A27 2391 .
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wSi.t�{_ Evaluation Ap�lication
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Fee�Coll�bcted YES NO
7
� Date: ��
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� �/� � PPLICATION FOR IMPROVEMENTS
1. Permit requested by:
Address:
Home Phone �� :
owner{;�rospect' .
agent:
2. Name and address of current owner:
Business rhone �r:
3. Property Description: Lot size: �`�,���t�
4. Tax map ��: /e� ���T�wnship: ^ '
Subdivision Name: Lot ��:
S. Directions tp property:, • State Road�& Road Name�s, 'et �.J n
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6. Permit requested for: New Installation: ✓ Repair:
Additional Renovation re-u ing 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? community? spring?
Other source? (Specify):
Are there any wells on a
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12.
oinin property?
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If ;o, identify location:
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Type of structure or facility: P oposed: � Existing:
Type of dwelling: House: � Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No ,
Basement? Yes � No If so, number of basement fixtures:
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 (F)
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ed Owner or Authorize� Agent
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Permit Issued
Permit Denied
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
1. SLOPE (X)
. SGIL TEXTURE (12-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
. SOIL STRUCTCIRE (12-36 in.
(Clayey soils)
4. SOZL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
(Im�ervious Strata, rock)
. SOIL DRAZNIAGE/GROUNDWATER
(�cternal & Internal)
7. SOIL PERMFABILITY
(Percolation Rate)
$. OTHER (speci£y)
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9. SITE CLASSIFICATI�JN
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�4�NDATIONS / COMMFSiTS :
S.�_TE CLASSiFICATZON DLAGitAH (Include: Soil areas, property lines. roads, streams, gulZies.
Wet areas. fill areas� crells, water bodies, sZope patterns, etc.)
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ts Permit. (EstablishedlRecorded Lot) I_. Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Bacteria
it requested by: .
rospective ownei
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_ Chemical
ome Phone #: � �-�
usiness Phone #:9'�9.�.711 /��-�
. Name and addre�s of current owner:�
. Property Description: Lot size:
. Tax Map#: �. �
Parcel#: _
�Township: � -
l,cJ
_ Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
_ Petroleum � _ Pesticide � _ Lead
7. Dimensions or Proposed Structure:
Depth:
��N—� 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
tha[ this sewage disposal system is intended to serve?
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. Directions to property: State Road #& R�ad-
iames;�tc.
_ I �g (� , � � o ±� v1 �.(� ��s,-J�-� —
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Number of occupants or people to be served:
9. Water s ply ty-pe:
private �. public ❑ community ❑ sprin�g ,❑/
Are any wells on adjoining property?Yes L�" No (�
If so, identify location:
,�'^� 10. Type of structurelfacility: Proposed: �Existing: Q
� Type of dwelling:
House: [��Mobile Home: C� Business: ❑ ,
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes, �❑� No �
Basement? Yes ❑ Nol� 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 PerSOn COunty Health Department for a site evaluation for the on-si[e
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 alteced or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permi[ can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Heallh 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.
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z Signc� Owner or Au orized Agenl
permic Issued ❑
permit Denied ❑
Plat Observed ❑
Signature
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SOR. STRUCiURE (12•361N.I
I.AYEY SOf1.S�
SOILDEPTti (W.) �
, RESCRImVEHORfZONS(IK.)
].tYERV10US SiRATA. ROCK)
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6. AVAlIJ18LESPACE
9. SCfECIJ�SS[f7CATION(SEEBELOW)
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SSUttABLE PS�PAOYLSIONALLYSU[TABIE U-VCLSULTABLE
RECOMMENDATIONS/COMMENTS:
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, we[ areas, fil
areas, wells, water bodies, slope patterns, etc.) C:UM[PRlT��MPPSEC.SM F�AN�F
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� ' PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �' � �
Zoning
Owner/Contractor PCi,U � /l/�a-c
Location/Address l� R l,� T�C
Subdivision Name tC �
Parcel # 2 3 �'
Township ; V 2 (-( �
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Date �f- 5 --
nC � T��-
S.R.# 13D(�
Lot# A- - Z
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ], y?� _/-} C� Size of Tank � IJ'� D
SFD ✓� Mobile Home Size of Pump Tank n' /,4
Business # of Bedrooms�_ Nitrification Line J 35 X 3� __
Max Depth Trenches I g�' , o?O "
Permits may be voided if
Well and Septic La out by_
Comments: -� ���v�/��
Date I� -/6 � 47 Installed by
ell Permit Paid
altered or ir}�ended use changed.
ividual_�,�Semi-Public
Site Approved_�
Well Head Approved
Grouting Approved t
Comments:
Date
Approved by
� -�-y s ��
SYSTEM SPECIFICATIONS
Required Slab i�
Air Vent
Required Well Log I�
Well Tag _ 1%
This report is based in part on information provided the homeowner%r his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. 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.
c:\amipro�permit.sam O1/95 rev.l.l
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Date: !P / 1Z / ►�
Tax Map: „�}--Z7 Parcel: Za�
Name:
Address: � � p�����.,—�p� g�,
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Re: Bacteriological Test Results
�"• u ✓ .�.s % � .
Your well water was sampled on !� /�o /�, and tested by the Person County Health Department for
biological contaminants (total coliform and fecal coliform bacteria).
The results of your water sample are noted below:
� No co[iform bacteria were detected in the sample. Your well water is safe for normal use.
_ 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 are associated with animal
and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that
a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be
entering the well. If coliform bacteria are present in your water sample, the water may not be safe for
use. Young children, the elderly, and individuals with compromised immune systems are especially
varinerable and their physicians should be notified of the test results.
A well that tests positive for total or fecal coliform bacteria should b�roperlv 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 (597-1790) to request a re-sample.
For additional information, please feel free to contact Environmental Health at 336-597-1790. Our office
hours are 8:30 to 5:00, Monday through Friday.
Sincerely,
v '�
Environmental Health Specialist
Person County Health Department
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808
(revised 07/29/13)
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
.__ROXB_ORO, N.OSTN. CARDLI.NA �7573. _ _ . - --.
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant `����t -�,r[Gi E 1�I:a,2-ft t�
Address � � Sd �Y�bb��F-So ri ��. County ��.�a.�.�
Coliected By �- �[�
Date Collected `P�f b�i S Time Collected I b'. t D
Source: o�l ❑ Spring ❑ Other
Location: ouse Tap ❑ Well Tap o Other
o No Charge harge
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Results
Present Absent
Total Coliform ❑ �
Fecal/E. Coli ❑ ,�
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Reported By � � �- � 1
Date Reported �" l 1-� S
Report Calied ❑ YES �d0
Called To
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