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A26 146, _ __ o, = �. ,� .��.��- _ 3 � 6� � � `�� Aa�lication Date: 7 �'�% � � �,� � n�j Ta� ��p �: Amount Paid: �� j� �Jr �Ze�eiqt #: �.� <}- � �� "Y �� arc2f #: � 3 Q ��_.S� ��..� �� 7 - -_ � � �� °� � �a�a_�-s.a-oaa.-�-�--,• .caa�.eo..11. 7E—��u.Il.�7�a_ A�PLICATiOId FOR SERVIC�S I� THE IfVF�RMATION 1N Ti-iE APPLICATlOId FaR A1N fMPROVEMENT PERiVi1T IS INCORRECT. FALSIFiED, I.UN� 1�'CUI+ 1.71'7HL�. 6CVVWlC IIV VALILJ. i 1) Permit requestecl by: (Ownerla ent/prospective owner): C da Home Phone: .5 �� Address: / Business Phone: R�-3h � . ,� � J 3 2) Name and acldress of.caarrent owner: 3) Property Description: Lot size: l�Township: D'� '� Subdivision: �1 0 ! Lot #� Directions to the prc �) Proposed Use c9 Structure Description: answer ach of tF�.foll9 ing questions: a) Proposed Existing Type of Structure: ��{ , Width: �/� Depth:�1_ b) Number of edrooms: � Number of occupa s or people� be senred: c) Basement: Yes No � Will there be plumbing in the basement? d) Garbage Disposal: Yes J No �, 5) Water Supply 'iy�se: Private �, (new � o� existing�, Public , Community , Spring _ Are any wells on adjoining property? Yes No _ If yes, please indicate a�proximate location on the site plan. 6) Does your property contain previously icienti�ecl jurisdictional wetlands? Yes_ Ido� � PLEASE NOTE THE FOLLOWIPIG: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMI"1'TED WITH THIS APPLICATiON. ➢ PROPERTY LIRlES AMD CORNERS MUST BE CLEARLY MARaCED. ➢ THE PROPOSED LOCATIOPI OF ALL STRUCTURES MUST BE STA�fED OR FLAGGED. ➢ THE SiTE MUST BE READILY ACCESSIBLE FOR AN EVALUATIOPI BY THE HEALTH DEPARTMEfVT STAFF, I hereby make applicaiion to the Person County Health Department for a site evaluation for the on-site sewage disposal system for. the bove-de cribed rop . I agree that the contents �of this application are true and represent the maximum facilities to b placed o the p pe 1 understand ifi the site is altered or the intended use han s, ttie permii shall become in id. � � D3 wn r or Legal Representative Dat • , PCHD, rev. 06l27/02 : �'; �; PROPERTY SKETCH THE MEADOWLANDS PHASE 1 LOT 1 SCALE 1"=50' _.- I I � � '. � .. 0 _�' � 4�� 11fJ �Vr/ �� .� � � � �� aa.�na-��n.a�ra�satE�.Il. �'��►.Il.��n Applicant: Location: � in5-�-cad T��x M�a.F� � � P�rcel # � S�uihcl'ivi�s•iom -•.• � • Ph��se Sect�ion Lot i? Permit Valid for Type of Facility: _ # of Occupants � Proposed Wastew Proposed Repair: Pernut Conditions: ,/ Improvement Permit V Five Years No Ezpiration '' n( t, �ccm i L ,17wc.( ( i New� Addition _ Water Supply ri �h�-l�c� I # of Bedrooms Projected Daily Flow �(o� g.p.d. : System: �nnflVn-�t"dc oZSia rc.duL�l'on) . Type: L�. � �U.m U�n r'1 O Va-b y c. C�,.5 �� r"cdu.c�i'o,� ) Type: Tn,S-� t I 5v S-�cm or1 cor�to��, I�c.co b�5-E�.m �`� arc� 5�•�� . �,-.E-< � F S�n•�tc, o�u� oF i ow -( �r �`�a � rc�a., 7'an K L c�ca-f�' on iS � -- - , , . < ., . , _._ _ fi Owner or Legal Represe Authorized State Agent: w �� -- � Date: ld /� °3 Date: - The issuance of this pernut by th� Health Depariment in does not guarantee the issuance of other pernuts. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze me� This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewa�e Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (�. Proposed Wastewater System: Tn n�ua-�i � � Type � Wastewater Flow �g.p.d. New � Repair Expansion _ Soil LTAR: .