A26 35�
��lication flaie: l b -10 0.�
�mount Paid: ___ ���
Recaipt #: �, q 4 3
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Parca! �: 3 �
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APPLiCAT10R! FOR SEiiVIC�S
0� Acre.
9F Ti-IE INIF�RNiATION IN Ti�ilE APPL@C�►TIOPI F�R ,�fV I�APR��lEMENT PE�flfll'9' IS INCORRE�T, �a�►LS1�8E�,
CHANGE� OC� THE SIT� IS ALTE�ED, T�ER! '�HE InIIPROVE�lfIENT ��E9iiUiIT A(�D AUTHOi21�ATl�b� TO
CO(VST9aUCT SHALL �E�ORflE IIVVRlLID. �
1) Permit requestec� by: vun agen#/pras�eciive owner): Z a
Home Phone: — Address: 3
Business Phone: �- a G.
; 2) ��ev�e and acldress of current ouvner: 5�.-�-�.� 4S �o�r'e
�) �'ropeety Desc�iptcow: Lot size: n�r� Township: Subdivision: Lot #�
Directions to the property (Including road names and numbers):
, ,1.1�e X-�' to 3`i e�o ra �
4) Q�roposec! Use ay�d Sinac#ure Description: answer each of the foilowin questions:
a) Proposed✓ Existing , Type of Structure: �-'4-iC� [�1`% ,�-�e- Width: Depth:
b) Number of Bedrooms: �_ Number of occupants or people to be served:
c) Basement: Yes /, No _ Will there be plumbing in the basement?
d) �arbage Disposai: Yes , No � �
5) lAlater Supply Type: Private �new _ or existing�, Public� Community� Spring _
Are any welis on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
`site pian.
C) Does your property c�ntain q�revious9y ic9entified jurisdictional wetlands? Yes_ No �
PL�SE NOTE Tf9E �OLI.ODUIMG:
9 A PL.s►T OF Ti�99E f'ROPERTI( OR SITE F'LQPI i1�UST �E SUBii�l'i'TE� NVI�9 �'9�iIS ,APPL9CATabfil.
➢ PROP�ERTY L1NES AND COR6dE3�S MUST BE CL�AFYLV iNARS�CED. �,
➢ T6-IE PROPOSED LOCATION OF ALL STRUCTIlRES fifiUST �E STAFCEi3 OR FLAGGED,
��➢iE SITIE iVIUST �E READILV ACCESSIBLE ��l� AN EV9�1LU�►'i'ION BY T�-IIE liEe�LTH DE�'�RTRf1E�T
STAFF.
I hereby make application to the Person County Health Department for a siie evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
facifities to be plac�d on the property. I understand ifi the site is altered or the intende� use changes, the permit shail
become invalid.
Cwner or Legal Representative
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Date
PCND, 2v. 06127102
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I��-�a.�-��T-�--. ����.IL I�IC�.�.II�II�
Applicant: �'�v� � ��
Location: �
T�x M�� P�r�cel �
S�uhclivi.5ion
Ph,:�.seaSecti � n�Lot : �
Iffiproveffie�at Pe��t
�es�anit �7alaci �m� [ `�ly� YB�fl S _ �� E�DiH'�i10Y1 ((
Type of Facility: '2�I�
# of Occupants # o � edro�
Proposed Wastewater System:
Proposed Repair: ��cv�,.%�s+-
Permit Conditions: ��
Owner or Legal Represe
Authorized State Agent:
New � Addition �1�t�s� �aapply w`P
Projected Daily Flow �(��o g.p.d.
Type: C�'�►
'Type: -
�-� I.-� s� (�,�� � �-�-, � rQ,�l S
ua�c.
Date:. ` �'�
The issuance of this permit by the Health Depariment in does not guarantee the issuance of er permits. It is the responsibility of the
applicandpmperty owner to in sure that all Person County Planning and Zoning and Buildin Inspections requirements are met '�1ais
�proveanent Permit is subject to reaocation if tJhe site pla�, plat or the intended use c ges. he Improveanent Permit is not affectesl
by a chaaage in ov+�ner§hip of tlae property. �'his permit svas issued in compliance evi e ro ' ions of the 1Vmrth CBr�lana `Laws anai
Rules for Sewage 7'reatment and I)isposa! Svstems' (15A l�iCAC 1�A .1900). 1�T n ty nor tlae �vnron�ental �eal#�a
5pecialist warrants that the septic tank systepi w�ill continu� to functnon sat�fac rily e e or that t�ae vv�ter. supply vvill remai�
��a
* See site plan and additional
Proposed Wastewater System:
New � Repair Ex�
Type of Facility:
Co���uct �
1:1
�Reqaaared %� �uild'ang Pet�i$)
\ Type� WastewaterFlow ���g.p.d.
