A40 152. . .
Site Evaluation Application
Fee Collected YES ��
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Date: l3�1�C? 93
NO
APPLICATION FOR IMPROVEMENTS PERHIT
1. Permit requested by: owner/prospective owner: �iaF
agent:
Address: �. C� . QoX � 7� 3 Ro�(bo1�D �U�,
Home Phone ��: �'� �- 533 C Business Phone ��:
2. Name and address of current owner: �
3. Property Description: Lot size: %,oZ� �,?nes
4. Tax map ��: _ Township:
Subdivision Name: C'ouu�,�. ��voke. i�ST�T�s Lot ��:
5. Directions to property: State Road �� & Road Names, etc.
I��n,�4L ��rdc � i t /4� r
y
6. Permit requested for: New Installation: �1 Repair:
Additional Renovation re-using present system:
7. Number o£ occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: �� FT
Depth: � oZ'�- � � ,
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?
�%Ol+��'
10. Water supply private?�1
Other source? (Specify):
Are there any wells on adjo
11,
public? community?
property?
If so, ident
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spring? ,�
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ifv location:
Type of structure or facilitys Proposed: �P Existing:
Type of dwelling: House: � Mobile Homes Business:
Type of business: Number of Employees: ,
Number of bedrooms: �_ Garbage Disposal? Yes No �
Basement? Yes No �If so, number of basement fixtures:
12. 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. Permissio -hereby granted to
enter the property for the evaluation. G.S. 130A-3 5(F)
/
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Signed Owner or Authorized Agent
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Permit Issued �
Permit Denied
Plat Observed �'
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rACTORS — SITE EVALUATION Ag� 1 �� 2 �� �� 4
S S S S
1. SLOPE (x) PS PS PS PS
U U U n;, U
2. SOIL TEXTURE (12-36 in. ) � S S, i' g r
(Saadp, loamys c1aYeY. PS �� (� S� CPS� r pS l��"
Note �:i �ig � U - � �� J �: Lv'� ��
�T �T U
3.. SOIL STRUCTUI{E (12-36 �ai. ) S S S S
(Clayey soils) PS PS PS PS
. U U U U
S S S S �
4•` SOIL DEPTS (in.) PS PS PS PS
u U U U
S. RESTRiCTIVE KORIZONS (itt. ) 5 S S 5
(Impervious Strata� rock) PS PS PS PS
' U U U U
6. SOIL DRAZPIAGE GROUNDWATER S S S S ��
,(fi.�cternal & Internal) p5 PS PS P3 '
U U U U
7. SOIL PERMEABILITY g � g S S
(Percolation Rate) � PS PS P5 PS
U U U U
• S S S S
$. OTHER (specifY) PS PS PS PS k
U U U U
9• SITE CLA5SIFICATION �
(See below) . � � , .
SOIL SERYES
S- Suitable PS - Provisiona.11 Suitabl� � •U - Uasuitabl�
RECOA4�NDATSONS COI4IEriTS:
.
�L�TE CLASSYFICATION DIAGRAM (Include: Soil. �rea�, property linee� rcads, streams. gullieg�
aet areas, fill ar�as, Wells, aater badies, glepe patterns, etc.)
application Date: 7 ;,Zo?-0 �l
Asnount Paid: ( � � . 00
Receipt�: 5 7� q 3 7_
Tax ylap: � � �
rarce! ri: �S�a
� o � ��� �� �... � ;� �.� ' � �\�
, � �.. - ��- _ ;� �� �Q i'��� '�' �.�
Z�.L.. �x�a `Z-•:L•r �c� s'� �,.-.-„ �r..^_ s�-la iY:=.az �� 1�'�� .e:�.�ro.. �� ti;�Z.
1-����a���fron ���' �e�'y�c�s (Septic Systems and Wells)
Sea�vie�s �e uested
� �mprovement �ermit {Site �valuationj C� Construction Authorization
�200.00/$300.00 (if> 600 g d) (Fee is dependent on the tyoe of system permitted)
vTooile �Iome.i2epiacement or �uiiding Addition �J Permit 1Zevision I
$1�0.00 (if site visit re uired) $75.00 �
C�eil Permit (rdesvi"�teplacement/b2epair) fJ klepair of Exisiing Septic System �
$300_00/$200.00/$75.00 No Char�e �
�� �ers�ic�s Reques#e�l ny: �
Name: �= lq 21 L. �--� N�
Address: (�c.�. [3�, ( !< C',T'
��.� joN N� �7��n
�a.� � , �-
���Mi Phone#(home):�1g� `j3� —9�`E'�
(�cell}: �33G, ,S'ot} — 3� �7
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i)l��rn� ar�d addrass o� zurr�at aw�ea� (i�' differ��t than ap�licaa��):
Name:
Address:
�) �ro�es-Q�y �escrS��sc�n: Lot Size: � n� A� Subdivision: CG�
Address and/or directions to Property: �2 �/l7oA H��� � s R�l
Fs�R��s
.� IR7 �t�sce �ot #: _
. �vx�1-�oRv ! '� 02
4) �roQosed iTse aud 'Py�e oi Structure:
R�sidential � Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes � No�_ (with plumbing: Yes No _�
Garbage disposal: Yes No �_
5) d'Vater Supply:
Private Well � (Proposed Existing _)
Community Wel : Public tiVater System:
Are there wells on the adjoining properties? T10 _
Yes �(please show location on site plan)
l�lote: ,�1 eornpleted n��lication musE ndso inclucie:
�.=4 �lat/site plun of ths pr�peyty �liat sliow� �; c�er� dir;xen$ions r�,nc� t�ee siz� �grd docr�tion of �11
pro�osed structures. � .
