The URL can be used to link to this page

A36 42Application Date: '�D// p d 7-1 '� � Tax Map: _� Amount Paid: �-o� � �0, �� z�/�� Parcel #: _�"� . Receipt#: 1n�3��t5 51�� U, �� QQ& i, a�f� GI�'� 1�'1 ,�� ) � tt �Jl`�� 3 `".' � � � � � TC�� 1� ed, /1� l� rI r '�1 � �� 1 1��1�+Y��NIL'li'�KD'1CL'JY'Ii]\.C.-]Y�alL:ntiL11 ZL—'—�L�C^t.LR.J�Q::117L Application for Services (Septic Systems and Wells �..► "`" ' ) Services Re uested � Improvement Permit (Site Evaluation) � Construction Authorization $200.00/$300.00 if> 600 d (Fee is de endent on the e of s�stem ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision ( $150.00 (if site visit re uued $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e 1) Services Re ue d _ Name: ,,r.� �� Address: u —� `� — �Q� — � Z,S � l� Phone # (home): �.36 Sj — ,�� (work/cell): S s� //7� 3 eo 0 0, 2)Name and address of current o��ner (if different than applicant): Name: Address: 3 Pro er Descri tion: Lot Size: . Su, d�s o" n: ) P tY P 1 f�C' Address and/pr directions to Propertv: /'�u.6 .�-,�Z ,�� Lot #: _ .� o�� a r/�l'` . . , � i� �� 4) Proposed Use and Type of Structure: Residential � Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes No -/ (with plumbing: Yes No _) Garbage disposal: �Yes No / 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 comvleted application �nust also include: ➢ A pladsite plan of the property that slzows property dimensions and tl:e size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying tl:at tlTe property is ready to be evaluated. I am submitting this application to request services from the Person CounTy Healtli Department. I understand that if the information provided is incorrect or if the site is s bsequently altered, or if the intended use changes, all permits and approvals shall become invalid. , Signature (Owner/Legal Representative): � � Date : 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��, ; ,�� I��u��.��aIl IHI�,�.Il�I� Applicant: �Tav 1or 6a�1e ♦ T�x M�� i/ P�rcel # � S�rbd�ivi�sion ',Ph,� �s.etSe�t�i,on Lot # Improvement Permit Permit Valid for—� Five Yea s No Expiration Type ofFacility: i��a�esi�(p��[;2 New Addition_ # of Occupants ,� �o # of Bedrooms Projected Daily Flow Proposed Wastewater System: - ( Proposed Repair: ec Permit Conditions: Owner or Legal ] Authorized State Water Supply I�/ei � g.p.d. i Type: Type: Date: `�- �1�� Date: Z - /!� -// The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (�. Proposed astewater System: - o� KG�P✓) Type� Wastewater Flow 31�0 g.p.d. New L� Soil LTAR1 3� ..d./ ft 2 Repair Expans n p Type of Facility: �-��/Q� �,�Si e�1Ce, Basement _ Yes _ o Wastewater System Requirements Tank Size: Septic Tank: `GDU gal Pump Tank:-- gal Grease Trap: --�al Drainfield: Total Area: iQ� sq ft Total Length 3tl0 ft Maacimum Trench Depth � g� in Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Separation: � ft C. Distribution: Y Distributiot� Bo�c-, . Serial,Distribution Pressure Manifold Specifications: � Authorized State Agent: Permit Exp Date: �- —/L.—� The type of system permitted is Conventional '✓ Accepted Alternative. I accept the specifcations of the permit. �, �` �/ Owner/Legal Representative: Date: PCHD rev. 11/10/OS . . :��,� �� 1�1�.1��1� � � � � � �°�� .��,� ��.� �� Name Per�in Let,�ltS . Sub ' � 'on Authorized State Agent SITE S�TCH Taz Map #.� � . Patcel # �- 2. Section/Lot# � 2 -1�7-// � Date . System components re�resent aii�tiroa�imate�contours only: The caniractor must flag the system prior to begisrning the installation to insure that pmpergrade is maintained _ . ___ , , _ .. _ _ ------• —__--- -- -- _ _ =---- -L,T _�_ S �� s� � � �, �h� q, 1� = � ;P o c,+ � � a m r � 3� o Pd. 3�� .� o _ � �� n �oa �-cc� r .— �$ `' -�e�� SC�"l.E � � tr: 40l � ' �m� or Z � rnzcn -< a � , a�� q� ti o�c. �,JOfrr�C , ,cr�-il,Uf � < ` p"�" � Oi{-c�,� �� \ � � . J!� �\ I � � �u5f, Fro��' '� � \ ,�o . /- w � � � f, . o � . �o .