A27 136- �erson County Health Department
Sewage System Improvements Permit
Date: �" � � t' "I't
Owner: 'n ; "
Location/Direcdons:
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Permit Void
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SrYears SR# ��
C.. vi� - . : i �y 4�_
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Subdivision Name: � Lot #
Lot Size: �. ?� �" ` �� t Type of Dwelling:
Water Supply: Private: �� � Public: Community:
Bedrooms: ? Gazba e Disposal
Basement Basement Fixtures �
INFORMATIOI� C�ZT$IFD BY ------ ;r�-- _ _
Sanitarian:F� :;i{��r,.:,�r/ fi,t.:�.,.�.� r -_ -
REPAIR: � REEVALUATION:
Size of Septic Tank: %%gallons jSize of Pump Tank:
Nitri�cation Line: �_�-� � ? �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative Systcm: Conv. Pump LPP Pump
Remarks:
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-------------------------
Date Well Appmved:�,5��{ Well should be 100 ft from any sewer system
BY � � Sanitarian
Date Sew� S te pprov -- o
BY Sanitarian
/�CE�t,TIFIC�jTE O� CpMPLETION
Contractor. � �'1��✓2� (t/ 1 /�.
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrif'ication line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocadon.
(G.S. 130 A-335F)
I.ocation of sewage disposai sewage system sketched on back.
(OVER)
` P�rson
Date:�- �-9S'This
Owner.
Location/Directions: _
�-�7-13G
County Health Department X
Well Permit
Permit Void After 5 Y �
Rr,�-�`r�-��iLr�1 $R# l..3 DS' �t
Subdivision Name: U "' — Lot #
DrillingContractor:_����-n._e �,� .;, �
WELL CONS RUCI'ION
Distance from Nearest Properry Line�pl� Distance from Source of
Pollution O d ws � u-
Total Depth: Ft. Yield:��, _ GPM Static Water Level F4
Water Bearing nes: Depth ;. ��Ft FG �G
Casing: Depth: From_jZto �t. Diameter:_G � Inches
TYPE: Steel alvanized Steel •� i
If Steel, does owner approve: Yes No
Weight: %� Thickness:�ght Above Ground:� Inches
Drive Shoe: Yes �No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sand/Cement �.— Concrete
Annular Space Width� Inches
Water in Annular Space: Yes No �
Method: Pumped Pressure Poured c� ,
Depth: From�_ to 2 a Ft
Materials Used: No. Bags Portland Cement� Weight of 1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio: to�_
ID Plates: Yes V No
4 x 4 slab Yess� No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
Sanitarian's Signature
Sketch well location on reverse side.
Date
Date Completed ,
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
`supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
, located at later date. Note location of water supplies on adjacent lots.
s �, r . . .�DQ . .
Aaaltr.ation Date: � b'16 "6�
limount �aid•
Recaipt �:
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Tax Maq �: � ` a T
Parc2! �: � � �
APPl�CATiON F-0R SE3iViC�S . �
'IF THE INFORMATIOM IN 'THE APP�:IC�1T10iV F�R AN IMPRO�/EAAEi�T PE�tMIT 15 1NCORRE{.'.'T. FALSIFiE�J.
C�-IANGED OR THE SITE 15 ALTERED. TIiEi� i'HE IAAPROVE3NENT PEi�MIT APID AUTHORiZ�4'�ION TO .
CONSTRUCT SHALL BECOME INVALID. �
� � • �i�
r"`�) Permit requested by: (Ovmerlager�tlprospective ownerj. e, f 1
Hame Phone: 33� -- �i7-4 S► Address: � 'I 1
Business Phone: R I�C � 38�1 `� '�k' �} f �� bc� c-a ,��c �4 �S7 LI
2) Idame and �ddress of cvrrerit ovmer�C��rr`ac � 2�o �'�
• L`-1-1 C� M � 11 � \ �
� o � � tJ L 1 �71-� .
C`� � a
3) Ptnperty Description: Lat size: �`�� Townshlp: �� \ Subdivision:
Diredions to the property (including road names�and numbers): l"� �� ' Le c� s �
,. r � �` � � ��w�l • t���Q�1� C'N\ • �1��� -�� ,
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4) Proposed Use and St�v re Description: answer each of the fiqilQ�+ing questions: 2 �n
a) Proposed . Existing Type of Struch�re: MO C��,�v �t'�aw� Width: � Depth: J2 't�t
b) Number of Bedroams: Number of oc�pants or peaple to be served: -
c) Basement Yes . Na� Will there be plumbing in the•baseme�t?
d) 6arbage Dispasal: Yes �No _ .
