A35 191Application Date: � -� �c� ` �
Amount Paid: 02 DO . o O 9/�� /° � C,�c'.�G � �u'
F.eceipt� : �} Q 8' ���j � y2217 ,� G'f'�
�^� `--����5� ������
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OC � � .IL"'�.:3envnar-.c:axrn.:uv-n..c��rn.tL-..�n.�.Il. 7E�Ia.�.�ll.�a�:stv.
Application for Services
(Septic Svstems and Wells)
�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax.Map: �S
Parcel #: l �/
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: f tl:e information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then tlte
linpro ent Permit and the Authorization to Construct sltall become invalid
1) Services Re ested by:
Name: � Phone # (home): �-3� �`9 'J� .— ,S' 1� �i �
Address: , � (work/cell): _7,.jG- - �`�7� ��.y
C ,57� C-� 336—✓�0 5� -� 3�� S"
2)Name and address of current owner (if different than applicant):
Name:
Address: '
3) Property Description:
Address and/or directions
Lot Size: l, i� C Subdivision:
Property:
#:
4) Proposed Use and ype of Structure:
Residential - Business/Type: Other
Number of bedrooms � / Number of people ser�ed (seats/employees): �_
Basement: Yes ✓No _(with plumbing: Yes _ No l� Garbage disposal: Yes _ No �
Approximate size of building foundation: Length Width
5) Water Supply:
Private Well �Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that sliows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluater�
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
� Q�
Signature (Owner/Legal Representative): ���tp /� ���� Date: , � ! � �
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
VICINITY MAP — No Scale
CEH11fIGiE OF IXGF➢TpN: I(��) M1�r�GY aNry
Net 1 a �• ai�) N� o�Mr(�) ol u� proD�RY
.ne�m e� a..�nea n«.�. .nkn .<. .a.�y.a
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n<w u°on:'w��swuen�ie-i.Counb s��epa.wron
Own�r(a) �Ou
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aN ail W� � W�le Ir��tF w��
M ell��r a w E�Iyna4A upon WO pbl ar�
jwnpy GMkeW Iw 1� uw.
Survey For
Timothy W.& Cindy K. Bowes,D�.vayne A.�c Debra
Brodie H'.& Betty J. Bowes
Woodsdale TwpUPerson Co„N.C.
Aprll,1999 Scate 1'=200'
zoo ico o zoo aoa voo
— _ �— ���
SCALE IN FEET
Ernest B. Wood,Jr� RLS-2648
252 N,Lanar St�Roxboro,N.C, 27573 f
a�y pv4
NOMM GAOIYM. . NOWY VuOPc. ��xa0y
c.wh uat wr.e�aN wcew.a
e•io.. m. uN aoi �a a�x�o.i.a�.a u. a�•
«uuon a a� 1«wa^9 p�
YM�N m/ IqM oM wal NI� __ EaY eI ��.
19 �'�b� �vplru
My can
Noiary WWk
Slale ot NoM1h Caroll�w
Caunly of Penan
�, P ��A �� , PMw Olf er of
PMch�thla < A�flcab la af iaed m�ib aY �� 10
�lalotory rp�lromenb tor ncordiny.
PQ._o, co„�,& �� R
R�vi�� 011k�r �°��
en..wy «uM:
. Twl Ue wrvy «tw a�u4dM�bn / bnE 'Nin U� ww N o
eunry or kipa4b �t M� w aQron�� UM rp�bW pacel�
ef IanA;
e. ina� u. .�a �a b«t.a h a oenw� or a<ou�N w m��ido�b
uwt a o.���.d a�a on aawwMe Noi r.cu�o�. po.�. a a.e:
`� ma in. �w.�p��. o� a«i•n�« wrcd w wrex. or ta�a a�a
dow ol f+ U w��4��t ��9� a MUrq �W�1:
1. That VU� surv�Y h e!�^ M�tln:ol�rceu�ri�w�N✓ �trvchrw
w.a��ro��.., .
