# ��r ��
Subdivision Name: C�. � ��/C�h1" t # ''
Lot Size: � , � Type of Dwelling: '�� S f '"
Water Supply: Private'.� �' Pablic: Communi : �--
Bedrooms: Gar e Disposal 9
Basement Basemen� � s "�
INFORMATION CERTIFIED�Y • � ' ���� -Z `C
Environmental Health Specia st:= i 'o e���S�i c��e �
REPAIIt: REEVALUATION: �
Size of Septic Tank: � Q gallons � of Pump Tank: a��
Nitrification Line: " �
Depth of Stone: 12 inches �i �'
Max Depth of Trenches: � Q
Altemative System: Conv. Pump LPP Pump
Remarks:
--------1 ---------------
Date Well Approved: Well should be 100 fti firom any sewer system
BY Envir nmental Health Specialist
Date S ge S te A roved: - �
BY Environmental Health Specialist
� CATE OF COMPLETT9N ,�
r �
Contractor.
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Sewage System location, installation, and protection must meet state and local �
regulations. 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 Counry
Health Depaztment before any portion of the installation is covered and put into use. If
the site pians or intended use change this petnrit is subject to revocation.
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
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Q�ce Phone 59�3-989D ot 51J-$676
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j I h�l �,rlY LFtA�D S+�{� N�'�tA�T'[ h+� rG, !�! C.
�XCA1/A7EaN, (3ACKiiO� anti Sfi'TiC iANK $�RV10E
Roulc No.1, iiox 3Z5A
ROXRO�RQ, NdRTH CAROL�idA 275�3
D��ce�bP=• �.:i, lqqfi
�aR: '���ry I�les�
FRO�[: �IMMX Z,EIrJI a CClNTRACTINC, INC.
RE= 3��� I��t4�� View l,� tat� at .>horP Acr��
0"l9 P� 1
Home Phone 59�s 58#3
J i�7my I���wi:� �nade a vi.sual inspec� ir�r� for the abave
j nl� :� i t� . Ther� i s nv .nema box present and r�ir in� i�
incrampl�te. A dr�p corc� is usecl �or pow�r,
Just by visu�z inspe�:i:iori the �y�tPtm seeme to be in
wa•rk _i n�; cy rdE� t� .
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' ,7I�' � T,��+f,�'� COP�TRACT IPdC . I�lC .
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� �UR�`AC]a SYaT�I OPLRATt7R
CER�. �� 12261
C�RT�F'iED �-2$�92
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �����P �P 55
Address ��� Ke �r i ew ���' f�c� � County e �
� eMo �0. AJ �
Collected By �5
Date Collected �e' 23' �( Time Collected 9�.3�
Source: �'Well ❑ Spring ❑ Other
Location: �Iouse Tap ❑ Well Tap ❑ Other
❑ No Charge C1YCharge
........................................................................�
�***********************************************************************
Total Coliform
FecaUE. Coli
Present
❑
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Results
Abse t
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Reported By �
Date Reported
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a�
U
L.
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a
PERSON COUNT �' �H�ALTH DEPARTMENT
WELL AND�S/EWAGE SITE, LOCATION ROVEMEN'T PEKNIIT
Tax Map # � � '-t Parcel #
Zoning Township ' tG�-
Owner/Contractor r Y ate
Location/Address
�' ,,,� f ' �'t.m ��' S.R.#
Subdivision Name Lot#
A OL69
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank
SFD Mobile Home Size of Pump Tank_
Business # of Bedrooms Nitrification Line
Max Depth Trenches
Pernut Void after 60 months. Permit Void if not ' compliance with zoning regulations
Pernuts may be voided if site is altered or int d c nge
Well and Septic Layout by
Comments:
Date
Installed by
WELL SY
Approvecl
SPECIFICATIONS
�� -V Semi-Public Required Slab
Replacement Air Vent
re Approved�_
ell Head Approved
�outing Approved_
Comments:
Date Installed by
Required Well Lo�
Well Tag
Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit 'Ii►e
rnvitonmental health specialist is not responsible for false or misleading infocmation contained in the application. 'Ihe environmental heatth specialist
is also not responsible for concealed conditions on the property or for statements in th�s tepoR that may have resulted from false or misleading
statements pro�ided to him in the application Neither Person County nor the environmental health specialist wazrants ihat the septic tank system wil�
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pcmutsam 01/95 rev.1.0
OflIGINAL
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�nh.�'7R}L'�71,�7L��r1�i7L.¢.�.� �(�'.�.11��
Building Additions/ Mobile �ome Replacernents
Tax Map #:�_
Approvai Requested for:
Applicant Name:
A.ddress: �'
Phone #'s:
Parcel�#: /
Mabile Home Replacement
—� BuiIding Addition �
.� �
�
� Permit Located; Yes i� No
Installation Date: Design flow: t'vd (gpd) �
Current Contract with Cextiiied Operator on fite (if required): �
Water Supply: l�Well Puhlic or Community
Wastewatex system shows no visual evidence af failure on: -�f (date)
(Applicant's signature if site visit is not required)
AdditionlRepiacem'�nt Approved
-��.��i
Envuonme t ealth Specialist Date
I 1/15/05