A27 161S�te •E�aluution Application
Fee Collected YES ,i
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Date:
NO
APPLICATIOid FOR IMPROVEMENTS PFd2MIT
1. Permit requested by: owneri�ruspective owner:
_ , agent:
Address: ,�
Home Phone �� :
2. Name and address of current owner:
Business Phone ��:
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3. Property Description: Lot size: �, /y
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4. Tax map ��: �-G?%/lv/ Township: i�/� ,�,�,'
Subdivision Name: �{ FA��_ "�p��J,f� Lot �d:
5. Directio�,n/$ to prop erty: State R/oad �� & Road Names, et,c.
S`r7 /!� . % / L .. /i� n_ .c� /. U/i c, .57�1'P ��/ , aE
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6. Permit requested for: New Installation: �- Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? �/ public? _
Other source? (Specify):
Are there any wells on adjoining property?
community? spring?
If so, identify location:
11, Type of structure or facility: Proposed: � Existing:
Type of dwelling: House: ri�oJk/q,Q� Mobile Home: Business:
Type of business: Number of Employees: ,
Number of bedrooms: 3 Garbage Disposal? Yes No �_
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake all. corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130 335(F) �
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Signed Owner or Authorized Agent
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:ved
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 E1RF� 4
S S S S
1. SLOPE (X) P_ �_ S�p PS PS PS
U U U �T
2. SGIL TEXTURE <i2-36 in.) S S S S r
(SandS, loamy, clayey, PS � PS PS pg
Note 2:1 clay) U U U U
? SOIL STRUCTIIRE (12-36 in.) S S S
(Clayey soils) PS �� PS PS PS
U U U
S S S �
4. SOZL DEPTH (i.n. ) PS ��� �� PS PS PS
U U U
5. RESTRICTIVE HORIZONS (in.) S S S S
(Iu�ervious Strata� rock) P ND�Q PS PS PS
U U U U
6. SOIL DRAZIIAGE/GROUNDWATER S � S S S
(�cternal & internal) PS Nb /w PS PS PS �
� U U
7. SOIL PERMFABILITY S S S S
(Percolation Rate) r S , 3`'�' PS PS PS
U U U U
S S S S
g. OTHER (speci£y) PS PS PS PS •
U U U U
9. SITE CLASSIFLCATZON
(See below)
SOZL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�4�NDATIO fIS / CO2�41FSITS :
S:�TE CLASSIFICATION �IAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, c�ells, crater bodies, slope patterns, ete.)
__ . A 0`93.
, ' PERSON c:OUNTY HEALTH DEPARTMENT � .
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PE�,ZIV�T'- �
Tax Map # A� rf Parcel # �
Zoning Township � � //�' / '
Owner/Contractor f�,.- �- � � � ,� Date
Location/t�ddress �,`� /✓ � S2� 13� 3 �7� Sl0
s.R.# /3�.3
I Subdivisio��- c� r Ci� _L- ,S� Lot#��
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�13�f3 %3�ivcr Crez-�f���LH,� (%�r; �
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area a, /yAcr� Size of Tank °`�'
SFD Mobile Home� Size of Pump Tank N
Business # of Bedrooms� "''u'�` itrification Line �?( 3�
Max Depth Trenches a (� � �
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alter r' t ded se hanged.
Well and Septic Layout by
Comments:
Date %�-_-_��p�,� Installed by �l ,� m� /_.Q.�.� i s Approved by,
�
I/'Ai � c/ WELL SYSTEM SPECIFICATIONS
dividual�j f �Semi-Public Required Slab � .
iblic Replacement Air Vent �
te Approved ✓ Required Well Lo� �/
ell Head Approved Well Tag ,/
-outing Approved j/
Comments:
Date_ 5�22- q Installed by,
Approved
This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this permit The
environtnental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the endvontnental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permit.sam O1/95 rev.1.0
ORIGINAL
FROM
�vonn uaroun� • uepnrtm�nt ot Envlron�
plvi�fon of �nvlronmonta! M�ndS
, p.0, 6ox QOS3S • R�lel�
Phon� (019)
11.l6.1994
nt, Heelth, and N�t�r�1 Ro�ouroo�
��nt • Oroundwet�� 8�ctlon
N,C,27828•8536
WEI.� CON3TRUC'�ION R�CORD
DRI1.l.tNQ CONT�ACTOR: Y�'•.
ppll�ea R�QI8tRATiON �uMa�R;
r. wE�� �ocA��oN; csi
Nesrett Town: � /�
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qCi: 18 . te P. 2
BTATE WELL CONSiqUCTION
PERMIT NUMa�R; , /a �.Z9 � �
- _._._.—.�
sketch oi 1� locatlon below)
:.... County: � r 411 /✓ �----
�{Ro�d, Comm' Ity, or 8ubdlvl�lor,hend Lot N,) D�PTH
a. owN�R h��_ i�/-�C From to
ADDAESS..�.1��� 52 1-��5�-� iN�d S/d U -Za
� .���� (Strool or AOuto o,T_ �� � �G
. C' � � a!�.-
Clly or Town St�l� . Z1p Cod� —'