]. That Urv y� M a con4al wu•�Y'a
OThal U� aY b f aiwtM1er el�9wY. 'x'� a� N� ncem�matbn
1�.4Un pao�l� aW--arderM �uny. or aN�r wcpWn M
u�. a.m��en f ed.�:io�: .,,cn uae w.
�. 1Nal 11�� � lom.elbn ioEN b M� ���Y^� ��
: i::ia�ai ve�ir�i b m�:� oNs��ioi�:a".� O v awn (e) �oe�w�..r•
SUTE OF NORTH GVtOUWI GOUNI'f OF AE'S�i�
1. Ern�yt B. Wood. Jr.. c�M1ify Uat lhle Drval va� drawn
unEsr my au9arvlelon /rom a actual r/ ada �nEer
my s peMaion (deed MacAplio^ rw°rded in Book L4� .
vay �• e�.)(om.r): �n�e m. no���wn<. �o� .� a.a
�i.o,ry mm�aaa a. a.o., aem Nro�mauo� ro��e.a
In�tlook �. Da9a =: lhal lhs ral'u o( pn<lalon as
<aleuktW i� t:1Q.!een l�al lhi� plat rue P��Dar�d In
cordanc� 'th G.S. 11-3D ae adoJ.
Wilneae y Aq�nol dgnaWro 9k1/atbn number d
..ui w.m � aoy ue _���•—. wo.. te3L.
�y--� Ws.��c-zat9
flEGISTEAED 10110 SU�YOR RECISiRATION N0.
LEGEND ,,, r`t�..Cr1//��"�..
-r- fabt. ion Pin •J J�G�SfF1jf�'y �':�
-� 4on Dln ��t i2 @ � Y:
-o-- uatn. or 4a�. pl ony f $EhL
—�— ui�e .io�< o� �o��. mo�. ?.4 t�zsae `�I °
-t�- Cono. mo .��t �' F9 t�i'p SUWY f�:�
-�" N.C.G.S. mon. (hoAi. con4ol) ,''q'%FJ,� •••, �������•`
��'•i
I N���.�rw0��"`
PUT C18WEt �.� 14NCEF ��.
fi�J In Prwn teu�n�1 pP�a�} a w�
1n� drl dqr o JL_`-• 9
1 . f�M� '�w .k/. �q,/
l� ry���,{�'µl
MnaM�W. Garn� M, P� �� b�
C. Clayion
t
I
�
� ,bM � Lnasay vo9��av
0.6 266-6]3
EM 0.1. I33-320 �� N �� a2•59 _ . � _ � � _' "'
� �' -� �-' _ f' CP.4 l Tra�sr�asb� L�n=' �- �
�__�__�I _�--�_�__�� _�-._�_--_ 100=t1� �dNOV__�__�_ �- .�
_ _l_ �-_ ^--�_'"'� O a
MeWin R.6 V�My Mlm
0.B. 291'658
awwrt �
Ro�z.Yl
c.�e.nn. oa / N
V�oposetl 30' �
Eo�enmt so �„
w awroa y
iron Robart
Ransey L21' � \ / �'
/t
25,43 nc,
� Cv„mrowEo� praposea To Be Conveyed To
Tinothy V.6 C�ndy K. Bowes
_ L1] ' O- S B6•1Y22•E
_ ----��l�g� , 303.00
S 86'13'22^
� Q-� � 843.U8
���'
�� O
2
25,43 ac.
/ To Be Conveyed To
Denyne A.L Debra Q Clayton
O
40,0� 0.C.
a9
:oM L lMsaY vopstavf
D.0. 266-613
1_ � \,, _'___
�� �, Tu Be Conv ed To ---_
� �, Hrodie W.& Be y.1. Bow s
' ``-_
� (�I ` _ - �
1 � ~ � ��
� �\
I � � `� �\� >
1� ��. v �
Rolph L Go�e Etl�ards `�� ���
ai ns-it
� ``�-�` N��7039-�. CP,d �`'��� ChwUr JaY Est.
