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APPLTCA'�ION FOR SERViCES
Improvements Permit. (EstablishedlRecorded Lot) �._ Rei
_ Repair/Replace exis[ing Septic System
I 1-�29 —`� � .
Date
ion of Existing System (L.oan Closing)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Permi[ for New Well
_ Replace Existing Well
1, it requested by: . I
owne / rospectiveowner/agent: (.-bi5 �� ��nr
A dress: 41 q'l (`�1 or �-O n�i.t��iam �� •
r?i. _...�,.,.,�,. n 1 r . �'7.�^i3 _
ome Phone #: Q � - �qq - � q � �
usiness Phone #: - — -
. Name and addre�s of,current owner:
. Lot size:
Tax Ma �
� z e,
�: . � �--�-
Parcel#: . • � � 1 �
Tnwnchin' C:►�►JN(1J I.�L.n An
Directions to property:
ames,�tc.
" I33Cp m�lv�
'l Z r,r.; l e �u
Number of occupants or
Road # & Road
to be served:
7. Dimensions or Proposed Structure:
---. ... — .
Depth: �—�
8. What type (if any, additions, expansions, or
teplacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
9. Water supply t�pe:
�rivate �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes C�No [�.
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: Q!
Type of dwelling:
House: ❑ Mobile Home: [� Business: ❑
Type of business:
Number of Employees: . � _ ..
Number of bedrooms: .._._—
Garbage Disposal? Yes ❑ No 0
Basement? Yes � No�I If so, # of basement fixtures�
.�'—
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COunty T3ealth Department for a site evaluation for the on-si� c
sewage disposal systein for the above described property. I agree that the contents of this application are tru�
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 tfia[ before an Improvements Permit can �_ �
issued, I must present a survey plat of the property to the Heal[h Dept. I understand that in the event I have nc �
delivered a survey pla[ of the property to the�Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
W .
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z Signcc� Owner or Authorized Agent
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Permit Issued ❑ Signature Date � t� ��
Permit Denied ❑ -
Plat Observed ❑ � `
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1. SLOPE (%) $ S S .._ s.
PS PS PS PS
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2. SOII.TFXi17REU2-36INJ S S- -- , S.. S
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(CLAYEY SOiI_S) PS PS PS PS .
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3. SOILDEP77i (IHJ . S' S S S
• PS PS PS PS
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S. RES7RICIIVE HORRONS (INJ S . . S _ . __ ., S . . . . . � . '. , . 5: •
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(BdPFXV10US STRATA. ROC1C)_. _. . . PS - PS . PS .. . . . PS
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6. SOILDRAINAGFJGROi1NDWATER . . , - 5 ° � . ; . . . S . .. . , S S
(DC7ERNAL A II:iERNAL) , PS PS pS . �: ..
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9. STiEC1ASSIFIGTION(SEEBEIOYn ' • . ., : ; , � ; . ' . .
I.t.,._..e�. . . � " _. . � - . . ... . ... . � . . . .
SOILSFRIES::'. :. . . , . . . � " . . . ,
- � � -- � S-SUITABLE `PSPROY1S10NALLYSUTfADLE U-UNSUTfABLE � '
RECOMMENDATIONS/COMMENTS: � ` �
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ll :
__ -
areas, wells, water bodies; slope-pattems��C�C.� C:\AMIPRO�DOCMPPS£C.SAIFWANCEPC ,
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Tax Map #:
PERSON COUNTY ENViRONMENTAL HEALTH
'ACHED PLAN FOR SDIL AREA AND SYSTF_M l
Paroel #
Zoning Township
Applica�t
locaUon:
Subdivision• Section• LoL•
Improvement Permit
A_buildinq �ermit cannot be issued with only an Improvement Permit
New Repair Addition Type of Structure _�, Water Suppiy
# of Occupa���� #�of Bedrooms � Other
Basement? Basement Fixtures?
Projeded Daily Flow: c�'7U g.p.d. Pertnit Valid For. �e Year ❑ No Ex iration
Proposed Wastewater System Typ� : '�,�r�t��lC�-�l`2. - (''�1 �ef'�� �t�S�c,,Y�f����-`��--
Pump Required? Yes V No d
Proposed Repair : �,r1;i1l� 1�L�QrV�,
Permit Conditions:
Owner or Legal
Authorized State
Date: 3��% �'�/
DateZ� .�
The issuance of this permit�6y the Heafth Department in no way guarantees the issuance of other permits. The permit
holder is responsible for chedcing w�th appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the inte�ded use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This pertnit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatrnent and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System
Facility Type:_c�1��- il�—
Basement? 0 Yes [�}�
Wastewater Flow�t%C�Q.p.d.
