A27 170 & 171• P�r'son County�.Health Department
��w��e System Improvements Permit
Date: " e it Void ter 5 Years ermit #�/� � 7�
Owner: SR# �
Location/Directions:
Subdivision �j � G u V C r
Lot Size: � / • .Type of
Water Supply: Private: Public: _
Bedrooms: � Gazbage Disposal
Basement � Basement F' �
INFORMATION CERTIFTED BY
Environmental Health Specialist:
REPAIR: REEVALUATI ]
-------------------------
Size of Septic Tank: _����Of� �X 3� of Pump Tank:
Nitrification Line:
Depth of Stone: 12 inches 12"
Max Depth of Trenches: ��
Altemative System: Conv. Pump LPP Pump
Remarks:
� L � � � � �
�vv�u �-��r-r' l�� ---- ----
Da Well Approved: Well should be 100 f� from any sewer system
BY Env onmental Health Specialist
D ewage System Approved: � �"� �'Q1
B � '� Environmental Health Specialist
CATE OF COMPLETION
Contractor. �� �Cl �� �isZ�lQl n �ti—�
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc 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 hazazd. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Departrnent 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 revceation
(G.S.134 A-335F) ��
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
^ st;�plies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�t later date. Note location of water supplies on adjacent lots.
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Date: 2 / z � /� �
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Re: Bacteriological Test Results
Dear WellOwner:
Tax Map � Parcel:�
Your well water was saznpled on Z/�/� and tested for both total and fecal coliform bacteria.
Your water sample test results are noted below:
� No coliform bacteria were detected in the sampl.e. Your well water is safe to use for drinking,
cooking, washing dishes, bathing and sho.wering, based on the bacterialogical results only.
Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are naturally found in the soil. Fecal coliform bactEria arz associated with
animnai and/or human waste. ThE presence of either total or fecal coliform bacteria in well water may
indicat�•. that a new or repaired well was not properly disinfected prior to use, or that contaminated
groundvvater may be entering the well. If coliform bacteria are present in your water sample, the water
�nay rot be safe for use. Young childf•en, tl:e elderly, and the individuals with conipromised immune
systems are especially vulnerabde and their physicians should be not�ed of the test results.
A well that tests positive or total or fecal coliform bacteria should be properlv disinfected and retested
prior to resumin� 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 Environmenta( health at 336-597-1790. Our office
hours are 8:30 to 5:00, Monday through Friday.
Sincerel ,
C\j�,��n/`R�
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person Ca!nty En��ironmerrtal Health; 325 S Mor;an St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Far 336-597-7R08
. •�::. ,�
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERlOLfOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant dby�1 � uln�2✓AK �
/�� p� t�
Address 23g t�� lA-t'e/� /�u/% County � .;
1
Collected By
Date Collected Z�Z�'"��i Time Collecied �0 � 2O
Source: �Wel! ❑ Spring ❑ Oiher
Location: ❑ Hause Tap o Weil Tap 1� Other �.� '� ��d"�
❑ No Charge �Charge
■t�����r�ri��r��Yy�rra������r����srar��I1�Rr/��[s�����a���i������ir��r�r���ar■a�
&�k kYr�F*ieat+F�k*aYiirieit�kok9rie***�Ir***ir�Y�k�kic& k�irdr**�k+4�i*9rir�F*+FaFtkk*ie+k*YtYr�ArrtvF�t#�Y�Ir�ir*ir�frir9rak�M#*�k#+Ir
Total Coliform
�'ecal/E. Coli
Results
Present
�
0
Reported By
Date Reported �� � 1
Report Called
o YES ❑ NO
Absent
Cailed To �
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S':.�e Evaluation Application Date:
Fee Collected YES �
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` X ��PLIC�TION FOR IMPROVEMENTS PIItHIT
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1. Permit requested by
Address.
Home Phone ��:
-- ��;`owne /prospective owner:
���� �� gent•
���' �- .�
7. � ^74r/ Business Phone ��:
2. Name and address of current owner:
3.
4.
