A37 29Application Date: � � ��—
Amount Paid: 200�'
Receipt #: ��� (�_
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Z(�� ,��.� S� 1C�1C��<���.�s ;`, Tag Map: r\�� Z�
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6 �' Application for Services
Services Requested
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$I50.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: RoS 5 CA�'J eY
Address: 6�p 7asor� CI,� Qn l�a•
j�xboco N �7S7�t
2) Name and address of current owner (if different than applicant):
Name: R,c� D�bb�c �9b�y � �oc�S Cat�l¢�
Address: l0 7a;oar GIa4�o� �a,
Roxboco i�f C �-7S%�
3) Property Description: Lot Size: (. 6 � Subdivision: l��
Address and/or directions to Property: �t'or. �}�i$ Mo�o
Phone (home): N/ �
(work/cell): 336 — 5 0�} —{� 13
Phone: 3 3�' SQ3 �%�� S
#: Nl�
❑ yes no Does the site contain any jurisdictional wetlands? °
❑ yes no Does the site contain any existing wastewater systems?
❑ yes no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes no Is the site subject to approval by any other public agency?
❑ yes no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
) Proposed Use and Type of Structure:
Residential �
New Single FamiIy Residence Maximum number of bedroo s:
O Expansion of Existing System If expansion: Current numb r of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? yes ❑ no With plumbing fixtures? �yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: � New well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative C7 Alternative 0 Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�;7�,Or%y � � Zg �'2_.
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxbaro, NC 27573 (336-597-1790)
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Itegnlatitms. ,_. . , •+.,. .., _ . . �� 10.d��. �(1�/�p�,y j � ,'�-
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N`AU j3¢ ( � .. . Date requ i r r�me cording. . .
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HAR�LD R., DEBRA D.,
80BBY D.� & DORIS W, CAF2VER
O.B. 29G-680
P.C. 11 �75—J
RECN �437
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RECN 3437
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�� ! Tax Map: �� Parcel:�_
�.1 � � 1 `) f ���� �� Subdivision
�--' — � � � � � � Phase/Section/Lot #
]C�a�.�a���� ����.Il IL���.Il�I�
Permit Valid for: Fi
Type of Facility: Pr
Number of: Bedroom
Proposed Wastewater
Proposed Repair: �
Permit Conditions:
/ Improvement Permit
ve Years ✓ Non-expiring
i v a�C ��e5 i c�P � C,� New �Addition
s� f Occupants � D/ Employees / Seats:
System:. A cCer��-P��-S �% R p.a u c,-�-ioh �
�
Authorized State Agent:
(X) Owner or Legal RE
Water Supply: � /P;� I
Projected Daily Flow: gallons/day
Type: �
Type: ]��
`J
Date: � � /f -
Date: 7/�f�;
The issuance of this permit by the Health Deparhnent does n6t guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
lmprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with t6e provisions of the North Carolina `Laws
a1r�1 Rules for SewaQe Treatment and Disvosal Svsiems'(15A NCAC 18A .1900). 1�leither Person County nor the Environmental
Health Specialist �varrants that the septic system will continue to function satisfactorily ici the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Propose Waste•Nater System: � -i �(*)Type �_ Design Flow � 6 o gal./day
i
New Repai � Expansion Soil LTAR. � 3c� gal./day/ft2
Type of Facility: ��; �a�e 5; e�� �. (�S�Ri Basement: _ Y�s _ No
(*) System Types Illb, Illbg, IY, and V, require periodic system inspections by the Person County Health l�epartment.
Wastewater System Requirements
Tank Size: Septic Tank ���5n gal. Pump Tank gal.
Drainfield: Total Area Ob sq. ft. Total Length SO4 ft.
Trench Width 3 ft. Min.Soil Cover _� in.
Distribution: Distribution Bax V/ Serial Distribution �✓ % Pressure Manifolc
Specifications:
Grease Trap �---gal.
Max. Trench Depth 2$ in.
D�C�
Min.Trench Separation � ft.