New ��air DExpansion 0
Basement F'ixtures? 0 Yes �o
Wastewater Svstem Requirements �
Septic Tank Size: V� gallons Pump Tank Size: �� gallons
Total irench Length: �� feet Maximum Trench Depth: � inches Aggregate Depth:� �in.
Maximum Soil Cover. � inches Trencti Separation: � Feet on Center
Other.
Permit Expiration Date: 1 � _��� � �
Authorized State Agent: Date: `�
The type of system permitted 0 does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature: ��" `���-LL� Date:�� � � � �
PCHD, rev. 11/18/99
AppUcation #:
Tax Map #: Z��
Parcel #: q
• Person County Health Department
Enviro�mental Hea(th Section
SiTE SKETCH
� �,�,(,�1�' i G� �`d�'�� �
' Applicant's Name Subdivision/SectionlLot#
, � �' I�� ��
Authorized State ent Date
Svstem components represent approximmte cvntours only. The contractor must flag the system
io beginnin� the installation tv insure that praper gracte u mainracnea.
�a�.s�
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scale:
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PCHD, rev.10112J99
A�rlication Date:
Amount Paid: _
Receipt#: _
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Application for Services
(Sentic Svstems and Wells)
Services
❑ 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)
$225.00/$125.00
Tax Map: 2 �
Parcel #: _�
❑ Construction Authorization
(Fee,i�denendent on the type of svs
�ermit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If tlie information in tl:e application for a�t In:provement Permit is incorrect, falsified, or t/:e site is altered, then tlie
Improvement Permit and t/ie Authorization to Construct shall become invalid.
1) Services R ested by:
Name: �d�1Y-}-(.,�1 � ��'P ��,'-�dYN.P�' Phone # (home): �7 ��-3 g
Address: 3-r't 7 0 �v� a.w� � �P (work/cell): �-r'i �l �Z� Z.
2)Name and address of cur�ent owner (if different than applicant):
Name: �� ����5
Address: f�/ Z�� n.� a.wa.N
�-a, it1C 2 73 �1 �
3) Property Description:
Address and/ox�ir'�ction
Lot Size: �. � Subdivision:
to Prope v a. G,
�� /�tJ.��l dt.t�- _ _ � b
4) Proposed Use an Type of Structure:
Residential Business/Type: Other
Number of bedrooms 2- / Number of people served (seats/employees): �
Basement: Yes _ No ,� (with plumbing: Yes _ No � Garbage disposal: Yes No �
Approximate size of building foundation: Length /� Width ��
5) Water Supply: / �
Private Well f�(Proposed Existing _�
Community Well: Public Water System:
Are there wells on the adjoining properties? No �'�s
#: �
(please show location on site plan)
Note: A completed application must also include:
➢ A platlsite plan of tlze property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. The informallon
provided is accurate. I understand that if any site is al or the intended use changes, all permits shall become
invalid. �
(Owner/Legal
Date: � � �
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax iVlap #:�?,(t
Approval I�eqLested for:
Applicant Nanze:
Address:
Phone #'s:
Parcel#:
v �Iobile Home ��placement
Building Ad�l.i�3on
e � 't Locate�: �' `Ies No
P rru
Installation Date: - 2- Design �o�r: 2�0 (�pd)
Current Contract with Certified Operator on file (if required):
Water Supply: V Well Public or Community
Wastewater system shows no visual evidence of failure en: / p- q-b g (date)
(Applicant's signature if sit� visit is not required)
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Environmental �alth S�ecia ist �atz
11/15/0`
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T�x M�p ! . Parcel # '
Subdivision
Fhase Sect�ion Lot #
Improvement Permit
Permit Valid for Five Years No Expiration
Type of Facility: � c i�! q� ��e � j�, e V�L�' New _ Addition
# of Occupants # of Bedrooms _ Projected Daily Flow _
Proposed Wastewater System: �X_`�,�'1 q _ _ _
Proposed Repair:
Permit Conditions:
Owner or Legal Representative S
Authorized State Agent: �
Water Supply
g.p.d.
Type:
Type:
Date: J �Z � "
Date: — Z.3 -"
The issuance of this permit by the Health Deparhnent in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. 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 ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment arid Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
EnvironmentaI 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: Type Wast�water Flow _g.p.d.