� ��oqaM�r � . Pt� 25�-13
L� BE�RING DISiPNCE LI'� B��' OISTpNCE �`_ °i� tq� \�
1 N 09'�3'2]•E SS� 13 N 6M32'JS•E 5G70 �`__ .``
2 N CB'3�'SI'E 83.�2 16 N 72'SB'03'E 3t2.43
3 N OB'oo'a3'E II�.SB 1] S BS•l2'Ot'E 32aJ♦ \� ` G�arytlRw �\
! N 0/•�8'09'E IOl.11 19 S]9'�0'3J'E 191A0 �_
5 N 00•03'0]'E l0)A3 19 S 6]•21'07'E 118.29 ��` -``
6 N 00'O�VI'E 91.39 20 N Bt'JS'1l'E 1%.)7 -�`_'
] N 07'SY12'E 116.32 2l N 5)•11'OJ'E S2.B9 �\
8 N OB'06'00'E 102.34 22 N O2'Ul'2�'E 3�.63 ��, �`_
9 N Ol'1�'Sl'E B&30 Rolph L Ctara Ed�arHs `
10 N G6'J2'32'E 6&?I RFlERF1:CES 0.& 239-)2 `��` � ,�_ ..
11 N O�'10'39'E 3923 � { - � �
12 N 02V3'29'E ]0.89 0.&163-�21 � . . .• . � ��
]3 N 3B•26'36'E %BI p,& 23-]6 ��
11 N 2J'11'IB'E 12.06 TM A16-8 � �\
P/al• Gab �1 ��r-�
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Sui � divi i � n
' h�se>Se- tio�n: � �
��� ��a ���
Type of Faciliiy: _
# of Oc�upants /�1
Proposed Waste�v
Proposed Re�air:
�3
�
#
���a�����
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rre� 7�.a�ti� . . �vv��� ������ Qll
edDa�y.F�low 3rov g.�.d
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Type: h
Typ�e:
Peimi:t ConditiQns: � P S�'f� 5��'� � ,
'� Owne� or egal I�eprese
Authorizesi Stat�e Agent:
Date:
Tbe issu�cv of tfi�is pe�it liy ti�e Health Degazmieat in does nat guazant�e the issuanc� of other persa�its. If is the responsibila#y of the
agpli�antlpraPerty owner tn in sure that aIl Peison Coim�p P]a�ung and Zomng � Btuit�ing Iaspeitions requnr� aie me� 3�i�
�pcov�s�# �'es�sat i� saa�sj�i ta reva�ti�n if t�ae sa-�e �Oi�;'pl�ti.''�a� tiae iniestd� eas� cia�g$s. '� �rv�emea� ��i is mm��
�'ee� 3ig� a c�a�ge in ��vsa�iup o� #he gasoperty, T9�is pernait �as issn�ed in c��iiva�a �vit9a the �o�isamua� of th� l�orth �Carml'ana, .:
`Z�vs ra�ad Raales f�r 5ewa..�e 3're�era� ared �isuosal �'vstes�as' (15A NC�,� 1�A .190�). 1�Teittaer �rr�oa ���#y: mo� �:t�r':e.`. �:
�nv'sa-onment�i �eadt9i S}�er,iai�t vv�s~.�#� th�t t�� seg�tic t�k. sy�� �nii c�n�ue t� fnnc�i�n s�#i�fa��a�a�y i�i tbne faatntre'or:#�t�t.
tla�wa�r snpp�lp v�ell �e�sin �tatsle. � • •
� ��atin�a��tion t� C�a�strnci � wate� S�s� (�a�r.� f�r �a�a�g ���t� � �
*.Ses site pl� cr�ad additiayaal attachments (_�. �2 � U✓' Ck�'h �er-� � .-�
, � .
