A25 162� z�ssiic�tian Da-ie: /�-t -D I
;�nnce�rea aaim:
���..�°# �:
� - � ' �Arson� �acsn#v �?ealth Deoartrneni
�... . .._... .; :-Envirmrm^�ntai Healtfi Section
T��: �lla� � �%
�. 1;�?ecai T.
. �r�, . . �.. ._ ._ . -.. .. ..�. .
. • . . . ;•: ,•;:. APgL1CAT10N i-0R S�VIC�3 •
IF THE 1NEaRMATfON IN THE APPLICATION FOR AN IMPROVE�AAE311T PE�tMIT IS FALSIF'�ED. CNANGm. OR THE SiTE iS
ALTE3iE�. THE3V THE IMQ1iOVE�AENT PE�MR AND AUTH�RfZATfON TO CaMSTRUCT SHALL BE�OME INVALID.
1) Permitrequeabadb� {Ownerlage�rosQec3tveowne�: �/��it��/f.� �%OO.l,s
' 1-IQm� r1KN1Q. � 9���3 g 1'SY�: Z' 3� /� �/"�H �+�?,�"�' ��v
8ueirtess Phone: . . D�?'�C3a/Zr7 � �t5'"73
2� Name and addre� �of carrerrt owner. T•'��/--s�/3 � GU o o,�s .
. ' a 3 � - G.Gl.9/%� �i p ,
. � .�73
3) PraQerty Descripiion: t.�t s�zs: �� 3 Taw�s�tp: __Ls%�.LU/,�J �f/5�/!� � .
Dlrec�ans to the property (lnduc�ng caad�names ar�,d numbers): �}T C,�'�`� �
C !/N �' C/LG. l� � l�7J � !l�'T
d /�' ST� ,.. '.- � / O v� ^- �/�/"--/L'%i`.='
- � � . Co� v2/'r•l� 2 --s7'a/�y
4) Propoaad l7ae and Structurs Descri�itian: answer eact� of the follawing ques�ons: �ff/7���
� P�P� 4�s 4�� ' .
n� saac e�t naoautar a, stn��e wwe a. ao�iB virtae o �
c} Numi�er of 8edrooms:. 2 • c� Number of ocrupants ar people to be senred: �
• �). ..Hasemer� : Y�es� Q Na� yes, #-uf basemert fn�u�s: . . . : . . . .. . .. � _ �- . �
� ' la8[YI�„�e. �iS¢C+3�. '(83 u' i+'.iA�-•-, ...r _ . " " . - _ .. • . .. �- . . . . _ _.,..._ . ._ . _ . ' _ ._
gj Dimensians of Proposed Structul�: Width: Qep : •
� 1Ala�r Su�piy Typat. Private new � or exisfing � P+�blic Q Cammuni�i�l� pring ❑
. •� Are acry v�lis on adjanin9 ProPe� Ye9 ❑ No Wf yes, lara�on
.
6) P�e�e Indicaie D�tred System Type: (systams can i�e ranked. in ottler of y�r pr�fecencs)
Ca�tve�iarol _„Mo�fied Ccmrerrtlonal �Altemative. Innovative
Qther (speciiyj:
CLEARLY STAKE ALL CORNEiiS AND UNE3 OF iHE PROPEii'iY,
STAKE THE CaRlVEiiS OR a4L1. PROPOSED STRUC'TURES.
PL.�4SE ATTACt13!!R1/EY Pl.AT OR SRE P�.AN TO THIS APPt1CATtON
1 hereby make appiir.ation to the Persan Caurdy Hea�h Degartment for a site e+raluaticn for the an-site sewage disposai system for
the a6ove-descn'�esi properiy. I agree that the cartterrts of this appiicatian are true and represent'the maxirn�un faciG�es to be
piacad an the progerty. I understand if the siie is altered or the intended use ct�anges, the permit shail hecame imraiid. l understand
that as appGcard, 1 am �+espons�ie for ide�fijing and mar�r�g property Gnes, came�s and rnaidng tha siie �ss�bie fo� the
persannei of the Persan Cowrty Health Depsrtment to candud their evai�at[ens. l understand that I ara respansible for natiiying the
Heaith �epc�%� praperty carrtains arry weilands as designated by the Army Corps af Fngineers.