New Repair_ Expansion Soil LTAR: � g.p.d./ ft 2
Type of Facility: r r i v c� �S� �� G� Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: OD� gal Pump Tank: D 6C� gal Grease Trap: � gal
Drainfield: Total Area: sq ft Total Length ft Maximum Trench Depth
Trench Width ft Minimum Soil Cover: in Minimum Trench Separation:
Distribution:
Spe
Authorized State Agent: �
Permit Expiration
Box Serial Distribution
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Pressure Manifold
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in .
ft
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Date: �'"� 3�Q`�
The type of system permitted is onve tional Accepted Alternative. I accept the specifications of the
permit.
Owner/Legal Representative: Date: �~7.`f "
PC D rev. 11/10/OS
. � Person County Heaith Departrnent .
Environmental Health Sectton �
Tax AAap �: � � � Parcel #: .�,
���g; Township: Cu /I r�
Subdivision: 8ection: !-o�
a u� �ur� r�. L� ��-
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Locatlon: �� � ? Ca�r�n�cf �P FFo �—� � �o�j�i� ��l�G,�-� /�
Qpe�ration �Permit
�
System Type (In Accordance Wtth Tabie Va): S" �^ ��%�a�
THIS SYSTEM HAS BEEN tNSTALLED IN COMPUANCE WtTH APPUCABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEIAIAGE TaEATMENT AND DISPOSAL;
.AND ALL CONDlT10NS OF TME 1MPROVEMENT PERMIT AND CONSTRUCTION
AUTHORlZATION.
s � � l a of
Autho State Agent Date
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PCHD, rev. 10J1?J99
Person County Health Department
Environmental Health Section
�onin Township: G� � � �
9�
Subdivision: Section: Lot:
Applicant: �G�,� !' � �—� C, r �l �
Location: S7 � �f1Gof c ��� °��� ��!<rc(/Y2 �
Operation Permit
1. LOCATION AND SEPARATfON DISTANCES �
A) System meets .1950 setback requirements � / �
B) Distance from system to any wells d ?�a �� ���,.. p� C o
C) Distance from septic tank to foundation
D) Distance from system to property lines !o' ,O ,%..
2. SEPTIC TANK �
A) Visually inspect the exterior walls and top of the tank_��
B) Visually inspect the interior walls, cba�ffl^e, tee, filter, rise ,f lids, air vent,
bottom, and water tight outlet �J
C) Date of tank manufacture !a -��-a �
D) Tank serial number a
E) Liquid capacity of tank 0a0 gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is constructed from Sc �i ,�� v�U �
C) Diameter Y `�
D) Length � � �
E) Distance from tank to drainfield/distribution device �_
4. DISTRIBUTION DEVICE(S)
A) Type
B) Is Device water tight
�C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
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5. NITRIFICATION FIELD
A) Trench depth j� inches � �
B) Trench width inches /�
� C) Distance between trenches `1 6� �
D) Number of trenches � q �
E) Length(s) of trenches �' �7' �l.s � �3 f �fSr (3 � � c�� l
F) Aggregate depth inches
G) Aggregate material and size �
H) Record septic tank outlet levation '%''
1) Trench grade �,ee_ �� (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down �
c. Solid pipe used -� ('�vJ �
d. Elevations of step owns �( ecord elev ions and show on as built)
See "as built" plan �n attac ed sheei.
�
PCHD, rev. 10l12/99
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- -� 1� _�. IaL 1�.1' :L�J1=:�l�.t ;��� � lli • � r • • L� �.• .,.li:t '1 � � ' _.. = z'.�� . .� �
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3) Prapatj► DMai�on: Lotat�x �'Y�awutrpc � L�rvn i vi� Gi G�
D4+edia�s fio �e �� (Inc�fng roed ne� snd nwN�as� _���
pu 1 �i�
4) Prop�ed Uao� 3truciure Descrtptlon: a�mvMer eact� of the lbilowtn9 �atlon�
� a) �d �o
b� suac e�t �wadutar a. w�ae Q�:wtds n
e) � af eer�oome: �. . c� w,mber ot oax� or peopis m be servec�
•) Baaement Yes 4 No �Jt yea, # bas�r�nt �rex .
f) G�s Dte�: Yes 4 No� .
gj Dimen�ians of Proposed Strudt�e: Widttr d� pep�r S� .