Prop�sed Wastewa,ter System: � {�X � �o�sl • ,' 'I�'pe � R�astewater �1m� �� �g.p.d. .
rrew `/� �� �P� � � s�a� ���: • 2,� g•�-dJ $'
Type of Fac�iiiy: ^ �7 � � � - Basetment _ Yes �C, Na .
���wa-�x S�'s��� �a�gr����
� �� ���: s�� ��:� Dcr4 �� � �� l �c� �i ��� ���: � �o�,� -,
7�r���d: T� �r� �0� sq i� '���i Leatgt.da 3(Pa � " '� T���a li��� �� la� 5_i �
. '�r.�n ��a _ �_,_ � Soifl �over: �� in . � 'I'��n�3a �e��"smna �_ �i
ID�ai�u��oa�: �a�bartaon ��� Sex�i�l ����i�m K �re��se .
Sp��tio �82 �t! '� /L1�7 � ��. �S► .5�7-A-�"{S.
� f -Q •2 •
.��a��� �t�� :�ge�a�.
Permit E�piration Date: 3 � �
Date; Z
�p, �: � C - �
The �,Jpe of system permiite� is Conven*aonai _� Acc�ted Asternaii.ve. I a.�ca�t the spe�iricafiions of the
y. ��rLI.,�� ���g°¢s�s���a�e: , Date: �/ l— 0 j
�i ,
� ,/ _
rC.SD rev, l l/10/��._
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7���s��-�. �.�. ���.Il IE-���.71�]!a
�,�yo STTE PLAN
Name ��',e �C(yH-e ��""`-' � Taa Map #�7Parcel #�
Sub ' ' �n� Section/Lot# �
Authozized Siate Ageat Date t—
System compoaeats tepreseat appma�mate conmurs anly. Tbe coatractor must9ag t6e system prior to be 'b nni �,o the insrallarion m
insure thatpmpergradeis aiaratained
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Tax Map: ?i � Parcel #: Date: 2 3 6
I.,�ae 'Tap '�a� (Sc�) Tap �'low Line �en� &'�ow / ����
# �i�ffie�er(�) ( �) -; f�)
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��� ft of line x 65 gal. per 100 ft= Z3��?c� '"—� ; 100 = Z� gal
%5°�o R 2'� gal = �7S g�i per dose �� gal per minute (gpm) = Flow l�i�
Frictfion �ead - �
�.oss• • ft per 100 ft of supply line x'���ft of snppiy.line =100 =�• � ft
.�ft x 1.2 =� ft of friction head �:
1Vlanifold Siae: 3'�i "�+'orc� 1VIain �ize: Z „ pVC
�otaI Dyia�mic �e�c� _.�.5 ft of Elevation head + 2 ft of Pressure head +�ft of
Friction Head = �O TDH
Pump ��g�aia�anent• 2� GPNI @ �� - ft of Heasl
13rawdo�vn: /� � gal per dose � 21 gai per inch =.� � inch drawdown per dose
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lizs l�nce bv 1/z for tap 'ne noth :
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2" 4 =
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Sloped To Shed Water
b" Covex •
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Inlet F:nm Septic Tan]t
4" SCH 40 PVC Pipe '
NEMA 4X Sunplex Cont:ol Panel
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+1" X 4" Press�u� Treated Post j
12" $epdration� `
Electrical ConBuit --_ _ I
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Poxtlana Cesnent Gmut (Dovm Hill)
Check
Valve �Pe F1oat Wiref �° �
High Water Alarm Lev�l , ;
(6" Separation� .
" Hig�t Level- Pump On i
;., .
g�� fiVaporLock i � Floats ..;
'-. �' xole .
. . � DrsxdAwIxi �Up H�1) ' rrRemovable '•�.
� y. F1oat Tree
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. Low Level -Pump Ofi .