Authorized State Agent: Issue Date: Z-11- l3
Fermit Expiration Date: Z-Ij - I$
Tile system permitted is: Conventional /Accepted v/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: �' ��7
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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� SITE S�TC�I
Name � n�S C a Yv �� Taz Ma.p #�- 31. P�cel # 2
�
�Subcl'tvision ' . � Section/Lot#
� �-z�-f3 �
� . A thorized Srate Agent . � Date .
System cumponen�ts sse, present a�ips,oximate �contours only: The conhwctor mirst j�'ag the syste�m prior to
be . n�in the inssta�llatx'on to insure thart m er rs maintained � �
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Taz Map R3`1 Parcel # ��
Subdivision
Phase/Section/Lot #
# of Bedrooms S
Applicant: R�ss C.F►w��. �
Location: sn -� oa r►o�co,� A�Ar� (Z4 � ft�' '�t $. if►M.'�. M�O�� tJYa� 4Ft'
3-wAY SpuY 7 Ar E�10 cc� 6�"�.�. ir�.a,•. �o.
O�eration Permii
System Type (From Table Va): 1'� G Product (IIIg): �'L �ww _
Type V& VI Expiration Date: t� A _ Type V& VI Renewal Date: A
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit aad Construction
Authorization.
i���� ,A- � � 1
(Autho�'ized Agent) (Date)
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Scale �TS
PCHD, rev. 12/14/12
Tax Map: /�3�_ Parcel #: a�
Septic Tank System Checklist (Type II-I� System Type: � 6
Notes•
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes•
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11��1L'Q�IL7L�ammm rmm �71.�.��.Jl �sL.ffi.1L'�.lYb
W��� �'ERIVIIT (New �✓ Repair�
Taz iViap: 3� Parcel: Z
Subdivision:
ApQlicant's Name: �os e
Mailing Address: 10 �.1 a
�ox�aro . IJG 2� -r, 1 �(
Phone Numbers:
Lat:
I'ermit Condit�ons:
1) Se� attached site plan for proposed well location.
2) Ald a�plicable State and County regulations governing construction and setbacks a�ply.'
3) Permits expire S years from the date of issue.
Other Conditions/Comments: ���,���, � i ( . .S�P����.l�S �
P�ranit issued by: _ '� I)ate: 3�Z7 -/ 3
C�RT�ICA'TE OIF CO11dIPLE'I'dOI�T
New Well Inspection:
EHS/Date
Location: S
Grouting: - Z-��
Well Log:
Well Tag: ' s 3 a� ��-
Pump Tag: �ta 3 a� ►�}
����$� Air Vent: }� 4 � �i
Hose Bib: 5 �� 1`�
Casing Height:
Concrete Slab:
Liner �nspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: . �A �,1 �� License #:
Pump Installer: License�:
�ell Approved by: �.�, Q. �� _ Date: 'i `F i
Date Sample Collected: SJ ly ��
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date Results Mailed: � �4 t`�
Phone: 336-597-1790 Fax: 336-59'7-7808
8/1/08
.RESIDENTIAL wELL coNSTxucTiorr uEcoRn
North Carolina Deparhnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # � � 7c� �_
1. W L CONTRACTOR: �
�b /�`/U� E� �� � �l �
Well ConUactor (Individual) Name
�3amette Well Driliina Inc
Well Contractor Company Name
611 Bamette Tinaen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code .
3c 36 � 599-0015
Area code Phone number
2. WELI INFORMATION: �� � � �
WELL CONSTRUCTION PERMI #
OTHER ASSOCIATED PERMIT#(if applicable)A-• ' � �i'�
SITE WELL ID #{rfapplicable)
3. VYELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED [ " l Z "� �
TIME COMPIETED / D�' AM ❑ Ph�'
g. WATERZONES(depth):��p
: Top �s Bottom � v 9�4 ffop �� Bottom 2 7C,1 S�ia �
Top J �O Bottom / �S6srRjrop Bottom
Top '�- Z-o Bottom 2- 30 ���gjop Bottom
Thicknessl
7. CASING: Depth Diameter Weight Materiai
: Top�_ Bottom�,� Ft.� Sv R 2/ � V� C
; Top Bottom Ft.