3. DAT� Df�III.ED _.�'�� ' 9s US� F WELL ,�� ✓
4, 70TAL D�P7H ,_ `� / S
5. CU771NQS C¢�IECTED Y�S C] N0�
8. DOES WELL REPLACE �XISTINQ LL? YES NO�]✓"
7. STA71C WAT�R LEV�L Be1pw�TOp o Casinp: '� FT.
(Use •' If Abov� Top ol CR�Inq)
8. TOP OF OASINQ IS.._._.L_ F"r, A ove Le,nd Surtdca"
" C�tlnq T�rm1n�1�4 �t�or b�iow I�nd �urf�a i� II �y�1 unl�ir � v�rlano� l� l�awd
In �oeord�no� with 16A NCAO ZC .0118
S. YIFLp (�pm}:._..._.�_ ME7Hp�D� OF 7EST �°� w��
10. WATER ZON�F (depth); ._--=-z.� � z��
11, CHLOR{NATIdN: Typa
12, CASIN4:
OOpti1 Dlamvt
From � To .—•�.�- Ft.
From----- To — Ft.
From .-._._-.�.-To Ft.
13. GFiOUT:
Dapth
From ..�—. To _.� Ft,
From To Ft, �
14, SCRE�N:
Depth Diameter
�rom 70 .._._.._ Ft In
From to __....� Ft. in
From _,.,.— Yo Ft. -- - In
1 s SANDrQRAVEI. PACK,
Depth 51ze
From ._ To __ Ft.
f�om To Ft.
i8. REMARKS: __._.
I DO H�REBY OERTIFY THAT THIS V
CONSTRUCTION STANDARDS, AND
aW1 AEv, 9ro1
�
,_,QRILLING k.OQ
FormaQon �olcriptlon
- _______.-
_ Atn0u11t If �ddltlon�l �pRco I� nc�d�d ue� b�ok ol torm
W�ll Thia1����� LOCATION � EK TGN
or WoiphUFt, ��torl�l (6haw dir�otlon �nd dlttano� from �1 IoR�t two 8t�to
/S B � Roede, or othor mAp r�t���nov polntt 1
/ � �
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Met��
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I Slat Slze Mat6rl�l
� In. �
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Materlal
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WAS CONSTRUCT�D IN ACCOADANCE WITH 15A NCAC 2C, WEtt
T A COPY OF THIS qECOAD HAS BEBN PROVIp�p TO THE WELt OWNER.
/C �_ . -�"��"
SIQN/1TURE OF ON7RACTOR OR AOENT ����
6ubmit orlpina{ to D(vllion of Envlro�rn�nt�} Manepemen� �nd copy lo w�ll ownsr,
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PE�tSON COUNTY HEALTH DEPARTMENT
325 SOUTH MORGAN STREET
ROXBORO, NORTH CAROLINA 27573
BA CTERIOL OGICAL WATER SAMPLE ANAL YSIS
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Name of Owner or Tenant ��.:�; 5Q `��y ���. '
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Address �--��'� � �� � � �r�� �w� County �� �5�-�
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CoUected By,
Date Collected
o" � Lc, �- v� Time Collected ���v
Source: Well ❑ Spring ❑ Other
Location: l,�'House Tap C7We11 Tap Q Other
C�o Charge �Charge
*�*********�************�*�**��*�***�*******��*�******���*****�**�x*��***�****
*�******************�*****************�*********�************************�****
Total Coliform
Results
Presen ' Absent
❑
❑ l� / .
Fecal/E. Coli
Reparted By �- ��1���� � M�
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PEi2SON COUNTY HEALTH DEPARTMENT
325 SOUTH MORGAN STREET
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATERSAMPLEANALYSIS
Name of Owner or Tenant ��(1 I Sc:- l>I � i"r�'� '
Address `�`� � �j�u �'c:' �+ `r 2t {� I�W'� County f � `,S ���
���xb:�r�
Collected By ��-- -�
Date Collected �U a9' �, `'� Time Collected � �� 4 C7 �
Source: � Well ❑ Spring ❑ Other
Location: C�ouse Tap OWell Tap Q Other
�To Charge OCharge �t-,�<.N-(�te
� i � - � It�"7 �►�� �
**�*�********�**,�*�****************�******************�*******�**�**�****�****
*�**�*********�***��**********�*************�******************************�**
Total Coliform
Fecal/E. Coli
Reported By
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Results
Present
❑
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Absen
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PERSON COUNTY HEALTH DEPARTMENT
- 325 SOUTH MORGAN STREET
ROXBORO, NORTH CAROLINA 27573
BA CTERIOL OGICAL WATER SAMPLE ANAL YSIS
Name of Owner or Tenant Qz n � S`- sc Lrrc•. �
Address ��� I�� �r �-rL{� `'���y� County ���,Sc�n
�
Collected By
�
Date Collected U� %� CQ --c�3 Time Collected � �� � S.
Source: C,�Well ❑ Spring ❑ Other �
Location: �House Tap
�to Charge QCharge
OWel1 Tap Q Other
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�icytit�tit*xitikYc*ic*yetltik�t�F�k�t�t�t*xyr**s*itYc�t�tie#dt�FlcYcileYlc�lrfti�vk�k�Y7ir�tyt�t*�r�tiF�k�lr�tr�kikiF*ikik�t*itsytdF�F*fr�t�le�tytit
Total Coliform
Fecal/E. Coli
Present
❑
�❑
Resutts
Abse
L�'
Re orted B � �� m�
pY =.
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