,`.. 'S � . p"�'`p ' :
' Precast Concrete Tan}c 4" Concrete -- ���,•
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T�x Ma� % F�rcel # �
� IIhC�IVI.S1011
P�lr}�S�Q'Ct1011 �l.Ot #
Du.ct Seal Both
Ends Of The Conduit Concreie Risez �
� 24° Minimum
�' - — 6" Separation
Threaded Gate Valve •
U211U21 , ' �� � r
. . ' � i�.�• .
�4__:^_re-Portland Concrete Gzout
Mutu • - '
Zip Coid-+ • � Opening Filled With
Ties r upply � portland Cement Grrnit
I L� �• �'
Outlet To Distn'bution
.�,t,Jy�n 2" SCH40PVC Pipe
���� �� ���� ��
\��. v b d /�� �\
� � / � ����
��a�na-��s�.����.� ����.���.a
Applicant:
Location:
�r�tt �+l�p � ��c�� � �
� � � �6ow
Pf��cal�t�o�aL�-o4 �
� p� ' 0 0 0 L
.
. , �
, ��
, ������� � �� \
. . �14'n., �41r� 1
r /
System Type (In Accordance Wi�h Table Va): ��
THIS SYSTEIVI NAS �EE�i 1NST�+LL�D IN COMPLIANC� WtiH �►PPLlC�.BLE . RTH
�AROLINA GENERAL STATUTES, RULES FOR SEUVAGE TREAYMENT AND DISPOSAL,
AIdD - Ai:L CONDITiONS OF � THE lIVIPROVEIVIENT PERIVIIT APdD CQNSTRUCTION
AUTHOEZt�►T10N. -
/ � �
� - . !�o �l Z-d� � .
Auth �zed State Agent Date
Installed By: r/ �[7 Date: � ��Z S�q '
. �� . : .
t" L �t�
�- � �{5 -�-� ..._
---- �tiQ �z ` � � ,/
. ✓ ✓ ✓.
� �
N �� : � � � ✓ � y'�1 �,�.,.a..'
�"' 3 '$'/Z � � ✓
�
.�5��f
�i�-� �I� :
✓ � ✓ �
�. ►' , ✓. �� � � �
,. �
f y .
Sl��
1 � �°�
PCHD, rev. 07129/0�?
,;
�
����lG �'�,�K ��S���T3O�! ��BE+�i��1SS +��Pe 9� � !�
Tax Map � �i � ParesD # /�i / Sysiterr� Type (Tabie Va)
OwnerlApplicant � � � Subdivis9on
Address/L�cation Sec/Phas� Lot # '
�e�tic. Ta�4� Ini�a�dl�ate N6�� oca�on in�s ln�t�a dat�
State ID/date ��ZZ�o q�zZ Trench �dth ft. S. q�?� �
Ca aci S?'3 ! ai. c� �✓ � Trench De th in. ✓
Tee and Filter � • T,rench Len th ft.
� Baffie t� � Trenct� G�ade � ✓
Sealant � " Trench S acin �
�..� � Riser ifi a licable �✓' � Rock De th and Quali ---�
� � Tank Outlet Seal ✓' Dams/Ste down� etc. =.
Permanent Marker Pressure Laieral� � �--
. Puenp i�nk � � Hole Spacing - --
State /date — —v z o e �ze ---
- Ca aci S' al. ✓ Pi e. Slesve �
Wate roof /Sealant � � Turn-u slProtectors � �
Riser ✓ �2equired� Seiba�6zs
Water Ti ht From Weils r�`
Purr�� From Praperty lines S� -
Checic Valve/Gate Valve StructuresBasements ✓
�� Anti-si on o e itc es / rama e a s '
Fioats/Switct�es � Surface Waters �/'
Alarm visable and audible Public VUater Su iies � �
Electrical Com onents � Verticai Cuts >2 ft. �✓.�
� Rate m . . Water Lines
A roved Pum iViodel Vehicle Traffic �
Bloc� Under Pum � Ad'acent stems � ✓� -
� Pum Removal Ro e/Cnain � �EasementslRi ht of Wa s
�'Dis�ribu$ion: Sysiea� O#6�er .