�� �. G�/���� ��'/—��
Owner or Legal Representative . Oate �
PCFiD, rev. t 0l1?199
I���a������n.��.� ���.���
October 3, 2001
Ms. Theresia Woods
4232 Morton-Puliiam Road
Roxboro, NC 27573
Re: Home Occupation of a Florist
Dear Ms. Woods:
The Person County Environmental Health Department approves of your in home
occupation and recommends to Person County Planning and Zoning Department to
approve your in-home occupation application for an in-home office. If the septic system
serving the residence at Tax Map # A25, Parcel # 162 malfunctions at anytime, the
business must cease operation until repairs are made to the septic system.
If I may be of further assistance, please contact me at 336-597-1790.
. Sincerely,
� � -c�� �----� ,-��
n R.S. ��
Ja et O. Clayto ,
Environmental Health Supervisor
Person County Health Department
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Roxboro, NC 27573
L
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
P � � . ��ZZp� q
Name of Owner or Tenant 1�� Q
Address � 3 2 %�n�r�nr► t'u ���am (�I. County �er5oh
Collected By � s
Date Collected_ � L�- D� Time Collected / Z��5
Source: ell p Spring ❑ Other �
Location: ❑ House Tap �Well Tap �Other
❑No Char e l� har e
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Total Coliform
FecaVE. Coli
Present
0
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Results
Reported By �
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. erson County Health Department �
�ewage System Improvements Permit
Jate: ��- = 3- ��= This Permit Void After 5 Ye s Permit #
� l l !'I!c� � /P�� , • YSR# " � s' � �
Owner: �_;-�,--�--,� , � —T��-�--
Location/Directions: � � ! .'' ; �;
� � � Lot #
: Subdivision Name:
3 Lot Size: ..�� �` ' Type of Dwelling: � ��� � � 1 � ' � !
� Water Supply: Private: - Public: Communily:
Bedrooms: �-- Garbage Disposal _
� Basement Basement Fixtures _..- ^ � --�
� INFORMATION CERTIFIED BY -' • '� `� - "
�' �` 6wn or ►eprese� tZLc��
, Environmental Health Specialist: �t'i; l�-�t �I��/��1 ���.� .
; REPAIR:----- REEVALUATION-----------
. Size of SepUc Tank: / ���-� gallons Size of Pump Tank:
Nitrificalion Line: ��(Z� � �
Deplh of Stone: 12 inches
i Max Depth oE Trenches:
Altemative System: Conv. Pump • LPP Pump
Remarks:
S-ZI-�_3
Date Well Approved: Well should be 100 ft. from any sewcr system
gy Environment��l Healtl� Specialist
Date Sewage �ysteq�► Approveci: � -� � �' `� �
gy �Q,,.:.Jl cj'v�-�._ Environmental Healllt Specialisl
� CERTIFICATE OF COMPLET'ION
1 .
Contractor: -► � ^- ^� L� ,.,,
Sewage System location, installadon, 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 healt}i hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Departrnent before any portion of the installalion is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S. 130 A-335F)
I.ocadon of sewage disposal sewage system sketched on back.
(OVER)
�
Person County Health Department
`�"� Well Permit
Date: ��•`f Z�s Permit V id After 3 Years �c, y`c. �:. ,:, f'
Owner: �y� �� ��i _ v SR# ��
LocatioMDirections: �
� . �'-�r
Subdivision Name: � �� #
Drilling Contractor. � 1� .
�J CO RU
Distance from Nearest Property Line � �/.y_,s Distance from Source of
Pollution �J a D /u-� -r---rT—
Total Depth: � FG Yield: GP;VI nStatic Water I.evel _� 7 FG
Water Beazing Zones: Dept}� �F� Ft. F� Ft.
Casing: Depth: From �J to FG Diameter: � Inches
TYPE: Steel Galvaruzed Sceei �--�—
If Steel, does owner approve: Yes No
Weight: ,.,L�'I'}uclrness: Height Above Groimd: � �ches
Drive Shce: Yes ✓� No
Were Problems Encountered in Setting the Casing? Yes No •..--
If "yes" give reason:
Grout Type: Neat Sand,JCement " Concrete
Annular Space Width ...3 Inches
wucr in Armular Space: Yes No ✓
Depth:dFzom � Pressurc �_ Poured i��- �
—�.5� F� �
Materials Useri: No. Bags Porttand Cement Weight of 1 bag
�� lbs.
If mixnue (sand. gravel, cuttings) - Ratio: 2-- t4 (
ID Plates: Yes L No �
4 z 4 slab Yes �— No
I HEREBY CER'TIFY THAT THE ABOVEWFORMATION IS CORRECT AND THAT
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEdLTH D PAR'TMENT,
% �
Si o on�r Date
l�'�
7 2 9z
aaitarian's Signature Date Issued
Sautarian's Signature Date Completed
i well locarion on revezse a'.de.
z
