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A35 191Application Date: � -� �c� ` � Amount Paid: 02 DO . o O 9/�� /° � C,�c'.�G � �u' F.eceipt� : �} Q 8' ���j � y2217 ,� G'f'� �^� `--����5� ������ �% � - `�`.= � � ��"�P�Y" 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 �o m�(w) M d«a r.eo.a. ��: eow�� c�. — �e uw' .aie p.op.�ry a� n<w u°on:'w��swuen�ie-i.Counb s��epa.wron Own�r(a) �Ou Qn.,,A._ M �. N-9-`�1 vw�m�y e =�i�v �anwwa<.�-- oaa v«.on co��y. M.c. ,�. �„�.,.� ,a ,.�.. a N. .�� � .�„� u• a� v� a^a .wa«�+an n..wr �n., ua n. µ..w �n. en ��wr�� <�a cwum�a�. 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-� , __ ._ _ .. . ! �,� � � ����.� �� ��, , ,1 � � � �. � � � � � �J ���� l�sa-srb��o-�-�, ,�,-n-„ <�s�.�.�.�. 1�"'���.�-�E.�a �li��� �3��•e x Maµ � ' �rc I R � 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����� -��� _�� ���� � rre� 7�.a�ti� . . �vv��� ������ Qll edDa�y.F�low 3rov g.�.d � 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/��._ ; .. . . .. . tl _ ��? �� ���� �� . �."= `�� � � ����' 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 ' - • / v � 1' \ �` _Ci �2��K GR��E � L3`— RD) _ 6�, �� (�yQ�✓1T+i�� ar� �� L4 `,.. L 5_ P(1gUC R/W � � � _.,_ Fj surtr� D 1� / _`'_- ` 6.�_ � 7 __ r�-�Q�K-� Y �' ; �.�e i vcs�t �la,�' �t • � � � �r �" Q�� f;��, � s�< < �qP , � N o � � ¢ �� ��� ( � � �/(��� du�r � / m c-� � o z r�, � �,1I ; �c -4h'��� � � - ___, � `� ( I✓9 �� � Sld�• / � "_ � / � p o . ,�Q Q(Ir�e9t �'tKS� � j C 14 D-��'i � � �c��✓� �'e�"� ; � r- m � cn ��2�� I A�M�t'� a��� � c^� � i- pr n-i r� /. �� p��' � � Q� rNS�-et��OcT��`)'� / � / - ,�.t, pr��+n '� -en� ► `��. � t ! � �� to�� � 1 � �` 0 i� � % �� ��,� Y ,; !v � � . % 9�;,,, � LQ � � � � � ,� p; ar►-�e� � ,� . -� � p' � � � ~ i' ,' /�(/i" S�c, g� �j�s> � � j' � � (,� � O� � g��iY' ' �� �`�(,�� �t� �rrt�S r*� v t" ;i �- v r� � r�-i � o c.,,, ° � / � '� v� z � o c,� 1� /� ! �' —i r N O � J = v /CN %�13� l��t � ���s m ` . � � '� i o/� � °j � U� ; C�Z��. 5��, �� '�S . a ���� , � o / �� '� / �.�- / / ' � .. �( ��� � � S�C-� � � . � � / � �;o � i � � , . � -� � � \ . i ��� � � � �zT z -� � « � m� ��,o i�o � � I I \ � I I � I I �� I I � i cn I � � I c� �!. I �, �� � , j �. � - � z i ,N.��I � 5� � i �� � 8� -_� 6 I � �,/ -� I _ � N � I � 3&R o GI I o _� i I ; 5�.�0 0� � bD- � � . � ,66"6 l G � � i � „Lt�,95�Z S -o ' I . . � �I Iz • I 00 - � ly �,�,�c�� � �, n��� _� � �`�`�. � 1�I�L�.� ��� . - ������ �d�s ?E�-�� ���t �[�.�.:1��. Owner: Tax Map: ?i � Parcel #: Date: 2 3 6 I.,�ae 'Tap '�a� (Sc�) Tap �'low Line �en� &'�ow / ���� # �i�ffie�er(�) ( �) -; f�) � 2. o .s p , oG 2 �. 3 4 5 5 7 � 9 10 . ��� 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 :�, -.,: ;r.:.,,�:� � :,. ,��,:.