� Serial Distribution Easements Recorded
� Pressure an oi q e�e erator ontract
Law Pressure Pi e � Tri-Partate A reement
A r. Pi e Itillateriai and Grad� � �
Valves � '
Co�amen� .
i '�P W 4 j�l Dv� 22 � �t -4 q Y�i H
,�.il. C� � u, n .' ^ 4.
�,c.c ��9 r:. � c o� .' l 1,tev 2
S-�: << a �► �f�� ,�Q� s�, b�c+ w a.s s�,pp�se -� r-�► „ a ve�
,�'i,t� v�.??�.4'�/�G� . (.{<!! i� Il23� �►'91� S 5� �%nst, � , .,� a( c��..�,�L-{' � �-Q-�'
✓
„�,,,�/L'Q�NI �V'en� ��"'� `
� .
pc:�d rev. 3/13/01
PERSON COUNTY HEALTH DEPAR.TMENT
Si1BSURFACE WASTEWATER SYSTEM MONITORING REPORT
- 2 - .�-25- 09 � � �tL_
Date of Inspec ion System Installation Date Typ Tax Map Parcel #
�7b OaK %rd,fe� f��
Property Address
Instructions: Check yes or no for appropriat:, iter�s a.�d explain in space provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N' and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of (eaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Required pumps p: esen: & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose t ):�
Elapsed time readings ?
Counter readings ?
Drawdown rate:
YES / NO
❑ � ❑
■ ■
■ ■
■ ■
DISPOSAL FIELD:
Evidence of effluent surfacing 7 ❑/
Evidence of effluent ponding in trenches ?❑ /
Surface water effectively diverted ? � /
Diversions/swales properly maintained ? ❑ !
V�geta+.ive cover maint3ir_ed ? ❑ !
Protected from tr�c/unauthorized uses ? [� /
Distribution devices in goud condition "[� /
Field free of settled or low areas ? �/
PRESSURE DISTRIBUTION SYSTEVI:
Tumups/cleanouts/valves/taps intact & ,.._,/
accessible ? L�' � ❑
Pressure head properly adjusted ? � / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
�
■
■
REMARKS
�"� -�ahK belor,� ��a�(e
'rtser5
Sure �a �e� S�P�rnqs o�� �
J
EHS ,
W �r�C� o u�
�r�in`f�{�� area
� ��� ; �.> _�r ' ���� `L_% �
�� Y � � � ����
7�.�.��.� � �a.-�. ���.�.�..Il .IL—�:.� � �.11. �I�.
'�1��� ����� (l�eyv��e�air�
�'a� I��ap: � S �a�se�: l � �
.�1d1�D(�YS'1SI031.
I,at:
A��lican$'� l��Taa�ae: Gi� � lt/� Gc� /:�'�1t.J� S
I'��ilian� Address:
�,.
P�one i�lunn�ea-s:
oi �ro�erty:�Ic G'�S /�.' l C l��C •� il�/ �9 K G'r''"�2�/h 7t� Z=".�
�,� r�-� ,� _ ��,� ��, � �so� 37
� ���
�Prmit cond�tdoras:
1) See attached site plan for proposed well location.
Z) All �pplicable State cznd County regulations governing construction and setbacks apply.
3) Pe�mits expipe S years fi•om the date of issue.
�ther �'onditior�s/�'�ona�nents:
�'er�a� issue� �y: Iz-i � ���'�'�� ��te: 2 3 D
s
��3�'�'���A'�'� ��' �OlV����'I'I�l�T
l��w `�e�l �mspection:
� EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
1'�''�il
�Z- ��'
�,iner ��nspec�io�n:
EHS/Date
Installer:
Depth:
Grout:
�efll ��anc�o�ffient:
EHS/Date
Completed:
Method/Maierial(s): _
We�i �3rille�-: Darn��e, _
Pump Installer:
`b�ell �pp�aved by --
L�ate Sample Collected: �— �'D
Person County Environmental Health
32� S. Nior�an St., Suite C
Roxboro, NC 27�73
Lice�se #:
License#:
�3a#e: �rl-1Z�09
�ate Results Nlailed: f / 3� ' �
,� 4��,..�: � .