�1S .p.d./ ft 2 Type of Facility: � f �(C, F4m i l e(` Basement _ Yes �No Wastewater System Requirements Size: Septic Tank: �Q� gal Pump Tank: N1 l� gal Grease Trap: IJI 13 gal � � Sidc field: Tozal Area: � sq ft Total Length S�� ft Mazimum Trench Depth o�o� in �h Width � ft Minimum Soil Cover: �D in Minimum Trench Separation: 1 ft Distribution: Specifications: .� � � � .... Distribution Box � Serial Distribution Authorized State Agent: Pertnit Ex� 0 n 10� p FF ct �� ro c�-Ey • I+` n FC�c.n c c. lS �� Ci [ ITC.,c'� Pressure Manifold m�.� d ' d,�st'u.rbanc.t� Date: �j 4 -t�� The type of system permitted is Conventional � Innovative Alternative. I accept the specifications of the permit. Owner/Legal Representative: ��i�� .' Date: / o /3 D C 7/30/2002 t��.� � �a �.� �1�1/ V � Lf ��J �T� �J.LT �,�'i�Il,T'am�-nrw@S.'L'�..�.JL ��.1� � �S S n•-, �YSAi��Y:: " . N La�y � i nSt��-d Taa Ma� #� 2G Pa�c�1 # �= S � un � • � Se�,on/Lot# I � �-19--�'3 : 1�uthorize3 St�te Agent �- . Date. . .Syst�sn c+ossa�on�s a�iaa�s� �ra.xsasa�e4�s�ssrs �►. �'':v.e ��r aa�st,�lag �iae s�,st�a,� ta. � be�g �t%ie s�a:rt�rs � � ��erg�fade ss �ned ' � � NOTC�G �ou.Sc Lc:c.a..�► o� i,.�aS .• � � p�,d� u.� t�ccd 15' ta�,3o rd s Qoad - -�o o�.c.c.a�oda�c� rcPa i t' , . y� a� a�ua- � c.�t �o c� a�� .. A� � � � �9s� . 1�� I oc.�-�on� ° �-1 ��\� \,� , . • _� v R.�Y` . �/ �5� � ��' q�, . � �y�^�' �� .�r►novu--�'`�c R,t�a�� arc� ,- s� �� sa , � �a`n (� �_ �� , �� — , , s s�^ � �` 2a' `�Sb�.l `( � �� aS F�aS� � b,� ��5, � GI� �� 1 (DO� '��0��, . ��-3�3, re�. fl9/�/�D1 � \ 1�� - \y*1�l� �\ ' � � �� 7E�.��-,� ,�, ��.I1. IL��,.71-�. �1X IVI��:'] , � � P��.t'rr�� r . �'.J,L��{7 �I� 1� �'ti��''.J �� %� I P�h�,�;�ei�ec�t;i�ai�i:�L.a�t � Applicar� �,, �� ns�e� � - . . . Location: 5'7 N� lo�- o.• � ►�Fo.� b�,��+ �ma� ' � . �� r"atio�i: Pert�'�it . . . .. . � . _ �- . System Type (In Ac�ordance With Table Va): // THIS SYSTEM l�i�►S BEEA1 IAIST�►LLED iN COMPt1ANCE VNITH APPLlCABLE NORTH � CAt�OLdNA GEAIERAL STATUTES,. RULES .��6Z� .$EW�AGE ��Ti2�+►'iMENT AND- �DISPOSAL, � � �►ND ALL CONDITI�NS � OF TH� IMP�20VE�VIENT ' PEi�IT . AND COi�lS'TRUCT90R1 .. AUl'HOR{Z�T10N. . . . . . . . _ . . ' : . .. . . . .. . . . . ' - ' . � • . -_. . _�. 5-� rr-v.y • '. � _ : . . . Autho Sta � � gent . . � .' . ' . . : - : � Date � - � �� Installed 8y. (��oQ� '�Q�A�s.a.. � ' .. Date, 5--//�'v� ' . . . .. . � . � ._ .i. _ � � . _ '.: � '.' �_. . . _ : :._ . ':�: .: -; ; _. :. �. . �� ." . . � .. a�, . �� — — —. - � �5� i�� ,- , � ' . r �� J - V�_ �' 's t D (` N 9 '�A f�1 = h � , � .� - BO' � � T � U � , � � i C!-i �_ ieV. G7/29/02 S�C� Z��Jd� [�l��tON. C�lE�1.lS'� (7'�� U � Tax IVIaQ ��'a� Parce! # t y l� System Type {Table Va) �,_ OwmenApQlicarrG Subdivision �Ca�� AddresslLncation � Ser.lPl�ase !�t # 1 . - . . St�te ID/date �a�ia-o3 �3-�ya Capac' . 7 -�o�o . gai. Tee and Fiter lAli�ttt ft. ✓ c -► r� in. � � - ft. Ba#fle Trench Gtade ,� � Sealarrt � Trench. S ac9ng � Rise� �fi a iicable ✓ Rodc De th and. Cdualiiy Tank Out1�i: Sea1 �� Dams/Ste downs etc. � � � Pennanent Marker � Pressure Laterals � : Pu�a�p �Tank � Hoie Spacing . . . . . tate e " � o. e� .. . . . � . . . � . � CaQacity . . al. ' �� Pipe Steeve . - . . . � . . Waie roof /Sealarrt � Tum-u s}Protectors • � � � . � � Riser . � •�equi� Setl�ac#�s Water Tight � � - From .Wells •.. � � - � - ,_ � . . Pu�np � Frnm Pmperiy lines � � . . . � �beck Valve/Gate Vaive . . : .Struc�uresJBasemer�ts_:: � �.� . � ip on o e .� es � ra�nage . a -. . .� � F"�oatsl�witct�es � : . � � . . � . . .