5) Water Supply T�e: Privabe _(new _ or existing,�, Pu6iic_, Commisnity� . Spring �
Are any welis on adjoining property? Yes;� No _ tf yes, piease indlcate approximate loc�tiori on the
�siie pian. �
. `7
6) Does your prope�ty cantain_previousiy iderrtiiied �urisdictionai wetlands? Yes_ Ido -
Pi.�ASE id0'TE THE FOLLOWING:
7 A Pl.I�T OF THE PROPEiZTY OR SIT� PLAi�I iIAUST SE SUBMITTE� WITH YHIS APQLiCAYION.
➢ PROP'Ei�TY UNES AND CORNERS MUST BE CLF�RLY MAR6�fl. �,
9 THE PROPOSED LflC1�T10N OF ALl,. STRUCTURES MUST BE STAkCE�D OR F�AGGE�.
9 THE SITE RAUST �E RE�►DILY A�CCESSIBI.� FaR AN EVAI.UA770N BY THE tiF�4LT6�i DEPARTME�IT
STAFF. �
i hereby make application to the Person Caurrty Health Department for a siie evaivation fo� the on-site sewage disposal
system for the above-described property. i agree that the cantents of this application are true and represent the maximum
faciiiites to be placeci on the proQerty. I understand i� the siie is altered or the intended use ct�anges, the perm�i shall
�eca-� irnalid. . . . -
Cwner or Lega! Rep�sentative
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PC�iD. �. �6127102
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Applican�
Location:
T�a�x M�aE� � � P�ecel #
S�irkoci'ivi�sioii '
Ph���,se Sect�ioii Lot #
� �i � P � = R � Improvement Permit
Permit Valid for Five Years No Ezpiration
Type of Facility: Ex i St i n �(,J m H New Addition Water Supply �►5t►n
# of Occupants # of B ooms Projected Daily Flow g.p.d.
Proposed Wastewater System: � . .Type:
Proposed Repair: �to q}- �n�spe ef �fzndoc,Jn• Type:
Pernut Conditions: t'(,�
�c.ndown �- IoaK
5c.-6. 9�D P ve..
Owner or Legal Represen
Authorized State Agent: _
Ta�,K ��`n
T�c � w;-�G, F� I t�.T Un cov �
Date:
Date: ( �-I S-Oa
The issuance of this permit by th� Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are 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 ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Zaws and
Rules for Sewage Treatment and Disposal Svstems' (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 Sy em: Type � Wastewater Flow g.p.d.
New Repair�Expansion _ Soil LTAR: .p.d./ ft 2
Type of Facility: '�� Basement _ Yes �No
�� y�,k� Wastewater System Requirements
Tank Size: Septic Tank: ��� gal Pump Tank: 1`� /� gal � Grease Trap: ga1
Drainfield: Total Area: sq ft Total Length , p
�SC7 ft Mazimum Trench De th in
Treneh Width ft Minimum Soil Covert in Mi.nimum Trench Separation: ft
Distribution: Distribution Box Serial Distribution Pressure Manifold
Specifications• � la0u.(ci. rc- �-O m Yn C- � a- l( �-�Cc-a UCt� t7n S b c- c1 an � by han� �.
��A�n�. I�( �1�� rccnMr►�cnd ad�ir�q I'o2 ./Oa�/s OFfpOSai l Ouc� SyStr�► a�"ca,
Authorized State Agent:
Permit ExX
The type of system permitted is
the permit.
Owner/Legal Representative: _
Date: f � —/� �a
Date:
Conventional Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
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SITE SKETCH
N e I�Se rr�ar i � Nn 1 k . �Tax Ma.p # a^1 Parcel # ���
ub '' ion N p Section/Lot#
lo-is oa
Authorized State Agent Date
System comportents represent a,{iproxi�nate contours only. The contractor must, flag the system prior to
beginninQ the isistallation to insure thatpropergsade is maintained
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant ��,u,� I"•�YSor� S
Address ���Z 1�� �� f���1 �.�� _ County P�¢�So�t
Collected By �S
Date Collected �� ��a �� Time Collected ! d� �Jr
Source: �Well O Spring ❑ Other
Location: ❑ House Tap
pNo Charge �Charge
ell Tap . 0 Other
*�******����*****������**��������*��*��*��*�*��*�****���*��*����**������*�����
�*�**�****��*��**��**��*���*�����*�������*�**��*����*�*�*�*�**��***����*�***�*
Total Coliform
FecaUE. Coli
Results
Present Absent�
❑ [II�
O �Y
Reported By � ��.W� MT
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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: Parsons, Paul
Address: 1476 Mill Hill Rd.
Roxboro, NC
Zip: 27524
County: PERSON
Report To: Person Co. Health Dept. ATTN: Person Co. Health
325 South Morgan Street (336) 597-2371
Roxboro, NC 27523
Courier: 02-33-15
Collected By: AR Date: 9/13/2007
Location of sampling point: Outside Spigot
Remarks:
Source of Water: Ground
Source of Sample:
Type of Sample: Raw
Type of Treatment: None
Type of Analysis Private
Time: 10:00:00 AM
Parameters Results Units Date Analyzed:
Alkalinity as CaCO3 270 mg/I 9/14/2007
Arsenic <0.001 mg/I 9/14/2007
Calcium 64.8 mg/I 9/14/2007
Chloride IC 40 mg/I 9/14/2007
Copper <0.05 mg/I 9/14/2007
Fluoride <0.20 mg/I 9/14/2007
Iron 0.77 mg/I 9/14/2007
Hardness as CaCO3 (Ca,Mg) 280 mg/I 9/14/2007
Magnesium 28.9 � mr�/I 9/14/2007
Manganese 1.90 mg/I 9/14/2007
Lead <0.005 mg/I 9/14/2007
pH 7.4 SiCI. iJi11tS 9/14/2007
Zinc <0.05 mg/I 9/14/2007
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Date Received: 9/14/2007 Report Date: 10/4/2007 Reported By:
-----
_ _ _ ��
Ref: 13042 Lo in Batch: � p
Today's Date: 10/4/2007 9 07090029 ; Sam le Number: A66235
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.
s
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
ir-on
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)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1