-•ti
Phone: 33b-�97-1790 Fax: .i36-�97-i808
8/1/Oo
��,�. M�,.�, �-3 S
�a��� I l °I 1
� RESIDENTIAL V4'FLL CONSTRUCTION RECORD
N� �O1ina pepattmrnt uf Environment and Natura! Rcsources- Divician of 1Yatu Quality
Rc. o
1'V�I,L CONTRACI'OR CERTIFiCATIOIy�} � � ` � I
t_ as�r�Ec�noN: Type HTH Amount .25 Cup
'i. VYELL CQ CTOR:
n
Weii Canttaci Ondividuai) -
Bamette Well Drilling Inc.
Well Conttactnr CampanY Name
s� �p�Ss 69 9 Bamette Tingen Rd.
Ro�oro NC 27574
City or Ta�n Stace ZP �
3� 36 } 599-0015
Area tioae- Pnone �u�
2 VYEIilNFOR#aATi01�
stre wsu. ro �c-� ��� tV/A
S7ATE W EU. PERMIT�Cdapp6c�eL N�A
DWQ ar OTHER PERMtT �l{'d app6cabie) N/A -
1NElL USE (Ct�edc Ap{Yecabie Baoc� Resida�l�a� Wate� SuPP�Y �J'
�,►��,� -�R-v �/
T1ME CORtPLETEO � Z � � AAA O Plat p�
3. YYEi.t_ ilOrL•
CITY: U 1�YD COUPiTY �Sn/1
�p � (��e �
( N�ne.:�asbers. CamnsunitK S��t�. Lot P1o.. Pa'cd.2iP r.o�le)
T RAP!-itC 1 IJWO SET7ING:
�'M�s pvaifey �flat �Rid9e D��+'
(� appraxaoe eo�4 �,�,y be in degms.
tATITUUE 3 mimues.smoadsa�
— . ia a dodc�al fornat
LONGIl"UOE _ _
Latimde!loaigitu� saurce: I�GPS OTopo$raPW� �P
(bcason at «�elmust ne srwwn on a us6s toPo maa and
attached to �is fbrm irw�t us'sxJ GPS)
4. WELLOYYNER
ow�Rs w�E r � �e �_
ADDRESS �
� �(/, � 2 ? �� 3
a�� � ��
c�3� r 2-z4- �2r� �
��- ��
5. WELL oETA1Ls:
a TOTAL DEPTtt � �
b. DOES Y1tELl. R�'IAG'E EXtS71NG WE11? YES {] NO �
e. yHATER LEVQ BeJow7op af Casing 25 �-
(Use'+" � Aboue Top of Casin9)
a. tvP oF casi� ts �-5 .� r_ n� i.�e s�n�
Tap d casi�9 �mireted atlar below Iand stxtaoe may requ�e
a vaia�oe in axardar�ce vuith 15A NCAC 2C .0118.
� Y� �� �_ ��� � � Bbw 20 min
g. WATER ZONFS (dePth):
F� a� To� Ftorts To
From�%to jN� From To
F� To From To
6. CAStNG: Tfiicknessl
Uiameter Weight �
F� O To q FL-�
from To F� � � �r .
From To Ft.
T. GROUT: Depth ���
From �% To 2.. Fc. GraveVCement
F� To Ft
��� To Ft
8. SCREEN: D�th 0���
F��_To FL in.
,VaF� To F� ia
F� To Fl. in.
Method
Poured
Slot Size Matetial
in_
in.
in.
9. SAt�/GRAYEL PACK:
n�, s;�e n��
Fran To F4
��� To Ft
F� To ' Ft •
!O OR1lUNG lOG
From To Fortnation Oescription
� (Z
�� � ` .
