A26 114Amount paid 161,n�
Receipt � � ! � ��'%
�i/ 3 ��?
� Date
�
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1. permit requested by: _ 7. Dimensions or Proposed SCcucture: I
a� W idth: 2�
owner/prospective owner/agent: C ' De [h: ��
22s S �t' E P
A dress: � - I
' , -_ 2- � 8. What type (if any, additions, expansions, or
� ^ ` replacement is anticipated co the structure or facility
,.� � N� r� that this sewage disposal system is�-intended co serve?
U Home Phone #:y� —4y� � % �
� usiness Phone �: � �
a
2. I�Iame and address of currenc owner: 9. Water supply t}'pe:
• ' private�,.public❑ community❑ spring❑
� Are any wells on adjoining property?Yes❑ No�
If so, identify location:
W
�
Description: Lot size: � �c
Tax Map#: .� ��' 2
Parcel#: �l'�% --r--
Township: _� � I i-�.� . L�f �
. Directions to property: State Road #& Road
J
lG
. 8 ►�
I0. Type of structurelfacility: Proposed:�Existing: Q j
Type of dwelling: ,
�
House: ❑ Mobile Home: Business: ❑ �
Type of business: '
Number of Employees: _
Number of bedcooms: _�_—__�—,/ :
Garbage Disposal? Yes � No !�" �.
� Basement? Yes❑ No�f so, # of basemenc fixtures: :
6 I�Iumber of occupants or people to be served' �I
CLEART.Y STA� ALL CORNERS OF TT3E P�tOPERTY AZ`ID THE CORNERS �F ALL
PROPOSED STRUCTURES• �
I hereby make application to the Pet'SOn COunty �ealth Depax'tment for a site evaluation for the on-si:�
sewage disposal system for the above described property. I agree that the conten[s of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Pernnit can i-�
issued, I must present a survey plat of the property to the Healch Dept. I understand that in the evenc I have nc.
delivered a survey plal of the pro erty lo-the Health Dept. wit#�in 60 DAYS after the date of the evaluation of
the site by the Health Dept., t' application shall becQme votd and all fees patd focfe�:�
��
� R.JU' , �--
2 S gnc� Owner or AuthoriZcd Agent
,errni[ Tssued ❑
>errni[ Denied ❑
�lat Observeii D
Signature
4
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_ Date ,
� •_ . . : .� .'.
� +, . � .
, _.. y
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��:uMM�NDATIONSlCOMMENTS: ' �
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, properly lines, roads,streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems� C�C.) �� C.1AMfPRCJ.DOCStiPPS£G.S7�1 FW�NCEPC
PERSON COUNTY
De�r Gwmer/Repr2s2ntative:
SOaGOUNfYGO�
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PERSON�COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH PROGRAM
325 South Morgan Street
Roxboro, North Carolina 27573
(910)597-2204
l/dGvs � �S� � 9��
Da �e .
Re: �-ac� . �ry �����J�'il�a/G�� KEc�vEST)
^s� e above r2fer�.nc�d lot has be`z evaluated by tr.e �erson ��z�y xea� ��
Dep�*�:ent. The resslts. or the evaluation, a coDy o� w-hich is a�che3, in-
c�.ca'�� that tn� site is �*isuitable for ins�llaticn or 'c. grC'L*?G'' 2Jsor�tion
SCtN�GC,e sys��*n for tne fcllcw� ng reasons :
!/NSviTi3�3tE ��-y •ry/NEILA�GG�'/ ��.��,,,.���o� is" ,-� ay ." ��� .i9yr�
c�NSvir�i�3� So�� G/E'TNFSS l'��/T/oNS i3EG/n�isi/N� /s y -,� ,�� : ' �R �' . / 9Y��
Lit< K of /¢ �'Ai� �ic�GE P�o�/Sio�Y.lcc `> Sv�,�B�E Soi� �ie�9. ��2v�E ./ 9 S�S�
�:� t0 t^.� 1]Ti11.�`..�..aCI15 on yo� 51��� t.�]1S ��zi'�i.�^t 15 I:C�`. 2TrTzr'e Oi u�.riy
r�c�'icat�cns or alt�_*��ive me?ssr�s t�t can �e i�-�al�ent� to u�gr�d� t^.e
C� z5�'_=1Cation f�cn ��UPSu].�L�.Dl.e'� tJ °provisionally SLL''�c?D12. �� VCIl�: �pD11Cd-
ticn �or a.n i*iprov�n�*�t Fe.�*-zi� cm:st, therefore, rz de.*Led.
Ycu hav2 t�e right to an info�l r2vie:a o= tis �ecis�cn by tns environ-
m���l healtn su�er�isor of this healtn cer�rt-��nt and also by tar regional
s��s"= c� the De�artrn�zt o= Fr•virccur�ent, Eealt'�, a.nd Natural Resources. Ycu
shculd ccntac� the Y1231�..R de�.�nent t� zrrnSe ior tzis f��-`�her rzview.
Ycu may also wish to cbtain t'�e ser�ic�s of a private c^nsul'-�:t to
collec-t sit..�--st.eci=ic data and sui-snit such data ar.c a syst�n desic,n to the
he�l`_z dep�*-tn�*�t for tec.znical revi�a. A site may r,e reclassi�ied tA pr�-
visicnally suitable provided writ��*� �.ec�-aentation, inciudir_g eng�_ne�-xing.
hycrcc2olcric, Seolegic, or soil s�udies incLcat�s to �:�e lccal health dep�-
m.ent t�.t a propos�3 septic tank syst`n or a p�ccsz3 al A..ative syst�n can
reascn�ly be exrect�d to function satisfactorily.
