A27 235r�Site 1Evaluation Application Date: ���� �/'�1G%`�'
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Fee Collected YES KO
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APPLICATION FOR IMPROVEMENTS PERHIT
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l. Permit request�d by:
Address:
Home Phone ��:
ownerf�ruspective owner:
agent:
2, �Ta�me and address of current owner:
Business Phone �i: i�,��7 -
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3. Property Description: Lot size: ���� —���
4. Tax map ��: � Township:
Subdivision Name: Lot ��:
5. Directions to property: State Road
& Road Names, etc
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6. Permit requested for: New Installation: f/ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: y�
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? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11,
Type of structure or facility• Proposed: � Existing:
Type of dwelling: House: �� Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes tvo ,� 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. 130A-335(F) `
a�
Si n ner or Authorizec� Agent
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Permit Issued - � ' . ,
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Permit �ehieu r
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Plat Observed ,
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARFA 3 AREA 4
1. SLOPE (X)
2 . SGii. TEXTURE (i2-36 in. )
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 in.
(ciayey Soiis)
4. SOZL DEPTB (in.)
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata� rock)
. SOZL DRAItIAGE/GROUNDW
(bcternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
$ . OTHER (specify)
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
�S
U
s
PS
U
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
s
PS
U
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
PS
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s
PS
U
S
PS
7�
S
PS
U
S
T� $
U
$
PS
U
S
PS
U
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PS
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S
PS
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PS
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g. SITE CLASSIFICATI�JN
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2-SMENDATIONS /COMMFSITS :
S:�_TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, Wells, water bodies, slope patterns, etc.) �
A0144
PERSON COUNTY HEALTH DEPARTME�TT ' : ;
� WELL AND SEWAGE SITE, LOCATION IlvIPROVEMENT PERNIIT
Tax Map # %� �.� �f Parcel # .3
Zoning Township � iYe �-- i/�
Owner/Contractor ea Date •- �'
Location/Address "' / h S/� /�O 6
S.R.#
Subdivision Name ► <.� r Lot# /�
.
Pernut Void after 60 months. Permi oid if not in compliance with zoning regulations.
Permits may be voided if site is a r or te d use anged.
Well and Septic Layout by
Comments: // . � a
Date.
0�
i
�.��� .,
Installed by � �---Q�I � Approved
jM,�-WELL SYSTEM SPECIFICATIONS
� �,-�� Individual Semi-Public Required Slab .� _
Public Re �acement Air Vent /
Site Approved Required Well LQ� /
Well Head Approve ,/ Wel� Tag /
Grouting Approved _�
Comments:
Date
Installed by.
by
This report is bas�d in part on infortnation provided the homeowner or his/her representative in the application submitted for this pemut The /
enviro�unental health specialist is not responsible for fatse or misleading infortnation contained in the application. The environmental heatth 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 environmental health specialist wazrants that the septic tat�k system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:lamipro�pemut.sam Ol/95 rev.1.0
ORIGINAL
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� - . I'I:It:�uN �:uIIIJ'I'1' I•:IJ�j`1lUNM1iW�l'AI. IIh:AI.'lll
L�a�e: � , `J� (
(.���rner
Location/Directions:
W�;LL LOG
S�2#
Subdivision �Name: Lot #
Drilling Contractor: � � _
WELI, CONSTRUCTION - .
Distance from Nearest Properry Line Distance from Source of
Pollution�.� � �
Total.Dcp.th: �� Fc. Yield: b_ GPM Scatic Wacer Level Fc.
Water Bearing Zones: D.epth Ft.�F� F� ��
Casing: Depth: � From_�to�� Ft. Diameter: Inches
TYPE: Steel - � Galvanized Steel �ES
If Steel, does owner approve: Yes No �
� Weight: � Thickness: .• Height;Above Ground: Inches
Drive Shoe: Yes No_ . �
. Were Problems Enc�untered in Setting the Casing? Yes � No,
If "yes" give reason:
Grout: Type: Neat Sand/�ement Coricrete .