� . : . �SurFace` Waters . . . _ . . . _ .. . Alann visable and audible � Pubtic Waier Su piies � Eiectrical ComQonetrts Veriica! Cuis� a2 ft. . Rate g m Water Lines Ap ro�ed Pump AAode! . Veh�le Trafiia � Blodc Under Pump Adjacerrt•Syst�ems � Pu Removal Ro elChain Easemerrts/Ri ht� of 1l1/ � . .Disiribution System �� Seriai Distribuiion ��xz �=�,-� Easemerrts Recor�ed . � ressure an' erator ritract Low PtEssure Pipe • Tri-Partate Agreemerrt Apor. Pioe Material and G�ade - I . Cominerats� 0 . " � pcf�d rev. 3I13101 - ��.�� .�� ---- � � ��- ��.�.��.,�.,.��.�. ��.�..� �� 5��5�� T� 1�Fap #: ��' Parcefl # I�i''6 Township . APPlican� i—� � inb�d subaav�saon: mca.�oc�lan.ds s�ion: �� Location: t/,� •- t ' �� , ,.i,- ;J:� ' . � • • �� . � �• •• � � � � ��i�i1�fCffiCIa$S: �- ' �� •�-• �� . .,.. •.... .�.-i .: ��i ��. - � _�i - _, „ i�di � ' � � / . , .. A. ., • _ . ' i- � I � �. �i�� • - : . �!_" � � � _�- �«-�- .•��%� � �� We�.�IOVCi� . T""�� 1'iIP.�CaCS1.7EiC JSCCIGIa ' WeIls must be 10 fest from property liaes. Wells must be 100 feet from septi.c systems. � Wells must be at least 25 feet from anp buldin.g foun.dation• Other conditions: (rlo+ in-fc� i n iDC7� � IuS fv a. t I Sc P�I� S,}�SttmS � K� �v w�.r l au---� a F L�t� rlrcn, 5. F,y,w 1 j� d h�.u�n E�fS Vcri FY�tac.�( Lac�-�.�o� W �u' j,d, ��-�-pn�n'� C!\. �' PCf-ID, rev. 09/07/Ol Prtt�r t.D CL�'� �I�nU /� IS) 1 .� �� •� \ Dr�iller ID � � i � " ,_ - � C o�rn� a ny N:��m e � � % � ' � � , , � _ �) � � 1 � � i= , , ,, _ i i i Dat�e Drilleci r r %� �l n� � � Grout Log ' �wne_r: /�� 1 � c C, t V� � w� Tax Map/� Parcel #� Location: � Subdivision: � � S Lot # �_ Weil Construction Distance From nearest Property Line (Minimum 10 feet) � � Distance from S ic System (Minimum 60 feet) Lo Z� Total Depth: �� ft Yiel¢:�_ GPM Static Water L:evel: a�5 ft Water Bearing Zones: Depth 7� ft ft ft ' ft ��snrng: Depth: From � Type: Galvanized Steel Weight: Drive Shoe: � Yes If "yes" give reason: _ _ to 73 ft.� Diameter: �_ in � Thickness: / v Height above Grouncl: � 7 in . No Any problems encountered' w�iile setting casing? _Yes _�'1�To �e��aa�: Neat: � Sand/Cement Concrete ,� Gravel/Cement � Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped Pressure ;;�Poured _� Depth C to �� Ft. I��erials LJsed: . No. Bags Portland cement Weight;of 1 Bag Pounds If mixture (sand, gravel, cuttings) — Ratio �to ID plates: �Yes _ No 4 x 4 slab `� 'es _ No � Drilling Log � Location Drawing �'rom To � � . Formatio � ;; � C?t- • � o " � , � � � s- , ��`� � � . �� . �� ' �k �'� � � I hereby certify that the above information is set forth by the Person Coun�eaith-�e� �ignature of that this well was constntcted in accordance with regulations ID # ��'�� Date �' � � �� PCHD rev 09/30/02 �� ,•�;�1 I.1 / 1 nc department of health and human services �, ,� � � � � �, �; � � � � u � t � � . ., s � � � � � � a � xs F�,aw� S � � �' 3��i � s� � �� k �� R "i� � F �s � � ., t! �' .� �.`:,r�w', ..� ...n �r,a� ,s .� `�sa� Z : _ tf €1 r,. � .. a � >.� �._� � <s .�r :�� - r.. a �� .� fi 3 �"�. :?� : ft^ "•b r ,z�"� �.�,"'* e.� �*'iA t% a `^a� ��'� � � ..:'�"� � '� �r"�"-3 ( } . ¢ „`7� d !y j � F f .� i e ? i ,.x � s r � x � r s'i rv � e7` s y �a <a 1 � � ¢{ � ;%"�`� � ^e �i i� � m� <_ ,.�- b .. , ..� , x_.�. ... .. �,� . � �.. . r� a �> '^�=�,Y a, .� �.,r=i ��:»�ia .� i ��..��' .a _� �,.:,r For lnorganic Chemical Gontaminants County: � Name: GZ, Sample ID #: — 1 Reviewer: , �t"u�. TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic c/remicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorQanic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. ❑ The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for wasliing, cleaning, bathing and showering based on the inorQanic c/:emical results onlv. Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron Manganese � Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH 3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inorQanic cJremical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc. 4. ❑ Re-sampling is recommended in months. 5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably tlie kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. 6. �he following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorQanic chemical results onlv, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride KlronJ � Magnesium Manganese � Selenium � Silver � pH � mc Fnr more infnrmatio�t regarding your we!/ water resu/ts, please cal! t11e Nortl: Carolina Division of Public Herrlth at 919-707-5900. Report To: H. KELLY North Carolina State Laboratory of Public Heaith Environmenta! Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: MORGAN CARTER 4981 SEMORA RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ESO40716-0076001 Sample Type: Raw Sample Source: Well Date Collected: 04/06/16 Date Received: 04/07/16 Sampling Point: Outside tap Temp. at Receipt: 4.3 P.O. Box 28047 4372 District Drive Raleigh, NC 27611-8047 http:/lsloh. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Time Collected: 3:00 PM Collected By: H Kelly Well Permit #: A26-146 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 6 mg/L Chloride 6.90 250 mg/L Chromium < 0.01 0.10 mg/L Copper 0.29 1.3 mg/L Fluoride 5,4.20 4.00 mg/L Iron 0.30 Lead <ZS.005 0.015 mg/L Magnesium 2 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 1.30 10.00 mg/L Nitrite < 0.1 1.00 mg/L pH 7,p N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 11.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 31 mg/L Total Hardness 23 mg/L Zinc 0.14 5.00 mq/L Report Date: 04/26/2016 Page 1 of 1 Reported By: Dedd%.�foncoC � J l � �., � �. �^� �L./�� n.vvnzroanm��a��.� ��.��ia Date: � /�_/ /(p • � � - i i �� ./ ' �.' �� ., � i �i ,G� �s / Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel:�� Your well water was sampled on 4� / lo //!o , and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: �l_ No coliform bacteria were detected in the sample. Your wz11 water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total co�ifcrm bacteria are naturally found in the soil. Fecal coliform bacteria a:e associated �vith animnal and/or human waste. The presence of either total or iecal coliform bacteria in well waier 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 use. Young children, the elderly, and the individuals tivith compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested prior to resuming 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 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, Y � �G�� Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-179Q Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ESO40716-0093001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: MORGAN CARTER 4981 SEMORA RD ROXBORO, NC 27574 Col lected: 04/06/2016 15:00 Received: 04/07/2016 08:31 Sample Source: Well Sampling Point: Outside tap P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Angela Heybroek Well Permit Number: A26-146 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Owens 04/08/2016 E. coli, Colilert Report Date: 04/11/2016 Absent Explanations of Coliform Analysis: Darneice Owens 04/08/2016 Reported By: Susan Beaslev / � � If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sampte received and should not be regarded as a complete report on the water supply. . _ .: The��District:-:Heaifh- �epartment . _ ; . , _- Orange, Pers Caswell, Ch am, Lee Counties ., ' _ �� .