5oifl I:'Tt�i• ��7,�, g.p.d./ ft 2
> Basement Yes �No
Rea�uirements
Tank Size: Septac'I'aaal�: ��� al Punap'I"aaak: ga! Grease Trap: gal
Drainfield: Tota1 Area:��� sq �'ot�l Lengih �`�� ft 1Vl�ian�'�rench Dep�a ��f a�� �
'�'re�ec�a �Vidth � f$ l�xnaea�a Soil Cover: �_ iaa Minimum Trench Separation: � f� - C�
I)astrabaation:
sp��C�����:
� Distribution Box � Serial Distribution Pressure Manifold
n �(�� �-- Se�.�, � `� s � . �� — �� �-��� � ��c l �
Aut9bo�aze�i State �g�aet: _
Pennit Expi
C, �r,✓v-e�
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The typ�e of system permitted is 0� Conventional
the permit:
�wner/i,egal �epresentative:
�i'1��
Date: ` j�� �'� �
Innovative Alternative. I accept the spe�ifications oi
Date:
PCHD7/30/2002 :�
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map P,ar�el #
Applicant: �
Subdivision:
Location:
Type of Water Supply: iL Individual
Requirements:
Site Approved By:
Grouting Approved By:
Well Log:
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Well Approved by:
,
****See Attached Site Sketch****
Township:
Lot #
Wells must be l0 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:
PCHD rev O1/27/04
9
i��
�� SEWAGE D[SPOSAL RECORD
____�� rs �_�_______County Health Department
----------------------------------
Name of Occupant �ak�__�v4 b____
I�Tame of Oivner __ ~O��`1 _ �� �� ---
Type `of Privy Constructed__________
_ W__� C
_ W_�-' C__
----------------------------------------------
• %�j%� � /�v,Y o ro � � �dn�c /�o!
Location of Building ________� - ,------------
Date of Installation _�IP�_�_-!y Ly��_`-__
_Number________ ____.___- New or Repaired _______________
Septic Tank_Pr� `�a�Z_______- Date Inspected ��'-L� ��� Permit No. ______ Capacity__7'_�_�_______
� (concrete, �reiai; et�')
Numbers of Users ___J_T_—________________ Type Secondary Treatment ______________-__-----------------
Sourceof Water SuPP1Y--���------------------�------------------------------------------------
Contractor or Plumber_v r��s�'� � P���''�� ^'-�- r�'Address__1��r2'� ��'�=------------------------
_ r n
Approvedby-- ------ -- ----- �2�c�-'------�------------------------------------------------
-�/ , , � a�
Remarks /_2L�- G✓ds_ .4�fe r o �s�a�_ 6u i�%x_��e _ GL.��er 6T•✓� �•�y _ /�l � �'`�� ,�r/v_� (OVer) ------
w�au � d b� o v�e� 7�C�e ie�o� C•J6% 1 ro�v P.P ��-�.
N. C. STATE BOARD OF HEALTH 10M 3-39 FORM NO. 2O7
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adja-
cent property, etc. Write in measurements in order that installations may be located at later date.
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of O�;�ner or Tenant ��1���, l7J�K5
Address � �-�)1�1e� 1�d, County ��rSa;� '
Collected By �S �
Date Collected �— � ��0� Time Collected
Source: �Well ❑ Spring ❑ Other
Location: E'7House ap
❑No Charge harge
pWell Tap ❑ Other
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***�*�****�**��:�*��*���*��*������������**������**����**�*�*��*�**��**��*������
Total Coliform
FecaVE. Coli
Results
Prese�}t Absent
� �
❑ �d
Reported M �� � � ( Z� ��
bactreport
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant ��(a lf���KS
Address ���� ��ora h�• County p� ;��
Collected By �S
Date Collected ������ Time CollectedJ=�� _
Source: C�'Well ❑ Spring O Other
Location: p'House Tap OWell Tap .
� - [�w��L
QNo Charge ❑Charge
❑ Other
,�*�*���*�***���**��*���**��*�*���**�*����**�*��****��****�*����*�*�,����*��**��
***�*��*�*��t*��*�t�t*�����x*��t��t���**�����*���****�**��*�t���*����***�**��*��**��
Total Coliform
FecaUE. Coli
Reported By
bactreport
Resutts
Present
❑
L■
Abs pt
d
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