Property Description: Lot size: /, 9l ,�r � d�. ���C'
`� � 17��/�/ /
Tax map ��: � a" � Township: l/�
Subdivision Name: Lot 46:
5. Directions to pro erty: State R ad �� & Names, e
.�- � �r �o � �,�; ��� ��` �-�
6. Permit requested for: New Installation: v Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: �J O��U v Depth: �� /
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture o�,facility that this s�wage disposal system is intended to serve?
10. Water supply private? �
Other source? (Specify):
Are thgre any/� ls o� 2
'�'Q z° f'G �%�' Ci//Z L�
11,
public?
ing„groqerty?
community?
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3
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spring? _
If so, identify location:
Type of structure or facility�:/� op�osed: `� Existing:
Type of dwelling: House: 7i Mobile Home: Business: _
Type of business: Number of Employ s:
Number of bedrooms: rbage 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 ranted to
enter the property for. the evaluation. G.S. 30A-335(F)
Signed 0 r or Authorizec� Agent
�
Permit Issued �
Permit Denied
Plat Observed ✓-
X' Z
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7
t�`�3
i?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S
1. SLOPE (X) PS PS PS PS
U
2. SGIL TEXTiTRE (12-36 in. ) S 3�,� u I�
(Sandy, loamy, clayey, S' ����� PS S� � PS
� �h
Hote 2:1 clay) o�n (� N w. U o c�w. U
3 SOIL STRUCTURE (12-36 i.n.) � S '
(Clayey soil.$) PSJ PS - PS PS
4 • SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.
(Iu�ervious Strata, rock)
6. SOIL DRAItIAGE/GROUNDWATER
(F�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
U
S
PS
S
S
S
PS
tF-
S
S
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S
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S
PS
U
S
S
PS
U
S
PS
PS
G
S
$. OTHER (specify) PS PS PS �, c
u u u 'u'
�g. SITE CLASSZFICATION � C �
(See below) �
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�II�NDATIONS / CO2�41IIdTS :
�lTE CLASSIFZCATION DLAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
c�et areas, fill areas, wells. c�ater bodies, sZope patterns, ete.)
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'r� s
Special Note: Each application for a Zoning Permit shall be
acco�panied by a plat. drapn to scale. shoping accurate di�ensions
of the lot to be buiit upon. accurate dimensions of the building to
be erected. its location on the lot and such other infor�ation as
nay be necessary to provide for the enforcement of this ordinance.
AUTHORIZATION PER�IT #: F�`�733
PERSON COUNTY HEALTH DEPARTMENT
AUTHORIZATION FOR ZONING & BUILDING PERMITS TO BE ISSUED
(G.S. 130A - 338>
OWNER: ,� / " � • I�O �m,� nm� _ PHONE #: �9'7�,'�''i�'�
ADDRESS: `i� �1 �L l�'�c3 , `i� LQ�-�9• � � - 0�.�15'73
-LOCATION OF PROPERTY: � x` i3�' q�7 �
a. o� 4a.� . TAX MAP #: � A�,'7 f'7 l
LOT S I ZE : � 9� a�e:�i --
TOWNSHIP: c'�' � � `�1 � �r=��
�: a�
SUBDIVISION NAME: `�d n�u �. �ri= � �1 LOT #: �`-�
NUMBER OF BEDROOMS { �}
'HOUSE { } MODULAR HOME { }.,
OTHER { } SPECIFY:
DAT6: %D - �:� - 9-�
MANUFACTURED HOME {✓}
NEW SEWER SYSTEM {� EXI TING SEWER YST'EM {?.
MUNICIPAL SEWER SYSTEM { } '�
� Enviromm �t He lth Specialist
*********x**..*******«***********«*,.««****«****«****,�***««**«***«***
Certificate of completion or operation permit issued: (130A-337)
and compliance with local well rules where applicable. <130A-339)
DATE:
Environmental Health Spec.ialist
*,.********«******,�«�*****�*****,r****«**�r*«*************************
This is to certify that the above named addition to my property
will not cause an increase in sewage flow or interfere with the
operation of my sewer system. I certify that my sewage disposal
system is functioning properly.
_: Owner or Agent
YOU MUST OBTAIN PERMITS REQUIRED BY THE PERSON COUNTY ZONING AND
BUILDING CODES BEFORE ANY CONSTRUCTION ACTIVITY IS STARTED.
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