. Annular: Space Width �� 7nches � �:
Water in Annular Space: Yes______ No ; �
•Method: Pumped � Pressure_ Poured � ES
Depth: From �—to 2-0 F� �
Materials tTsed: No. Bags Portland Cement Weig�t of .l�bag,_.lbs.
If mixture�(sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ✓ � No._,� � '� �
� 4 x 4 slab Yes ✓ No
�
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T HEREBY CERTIFY THAT THE ABOVE rNFORM�TION IS CORRECT AND THAT ;�.
THIS WELL WAS CONSTRUCTED YN ACCORDANCE WITH REGULATIONS SET
FORTH BY•THE PERSON COUNTY HEALTH DEPARTME►�I'I'. �
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Signatute of C�nt� �� �<�r �%�<<:
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Building Additions/ Mobile Ho�ne Replacements
Tax Map #: � a� Parcel#: � 3 S Address: �q M. e a s b el� �
Approval Requested for: Mobile Home Replacement
Building Addition
Applicant Name: -T'1�aC C-1-�w�b e� s
Address: 1 I l 0 � o� er�s o�
'�o x bo ro 1�J C_ � 7.�'7 �
Phone #'s: 3 � /� -.�'o �F - � 4-�'3
Permit Located: Yes No
Installation Date:
Design flow; (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: �Well Public or Community
Wastewater system shows no visual evidence of failure on:
(Applicant's signature if site visit is not required)
(date)
Addition/Replaceme�t Approved
Environmental Health Spe list
<1 �s 1
D e
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-17901 Fax: 336-597-7808 www.personcountv net
NCPH - Water Laboratory Search
Close Print
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P.O. Box 28047 — 306 N. Wilmington St. — Raleigh, NC 27611-8047
INORGANIC CHEMICAL ANALYSIS
Name of System: Chambers, Tracy
Address: 1110 Robertson Rd.
Roxboro, NC 27574
County: PERSON
Report To: Person Co. Health Dept.
325 South Morgan Street
Roxboro, NC 27523
Collected By:
Location of Sampling Point:
Remarks:
Parameters
Alkalinity as CaCO3
Arsenic
Calcium
Chloride IC
Copper
Fluoride
Hardness as CaCO3 (Ca,Mg)
Iron
Lead
Magnesium
Manganese
pH
Sulfate
Zinc
ACS Date:
Well Head
Page 1 of 1
Source of Water: Ground
Source of Sample:
Type of Sample: Raw
Type of Treatment: None
Type of Analysis: Private
Attn: Adam C. Sarver
(336) 597-2371
Courier: 02-33-15
7/27/2006 Time: 1:20:00 PM
Test Results
Results
88
<0.001
17.0
8
<0.05
<0.20
105
0.17
<0.005
15.2
0.17
7.0
39
<0.05
Date Received: 7/28/2006 Report Date: 8/11/2006 Reported By:
Today's Date: 8/15/2006 Ref: 9726 Login Batch:
�
Units
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
mg/I
Std. unit
mg/I
mg/I
Date Analyzed
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
7/28/2006
06070059 Sample Number: AB451
http://204.211.171.13/EnvironmentalSciences/Inorganic/TestResult.asp?Action=Report&5... 8/ 15/2006
PERSON COUNTY HEALTH DEPAI2TNIENT
3�5� SOUTH NI.�DISON BLVD.
ROYBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SANIPLEANALYSIS
=
Name of Owner or Tenant
Address � � �C� �1�w1-s��. � County ��
Collected By
D1te Collected ��'S �C�(C> Time Collected 'Z= CO
Source:�Well ❑ Spring � Other
Location: �House Tap �Well Tap ❑ Other •
No Charge arge � _�j_ � � .
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�**��*�*�**�******��*�*��**************�****�****��*********�**�*****��**�*�**
Results
Present Absent
Total Coliform ❑ �
FecaVE. Coli � �
Reported By � �2dL� �� ��� M 1
bactreport