� � -Z n � w �� N � � ' J � J � �� N A �/ W � W � v O N � -� N ��O � �. _ / � / � J m O O�' / m � i �S � �� . / Tax Map: �� Parcel #: � Septic Tank System Checklist (Type II-I� System Type: __r� Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BLTILDING INSPECTIONS: Copy of OP (Revised 12/09 BH) e-mail Date: ��,s. f ��..� �� , � � �� I��n.�n.a-��n.�rn.��a��.11 �3LLm�.IL�I�n. Applicant: Location: Operation Permit Tax Map ��-�!v Parcel # _� Subdivision Phase/Section/Lot # # of Bedrooms � System Type (From Table Va): Product (IIIg): i� �z� .� This system has been installed in compliance with applica6le North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. ./ . (A thorized A ent) ��5 (Licensed Contractor) Sca1e: ��a '7�ioyy ` �'il %y`' Ty—/ (Date) �� ' ( ate � lo �� `' � A �` �,� r �° � f5' 1 I1�PJila.2. � L..�.�� Lad � 1�� . '� —'�,.�+c ��E'�J ��j- — LO�O `�'i'F3- �Z� '7-yo—�l Line Length / o Z- iDo 3 soo Total �oo � ��' �� ll �� ..� �� .��. n- � �.a�. � � �.ffi.11 IL�I � �.11 �.I� W�I,� �'ERMIT (New v I2epair� Taz Map: K 3� Parcel: �� Subdivision: Applicant's Name: !'or�ia l-ewi 5 Mailing Address: Phone Numbers: Location of Property: � Lot: I'ermit �''onditions: 1) See attached site plan for proposed well location. 2) All applicable State and Counry regulations governing construction and setbacks apply.� �) Permits expire S years from the date of issue. Other Conditions/Comments: � � . , - � CERT�F�CATE O� C�MP��'i'�OI�T New Well Inspection: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: HS/Date _ Z�—� � � Well Driller: �32✓'� Pump Installer: '` �ell Approved by: Date Sample Collected: � 2. � 2. Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 L'nner Inspection: EHS/Date Installer: Depth: Grout: Well Abancionment: EHSlDate Completed: Method/Material(s): _ License #: License#: I9ate• Date Results Mailed: '" Phone: 336-597-1790 Fax: 336-597-7808 siiios Report To: North Carolina State Laboratory of Public Heaith Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES012512-0030001 Date Collected: 01/24/12 Date Received: 01/25/12 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 6.5 Sample Description: Comment: Name of System: TAYLOR OAKLEY P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27617-8047 htta://slah. ncqublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 CHUB LAKE LOOP RD. Time Collected: 3:15 PM Collected By: J. Smith Well Permit #: A36-42 GPS #: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 6 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 � 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead 0.005 0.015 mg/L Magnesium 1 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 3.60 10.00 mg/ ;-�� -ry �-, x� ,— ,—=-: :.--� � �i.��:�._..1: `� -.:=, :�---. Nitrite < 0.10 1.00 mg/ � pH 6.5 N/A FEB � 5 2� IZ I Selenium < 0.005 0.05 mg/ � Silver < 0.05 0.10 mg/ ��, . I Sodium 11.00 mg/L - ' Sulfate < 5.00 250 mg/L Total Alkalinity 29 mg/L Total Hardness 20 mg/L Zinc 0.81 5.00 mg/L Report Date: 02/09/2012 Page 1 of 1 Reported By: �e�te �Kco� North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES012512-0122001 � �� ES Microbiology ID: 33640 GPS Number: Sample Description: Comment: Name of System: TAYLOR OAKLEY P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27617-8047 http://slph.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 CHUB LAKE LOOP RD. Collected: 01 /24/2012 15:15 Received: 01/25/2012 08:40 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A36-42 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 01/26/2012 E. coli, Colilert Report Date: 01/27/2012 Absent Explanations of Coliform Analysis: Susan Beasley 01/26/2012 Reported By: '� - �--- � - �— -� ` - ��t �' FEB f� � 20i2 I ;:��-- -- �� _�------ - Susan Beasley ��-%� If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. 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.