: Top Bottom Ft. _
: 8. GROUT: Depth Material Method
� Top�_ Bottom 'ZQ Ft. Sand/Cemenl Poured
: Top Bottom Ft.
: Top Bottom Ft.
' 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
. Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
4. WELL LOCATION: 10. SAND/GRAVEL PACK:
� Depth Size Material
CITY: C' � r� � CtOUNN Pe 2 s� n� : ToP Bottom Ft.
.�-� o � 1,,g,�
(� �� � .� �' Z 757� ; T�P 8ottom Ft.
(Street Name, Num rs, Community, Su 'vision, Lot No., Parcel, Zip Code) . TOp BOttOm Ft.
TOPOGRAPHIC / LAND SE7TING: (check appropriate box)
❑Slope pValley �Flat pRidge ❑Other
LATITUDE 36 "�� � L " DMS OR 3X.XXXXXXXXX DD
LONGITUDE �7�' ' � 2 c9 " DMS OR 7X.XXXX)oUCXX DD :
Latitude/longitude source: [IXoPS Qfopographic map
(IocaUon of.well must be shown on a USGS topo map anda(tached to
fhis form if not using GPS) ,
5. WELL OWNER
5 �,�� ve 2 �
Owner Name
�Ic� a �r��e � Cl�., �ti ��
Street Address
���C°�d �2 e'1 � � z- %" 7'f
City or Town State Zip Code
3s s�`� 7 ��' � � s'
Area code Phone number
6. WELL DETAILS:
a TOTAL DEPTH: � � c�
b. DOES WELL REPLACE EXISTING WELL? YES O NO �
c. WATER IEVEL Below Top of Casing: 2 S FT,
(Use `+" if Above Top of Casing)
d. TOP OF CASING IS � FT. Above Land Surtace'
'Top of casing terminated aUor below land surface may require
a variance in accortiance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2O • METHOD OF TEST BIOWII ZOR)
i. DISINFECTION: ry� Hl'H Amount 1/2 Cup
11. DRILLING LOG
Top Bottom
� � �
_�1�_
�l SD
�b / Z ��
/
/
/
�
/
/
/
/
/
�
: 12. REMARKS:
Fortnation Desaiption
o �tegb�.rcd.a�
.—.�/u Sf-!� IA
, it-a�-�S t�^ ro
�//a6Zt1 5'�'P r+) 3�a�:�'r���h?'
Yr4L�x
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANOAROS, AND THAT A COPY OF THIS RECORO HAS BEEN
PROVIDED TO THE WELL OWNER.
�P��� z . � � -�2 i3
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
%� �•.��1� /� ' 7'�R ll�� �
PRINTED NAME OF PERSO CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-�a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-63�0 Rev.2i09
North Carolina State Laboratory Public Health
Environmental Sciences
�licrobiology
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: ES051514-0105001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
ROSS CARVER
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
OFF MORTON PULLIAM RD
Collected: 05/14/2014 13:48
Received: 05/15/2014 08:55
Sample Source: New Well
Sampling Point: Well head
Derrick A Smith
Angela Heybroek
Well Permit Number:
A37-24
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent DBLYONS 05/16/2014
E. coli, Colilert Absent DBLYONS 05/16/2014
Report Date: 05/21/2014
Explanations of Coliform Analysis:
Reported By: Susan Beasley
�'.�C�Y'�7��
MAY 2 3 2014
BY:
/ , �•r„�jj
��
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.
Report To:
North Carolina State Laboratory of Public Health
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: ES051514-0090001 Date Collected: 05/14/14
Date Received: 05/15/14
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 4.7
Sample Description:
Comment:
Name of System:
ROSS CARVER
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slph.ncoublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
OFF MORTON PULLIAM RD
Time Collected: 1:48 PM
Collected By: Derrick A Smith
Well Permit #: A34-24
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 4 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 < 1.0 mg/L
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 7.1 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.90 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 25 mg/L
Total Hardness 13 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 05/23/2014
Page 1 of 1
Reported By: Arnold Holl