Z% � to.� �u
11. REMARKS:
1ODI�Y CEEt71FY THnT7i0.5 WEII WAS CONSiRUC7ED NAGCORDMlCE WRH
�����w�y ��1�NSTA►mAR05,� TWTACOPYOF'ltflS
RECORO
.,..�— � �.i- -v�
S � pF �1'� y1fE11. ONTRACTOR DATE
� � � � �
PRINT� i�A1J1E OF PE N CONSTR CTING lNE W ELL
Stsbmit the originat to the Division of Water Quatity withit� 30 days_ At�: hfomnatiun Mgt., Fa�n GW-1a
1617 Nlaif Secvice CenLer— Raleigh. NC Z7699-i617 Phane No. (919) 733-7015 ext 568. Rev_ 7N5
North Carolina State Laboratory Public Health 06 N. W?m� gton St.
Environmental Sciences Raleigh, NC 27611-8047
htto://slph.state. nc.us
M i c ro b i o lo Phone: 919-733-7834
gy Fax: 919-733-8695
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
Wayne Bowes
570 Oak Grove Rd
StarLiMS Sample ID: ES111709-0143001 Collected: 11/16/2009 13:45
������������������������������������������������������������������������������������������ Received: 11/17/2009 09:08
ES Microbiology ID: 11205 Sample Source: New Well
GPS Number: Sampling Point: Well head
Sample Description:
Comment:
J Smith
Angela Heybroek
Well Permit Number:
A35-191
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present Darneice Lyons 11/98/20os
E. Coli, Colilert Absent , , Darneice Lyons 11/18/2009
, . , . ' • � RA .
. � .: �,\ � ' ` �C`�J ��.... .. � . � . .
�- V
Report Date: 11/20/2009
�O, � �'p �
v
`
Reported By:
�^ng \
Susan Beasley
��
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.
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
Iron
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
Report To:
North Carolina State Laboratorv of Public Health 06 N. W?m� gton St.
Environmental Sciences Raleigh, NC 27611-8047
htto://slah. state. nc. us
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
Courier # 02-33-15
StarLiMS ID: ES111709-0030001 Date Collected: 11/16/09
Inorganic ID: Date Received: 11/17/09
Sample Type: Sampling Point: WELL HEAD
Sample Source: New Well Temp. at Receipt: 8.5
Sample Description:
Comment:
Name of System:
WAYNE BOWES
570 OAK GROVE RD
Time Collected: 1345
Collected By: J SMITH
Well Permit #: A35-191
GPS #:
New Well (Profile)
Analyte Result RL Units Qualifier(s)
Total Alkalinity 190 0 mg/L
Arsenic < 0.005 0.005 mg/L
Copper < 0.05 0.05 mg/L
Lead < 0.005 0.005 mg/L
Manganese 0.47 0.03 mg/L
Zinc 0.24 0.05 mg/L
Barium < 0.1 0.1 mg/L
Cadmium < 0.001 0.001 mg/L
Chromium < 0.01 0.01 mg/L
Silver < 0.05 0.05 mg/L
Selenium < 0.005 0.005 mg/L
Iron 0.36 0.10 mg/L
Mercury < 0.0005 0.0005 mg/L
Fluoride 0.591 0.20 mg/L
Nitrate < 1.00 1.00 mg/L
Nitrite < 0.10 0.10 mg/L.
Chloride 21 5.00 mg/L ; :: ,-;
Sulfate 17 5.00 mg/L �'�`'�
PH g N/A �� ,' .
Sodium 21 1.00 mg/L �
Calcium 52 1 mg/L
Magnesium 14.0 1 mg/L
Total Hardness 190 7 mg/L
Report Date: 12/5/2009
Page 1 of 1
Reported By: �%li�ie i�ucg
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hazdness
No established limits
0.01 mgll
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
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