���QPhI T9P+� Pri� rta+�► t�r eoa�9 �. Pub�c 4 Camtntm�Y o, 3�9 a
• � Ate a y�wegs on �p ptopariy? Yos� No � lfyes. lac�ffbn
� t�eas. Indic�. o�aiesd systan '�p�s tsya�• can be rarooed w order oiY� P�l
Canv�apl _„�b�lsd Cam�al _ AIE�s s/�u�ovatlw
��� ��)� � ...
' CLEARLY STAKE AL�. CORNERS �ND LJNES OF THE �ROPER7Y.
STAI� TNE CORNE�9 OE ALL PROPOSED 3TRUC"i1JRE9.
W.EASE ATTACtI 9URVEY PlAT OR SRE Pl.AN TO TH19 APQf.1CAT10N
I heraby mai�e ap�on• to the Pason� Coimty H�ith, D�psrtrnent tor a stis eva4�On far the cn-s�e sewage �posai ayatem iiu'
the above-desc�ihed proporty. �f apree tl�t the cattents af this appQr.�tion are true and rept�asetrt the me�a�uun � to ba
piscxd an ihe prop�ady. ! un�nd if the siia is a�ered or the lrr�ded use �tanga�, tl�e pecrNt shall bnc�rte inuid. l und�►d�
that as a�rt� 1 am re�Onaibie tor i�rin9 ���9 ProP�Y �. comers a�d meldng the �ibs �e ior the
P�'�'tnel of ihe Persan Coutdy Nealth Depsttment to. mnduc:t their aveiva�ona I �mde�nd that I am respor�3e far noi�ying the
Heabh ii my�; perty containa atry we8ands as daig�tated bY ��Y ��� .
' Q�� C-�l . � � � il-� �-� 1� . :
�' . owner or L.egat Re�tnaentative . Dste . .
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM
Name of System: Saunders, Donnie
Address: 3994 Morton Pulliam Rd.
Roxboro, NC Zip: 27574
County: PERSON
Report To: Person Co. Health Dept. ATTN:
325 South Morgan Street (336) 597-2371
Roxboro, NC 27523
Courier: 02-33-15
Collected By: MERLE TERRY Date: 4/20/2007
Location of sampling point: Back Spigot
Remarks:
Source of Water: Well
Source of Sample:
Type of Sample: Raw
Type of Treatment:
Type of Analysis Private
Time: 2:55:00 PM
Parameters Results Units Date Analyzed:
Alkaliniry as CaCO3 18 mg/I 4/25/2007
Arsenic <0.001 mg/I 4/25/2007
Calcium 1.8 mg/I 4/25/2007
Chloride IC <5.0 mg/I 4/25/2007
Copper 0.11 mg/I 4/25/2007
Fluoride <0.20 mg/I 4/25/2007
Iron <0.05 mg/I 4/25/2007
Hardness as CaCO3 (Ca,Mg) 6 mg/I 4/25/2007
Magnesium 0.4 mg/I 4/25/2007
Manganese <0.03 mg/I 4/25/2007
Lead <0.005 , , mg/I 4/25/2007
pH 6.2 Std. units 4/25/2007
Zinc 0.28 mg/I 4/25/2007
� ��j � GL✓G l�2SCJ �f S fo �,%rc/f�' O� [�a�G� o� S� �
� v �
a�. ��{� ��o �.� S/� , � s�o,��.
tv;t� ��-�- G,��r o vr ��-,� ,•�,�a �
l7/O!//�� H'�`�t/ S��LI.L(i's� P�/l �L!_- sa�� �� Z P/7 %i ILs � p� !ji' f. �OitC�i/� ,
�� �,v� r�-o�laC /;,/ e t� cW// �C;,.� ��s �# �s �I/9 —79�' �/,2c�o
Date Received: 4/25/2007 Report Date: 5/9/2007 Reported By:' ^
Today's Date: 5/9/2007 Ref: 6065 Login Batch: 07040051_ Sample Number: A656110
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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
sample received and should not be regarded as a complete report on the water supply.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below. " �
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1 A mg/1(as N)
Not less than 6.5 units
5.0 mg/I
01/06/1995 18:50 8044547843 SENNETT WELLDRILLING PAGE 02
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MetY�d af Ciro�ut: Pump�d P�ut� �,_, �"ourGd ,�/,,, �Pt� �.,� � � �t
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No. Baga �'or#lmxd �meat /� Waight of i B$g' �3 Founds
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