�.,� �: , - • _ �y _ "=�1������0 — . � : � � � .:. : , , ,. � �" � I I 1 1 ' ... �[t�l�om0o <-�-a-�-.. o-� � �-�-o-�-�-�-�-�-o-�-�-�-..-�-<-o-�-�-,-o-o-<.-. .. :- � . 111 111 111 111 �is�"a`iiiiwiaii��`.�i°iiiii�aiii'`�ii � � � � �. . : , ..._ . L : : : �: r.��� �a�m� 9ac� � �� �iianifoid Si� / � Ta �i%ld PlfazNa Tags o$'one �ide lizs l�nce bv 1/z for tap 'ne noth : �i" t3pS 3/s� t2p3 �» . 2" 4 = 3» 9 5 d� � Z i � 12 _1 • " F3.o-c� pe= Tau Si1.e ilTcaeriai FIolt� GPYl t!. " Sclied �0 �•� �. , ; Scited 40 i.' v • .Scl:ed $0 IQ.' � =; • I �ciieri ?0 � - = , ��� j�� �J1Gi �� �� �.� � � � ���� � ,��-,�,�- �, ]� ��„ �,�. �.�.IL I1HI � �Il �1� Sloped To Shed Water b" Covex • ..� Inlet F:nm Septic Tan]t 4" SCH 40 PVC Pipe ' NEMA 4X Sunplex Cont:ol Panel � I� +1" X 4" Press�u� Treated Post j 12" $epdration� ` Electrical ConBuit --_ _ I . . . • e.• , .- . 1 • : Acceis Cover• • , ' . ; 1 � • .. r • ! o ' ' << - ; • ' � � • ' . ; �., Opening Filled With Anti Siphon Hole � Poxtlana Cesnent Gmut (Dovm Hill) Check Valve �Pe F1oat Wiref �° � High Water Alarm Lev�l , ; (6" Separation� . " Hig�t Level- Pump On i ;., . g�� fiVaporLock i � Floats ..; '-. �' xole . . . � DrsxdAwIxi �Up H�1) ' rrRemovable '•�. � y. F1oat Tree ,� . Low Level -Pump Ofi . ,`.. 'S � . p"�'`p ' : ' Precast Concrete Tan}c 4" Concrete -- ���,• • � ;.; (Iviaterial Strength }3500 PSI) Block � I " .i. ' ,� ...' . . - . ' - r '. _ ' ' . ' . • '` • • ' � , 1 • �.' . . � �d 0� GAI,LQl�I' PUl,VIP TANK T�x Ma� % F�rcel # � � IIhC�IVI.S1011 P�lr}�S�Q'Ct1011 �l.Ot # Du.ct Seal Both Ends Of The Conduit Concreie Risez � � 24° Minimum �' - — 6" Separation Threaded Gate Valve • U211U21 , ' �� � r . . ' � i�.�• . �4__:^_re-Portland Concrete Gzout Mutu • - ' Zip Coid-+ • � Opening Filled With Ties r upply � portland Cement Grrnit I L� �• �' Outlet To Distn'bution .�,t,Jy�n 2" SCH40PVC Pipe ���� �� ���� �� \��. v b d /�� �\ � � / � ���� ��a�na-��s�.����.� ����.���.a Applicant: Location: �r�tt �+l�p � ��c�� � � � � � �6ow Pf��cal�t�o�aL�-o4 � � p� ' 0 0 0 L . . , � , �� , ������� � �� \ . . �14'n., �41r� 1 r / System Type (In Accordance Wi�h Table Va): �� THIS SYSTEIVI NAS �EE�i 1NST�+LL�D IN COMPLIANC� WtiH �►PPLlC�.BLE . RTH �AROLINA GENERAL STATUTES, RULES FOR SEUVAGE TREAYMENT AND DISPOSAL, AIdD - Ai:L CONDITiONS OF � THE lIVIPROVEIVIENT PERIVIIT APdD CQNSTRUCTION AUTHOEZt�►T10N. - / � � � - . !�o �l Z-d� � . Auth �zed State Agent Date Installed By: r/ �[7 Date: � ��Z S�q ' . �� . : . t" L �t� �- � �{5 -�-� ..._ ---- �tiQ �z ` � � ,/ . ✓ ✓ ✓. � � N �� : � � � ✓ � y'�1 �,�.,.a..' �"' 3 '$'/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