A24 66PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �c�F �1" M►�ss�`( wfla�`�
Address 9�-tRt..� �oP Kfl County PERSON
Collected By L�i�tG.ca�. A_ Sr� �;�
Date Collected 4' 3� f i3 Time Collected �1'. `l `i ��
TT
Source: �C Well D Spring ❑ Other
Location: ❑ House Tap ❑ Well Tap
❑ No Charge �Charge
�`Other (,��x�'s�p'e. SQ��v'C>
........................................................................�
************�***********************************************************
Total Coliform
FecaUE. Coli
Results
Present Ab�ent
❑
❑ ,�.
. �
Reported By h.
Date Reported � l i'�' �3
Report Called ❑ YES �NO
Called To:
Th�e District 1-9ealth Departmen�
Orange, Person, Cas�ell, Chatham, Lea Couaties
S w�
� SEPTIC TANK PERMIT
1 � Date � — � � � - l. V
�
� Name of owner: � � ��r��„�
e� � � -
� Name of contractor: A�a�+ p
Address and Directions � ~ � ' � � G� � � 9
► ,��"� � t � `� , i �-► �n � C��_�' ✓�_1� �u�'�
�,3, ; r„ rr1 e� � v � i� .
Person or firm doing installation: �
r� � W P11�/�i • � r
Address�.-- �—��--�� �
No. of persons to be serve�
— Bedrooms 1, 2,�•
Additional appliances to be used:, Disposal, dishwasher, w,� B
machine � � _, /
�� C( 1 �
' Recommended: Septic ta�
Nitrification line: . �
Above recoanmendation based on information received and observed
soil condition. Sevtic tank and nitrification line must be inspecfed and
approved by; � member of the Distaict Hea13h Deparfineni staff before
any portion of the installation is covered.
Date Approved:
By:
Countersigned
� /i
SignecL
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
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TaY Nlap #: �a�_ Parcel�: lo\o Address: �� 'ri�.� "�'o@ ��
� s�la ,�.c.. �t�3y�,
Approval Requested for: iblobile Home Replacement
�- Building Addition
Applicant Name: �SwR, t���.'c'�t-c �.
Address: Po t3'��. �qb
��►c� , �Jc. � ��13`�3
Phone #'s: 33tio- �1y'1-'1031 ��3�- a�'� � 358�1
Permit Located: � Yes No
Installation Date: $- \x - h�p Design flow: ��'o (gpd)
Current Contract with Certified Operator on file (if required}: tJ � .
Water Supply: x Well Public or Community
Wastewater system shows no visual evidence ef failure on: 1-1b-1� (date)
(Applicant's signature if site visit is not required)
Comments: 3�"d���s 'ihAx. � �.w�r�� k�cv�� S�c, �+a,�L
t�i�r,�eD c1- ArJ, �F�,a�c 'F►� _ i�Js�c� • s�.re s:,� s`��
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a.�iu,',�,-n s,�l� �: � oF �A:�,,�s A��1'C c��E.
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Envirorunental Health Sneciaiist
1
1—�0— IS
Date
Person Counri Env;ronmentai :�ealth; 3^� S. tiiorQan St., Sliite C, RoYboro, N� 2 i�; 3
Fhcne: ��5-�97-??9C/ ra;:: ����-�9"-i8�� � zv�:���i.�,ersoncoun�t��.i;e�
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SITE PLAN
Name ���1`.. �V���'TSE ��.. Tax Map #� P��� # bb
Subdivision Section/Lot#
`��cv. A. St-�� i-3p-i5
Authorized State Agent Date
System components represent appmxzmate contouts only. The cvntracrormustl7ag t6e sysrem p�ior to beglnning the insrall�tlon to
insure rhat pmpergrade is mairttained.
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Application Date• �' ("2-"�s
Amount Paid: 3 c50� "�—
Receipt #: '1133�'�
�,,�; -z29 r1
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Itepair)
$3 00.00/$200.00/$75.00
�� J f Jl �1111��� Tax Map: '��
', �.�•�- ������. Parcel#: �o–�
�L`..�IILWLLII�Qb�ILIIA'hK7II'Il�.lhA ll 1�K7t3LRQ:1[ll
�lication for Services
Services Re uested
Construction Authorization
Fee is de endent on the e of s stem ermitted
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: r- .�
Name: � �,CA R '�-� t V���' `� ��-
Address: ' o P� 2� �
�rKb rtA �rt z-7 � 3
2) Name and address of current owner (if different than applicant):
Name: "� {� fi l� t Ss �t �� (Z-��
Address: �%O � Tbn
�nna� tir c Z7 3 y 3
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 3 3� �i' `} "7 � a 3�
(work/cell): 33� 2l �{- 3 5 S�
Phone: ��� 3b� Z'ZL ?�
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ 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)�roposed Use and Type of Structure: , L
�1Residential � � y�,�� � ��}-1 �1 -r7 G'� •• 5''7 Z S-�'
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedr ms: �_
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well jd Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
6) If applying for °Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 certify that the information provided above is complete and correct. I also understand that if the information provided is
in�ate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
/�/ `7_/`✓ �t`QC1 � - ! Z � � S
Sigr�ture (Own�/'Legal Representative*)
* Supporting documentation required.
Date
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
• A completed °Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)