� . _ '� ct � � �-e �r,v� _ j � , � Water Supp�y�and Sewage �ispos�l �� ' - � IMFROVEMENTS PERMIT No.�_ .:. � Date 1�� , I� �' '� , _ � Owner• S ��1'l,�t�: 4=� � � �,_ ` !' L �� i.' �. ' � �•�� u • .a �-y-�--,�-r,P�C 3-7—�-r� ��f 1 r�Lt � • � �� , . pq Location: st �- ! �� ,'' . �f :Z.. , , .. r, a ('�nfrartnr� ..._4? t ;_.r� -' ' t�.�, � Wa3er Supplp: Private —�---„�-�= Public- ; ;. . �,:='' . � ewa ..Di�spas�l. acili3ies: No. bedrooms y� Dishwasher :Disposal, ashing machine, _ot er autom tic appliances ��` ,. i ize o"'�f tank: �' �`� Nitrification line: , ' �• � ° •i Other disposal facility: ' _ $��► G c.lSV - : ' Water supply and sewage disposal facil' a�nn,.- instal ' n d� ' protection must meet state and loca regulations. � � , Septic tank should be pumped out every 3 to 5 years and shall b�''main tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP'- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPAI�TMENT STAFF BEFORE ANY POR.TION OF THE INSTALLATION �S COV- � ERED AND PUT INTO USE. . :,. . . .:. _; _ _. . ;t �a ; r �i jpt �_� 1 • Date approved: Signed - Sanitarian Well: � ' Sewage Disposal: Counter- . ' j � signed ' ,, : ; • $Y� (Owner or his representative) . I Certificate of Completion ' . ;'� ` �. :` � Date Approved: i. � ` ° �� BY� : ' Sanitarian : _ � (OVEft) Location of well and sewage disposal facilities sketched on back. . . � . , '. Y �' . . . . . .. � � � � . Nni�: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water su ilies, etc. Note special problems e�sting on lot. Wrate in meas�rements in order that installations may be located �; 5_ ._ _:� ._ -= , , .- ...�.,_ � . . �� _ _. • � , -_ .,. . _ -T�e �g��r�c� I-�eal�� epar��ere� Orange, Per� Caswell, Ch'n'+}}�� am, Lee Counties/ . _� . . y 1 R (j � � � ��/ /� Q �� ` Cl�Y i � �I�a �' �a$�� Supp��nd Sew�ge �Aspos�l IMPROVEMENTS PER1K} T No - _ Date `� � � ��t�r-- � Owner• �e0''��e:s Y'�• r i;.�-�'PG � !�'t;^j-�-�r.,:.�,, o • . j��. .-. � Gq Location: - T-s _ y � . ,--�" .�._= ��- ,� / � a Cnntrartnr• .�3;,;� . � Waier Supply: Private " �� Public ` � V�' - �ewa i aciliiies: I�Io. bedrooms � Dishwasher ,Disposal, ��: ` ashing' machine, other automaotic appliances " _ , . i i e of tan : ' ��`� � 1Vitrification line: ' ! Other disposal facility: � Sc�, o �tils� Water supply and sewage disposal facil instal JV d�j ' protection must meet state and loca regulations. J�j� ,,.,,i,t(�I` Septic tank should be pumped out every 3 to 5 years and shall be�'main- _ tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTEB tYND AP- PR.OVEI? BY A MEMBER OF THE DISTRICT HEALTH DEPAI�TMEN'r STAFF BEFORE ANY POftTION OF THE INSTALLATION �S COV- , ERED ANT3 PUT INTO USE. . n, -_.. . _. - , � � , i , � .� , � a{'.rk #'Lj ..`�,� � .u1 Date approved: Signe Sanitarian � We1L• Sewage Disposal• Counter ' ' ' �, . By signed ,.. ^ . :. � ,,.Y,- .., (Owner or his repiesentative} Ceriificate of Gompletion .� , r' � �, Date Approved � �`By .; 7 '. � Sanitarian (OVER) Location of well and sewage disposal facilities sketched on back. Nn'�E: Make sketch of installation showing lot size and shape., location of house, septic tanks, privies, water su �lies, etc. Note special problems existing on lot. Wrate in meas�rements in order that installations may be located �, i _ ; ;;; ; `r ,