'The substantiating data frrm thesz studies mus� indicat� that:
P_. The ef�lu�zt (wasteT�ter) will r2c��ve aZecua`� t�.�3trae.zt;
B. The e�=lue.nt (Fra.st�:�t�r) will r.ot �nta.�inat� an.r grcund
wat�r or sur`ace watrr; and �
. . . • p,�ge 2
C. The efflu�*�t (wastewater) will not �e e�osed on the ground
surface or be discharged to surface waters where it could
cane intr� contact with people, animals or vectr�rs. .
Finally, you have tne right to a forn�I apreal of this Cecision if you
file a petition for a contes �d case hearing with the Office of P�ni n i s�dtive
Hearings, P.O. Drawer 27447, Raleigh, N.C. 27611-7447. A copy of a petition
fonn wili be provided to you upon rzquest. The petition must be received by
the Office of �ni.*iistrative He�rings witnin 60 days after the datA of this
notice. The hearing will be held in the county in which ycur property is
lccated. �
If you file a petition for a hearing, you �nus� sznd a copy of the
petition to Mr. Jo'nn C. fiun�, Of�ice of Gzneral Couns2l, P.O. Box 27687,
Raleigh, North Carolina 27611-7687.
Pleasz call or write this of�ic� ir: you have ques�ions or ne�d addi�onal
assistance. �
Since*-ely,
L��`-' ('""''`.'� � s-
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E7iv�rnr.ental Fealtz Soecialist
g�v; rcr.���tzl, fieal;h Divisicn
Person County Health Department
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � a i� Parcel # l��
Zoning Township � �'� � Z 1-� ; 1 1
Owner/Contractor ��� �G( �1J4 n �� Date ► o I � t I R�
Location/Address � E-1 �� r 5 7 N ��/� iV� b('i-o n 4�c l(: ct. v�n T I �.- � 0.-C K
�`�' m rn�-� � c,� o t- c� r� L��—�— S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area I.$yqC. Size of Tank /G��
..� - Mobile Home � Size of Pump Tank N
ness # of Bedrooms�_ Nitrification Line 5�,�' X 3�
Max Depth Trenches I � "
Permits may be voided if si
Well and Septic Layout by_
Comments: ��► �y�,o�`,�QQ
,�-� • E N 5
�ate 0- `7- 9 Installed
ell Permit Paid
is altered or
►, �,S�C�(�s
�� M d �
Individual ll Semi-Public.
Public Replacement
Site Approved �
Well Head Approved
Grouting Approved
Comments:
Date
Installed by
sC6. u c� � �� l� �s
le use chan ed.
�,��5,�� �
�r � L �
��.s o --s� r,o
�_Approved by
��- �o-�-�`7
SYSTEM SPECIFICATIONS
Required Slab 1/
Air Vent
Required Well Log
Well Tag I/
Approved by,
This report is based in part on information provided the homeowner or his/her
representative 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 County nor the environmental health
specialist warrants that the septic tank system will continue to fu�ction
satisfactorily in the future or that the water supply will remain potable.
c:\amiprolpermit.sam O1/95 rev.l.l �
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Date:1>-��-�
Owner. ��
Location/Direc
Subdivision NZrne:
Drilling Contractor:
PERSON COUNTY ENVIBONMENTAL HEALTH
WELL LOG
�
SR#
Y ._
Uistance from Nearest Property Line /O Distance from Source of
Pollution /CX� ''
Total Dep.th: _/ yc� Ft. Yield: /� GPM Static Water Level �S Ft.
�'�ater Bearing Zones: Depth �Ft. 8'7 F�. / f U F�_��
Casing: Dep t h: From 6 to <! � Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
� Weigh[: � Thickness: /F� Height�Above Ground: i�i Inches
Driv e S ho e: Yes ✓� No
Were Problems Encotmtered in Setting the Casing? Yes No �
If "yes" gi�e reason:
Grout: Type: Neat Sand/Cement �/ Concre[e
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - � �Pr:ssure � � � Poured,.,� � - •. - : -
Depth: From O to �. � Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttin�s) - Ratio: to
�ID Plates: Yes ✓ No � � � �� � .
�� 4 x 4 slab Yes�—No
u
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �y�THE PERS0�1 C�LiJTY HEALTH DEPARTMENT.
� ignature of Contractor Dace
�..
� PERSON COUlV'TY HEALTH DEPA�ZTNIENT ,(,�
355� SOUTH NIADISON BLVD. �
- — - - _ _ __� "�. _ __
ROYBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SANIPLEANALYSIS
Name of O��ner or Tenant �f'A�tl�t,ci IN t I�►���vtS
Address �,y� �t�(�,� tYQv��'� County� �ya
Collected By ��
Date Collected Z'21`a? Time Collected j2;/d
Source: Well ❑ Spring � Other
Location: ❑ House Tap �Well Tap C-�'Uther -
❑No Charge harge �
**********�*��**��*****�*******�***��**�***�***�***�******�**�****�*******x�*�
****�**�*******�*�**:�**��*****�*�******�***�***�**�**********�*�*****x*****�.**
Total Coliform
FecaUE. Coli
Reported By
bactreport
Results
Present Absent
❑ �
❑ C7�
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