5 A sagned copy of ldie `�aZ �'r���sration'��rrs¢ ve��an; that �he �rope�ry �� ready io �ie. ev�alura�er�.
� ana submiiting thas ��polncatioia #o �-e�a�est 3�rvic�s �'rorn t�e �Qr�on �ou�� I3e:�lth �epa;rtpne�Y. � unc��rsta�d tha�
ii th�e infor7nation aravide� is ine�rr��st oa- i�f #�ie �i#e :s suV�s��ue�t3 �r �#' #;�Q �ntended u�e ctcarg�es, a�l
per�its and appravals shai� became invalid. '� —_- _/
Uab���u�-� (C'wner!Legal Re�resentative): i� % �arQ : �'� � O �
10i08 Person County Lnviro�ii;�enta! '?ea�th; �?5 S. �iior?an �t.; �uite C; R�Yboro, NC ^757= (336-�9�-1790)
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1! •+�i:n,`�"�3"�1Z"IL.IT'J"rIl.�..3i.�1�� ���.JL¢�rra
�ui�di�ag Asd�fltions/ 1D�o�siie �o�ae ���flae��ae��s
Tax Nlap #:��
Approval Requested for:
Parcel#: 'SZ
Mobile Home Replacement
� Building Addition
Applicant Name: �►' �c O't
Address: ur
C A c- Sz o
Pi�one #'s:
/q 3s - �� s � so - 3�?
Permit Located: x Yes No
Installation Date: �f Z y Desi� flow: �(gpd)
Current Contract with Certified Operator on file (if required): _�g_
Viiater Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: 7 ZB' D (date)
' �(Applicant's signature if site visit is not reqnired)
�r�c��tio�ep�ac���nt A�p�-�vesd
w��/
vironmental Health Specialist
11/1�i05
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Date
..- , :�.
Application Date: $ 0;��(2 � `��.�� ��q ����T Tax Map:
Amount Paid: NIG r,. �- 1l.e �`7 parcel#i
Receipt #: � � ����
Jfu:rzny na-rcann�crca.a�an4i,m� ����a�.s.]�d,Iln.
for Services
Services Re uested
0 Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted)
obile Home Replacement or Building Addition 0 Permit Revision
� i SG.00 �if site visit required j $75,00
� Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: .'u r� a � ��.,5 Phone (home): 3 3 G- S�! �t - o G/ G
Address: � 2 � � o c, i� Q � i S (work/cell): �� G- .fs Z- �D�s 3
2) Name and address of current owner (if different than applicant):
Name: _�.�� (p `�_ �-i e ��it� Ph�r.e:
Address: ��1 � � �, !� ✓� -., ,, � y
����o,ro v].4 275 ��/
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Lot #:
❑ 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)
4) Proposed Use and Type of Structure:
�Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Bxpar.sion of Existing System If expansion: Cu:rzr�t r•�mber of bedrooms:
� Rcpair t� :�-�zlfun�i;oning System Will there be a basement? � yes � no With piumbing fixtures7 ❑ yes ❑ no
❑Non-Residential
Type of business: �(� �ZI �6 �L/ Total Square footage of Building:
Mzx:mLm 7umber of employees: � I�aximum numb�: o: seats:
�) Water Sup�ly: ❑ New well C'�Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccu�e, � if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid..
w�
Signature (Owner/ Legal Representative*)
�` Supporting documentation required.
,�-�a-�Z
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `LoiPreparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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��rn�'a��nn.nvrn,c�nv.��.� �c��,�,��n
Suilding Additions/ Mobile Home Replacements
Tax Map #: A�� Pazcel#: 16Z, Address:
Approval Requested for: Mobile Home Replacement
_ o� Building Addition .
Applicant Name: �a 1 N�rhs
Ac�dress: -�a� t���,�c�.��g d _
�J�ch�r-n f�� �'15'��
Phone #'s: �4 - �ol� 3 -5�a- ��
Permit Located: ✓ Yes No
Installation Date: ��- �3 -93 Design f ow: �to (ggd}
Current Contract «rith Certified Operator on file (if required): N�A
Water Supply: _� Well Public or Community
�
Wastewater system shows no visual evidence of failure on: (date)
(Appiicant's signature if site visit is not required j
Addition/Replacement Approved
� ���
nvirorunental Health Specialist
� 02 l
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www_personcount�net
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. .. . . .. .. . . - � . ._ . � . . . . . .
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' � _ North Carolina Division of Public Health ` _ , � _
Occupational and Environinental Epidemiology Branch, Epidemiology Section
_ __ . _ .,. . _ INORGANIC CFIEMICAL ANALYSIS REPORT -
Private well water information and recommendations
County: �f�h. Name: /�.✓Y� Sam le Id Nu o��
p mber 3
� . , ._:. _ - - Location: .'
� Reviewer �i�
......,.__ _ ..
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ANALYSIS REPORT
Your well water was tested for 15 metal�, plus nitrates, nitrites, and pH. The results were evaluated using the
federal drinking water standazds. The pH is a measure of the acidity of the water. Drinking water may '
contain substances that can occur naturally in water or can be introduced into the water from manmade
: sources: _
TEST RESULTS AND USE RECOIVIlVI�NDATIOI�S ��
Your well water meets federal drinki.ng water standards. Your water can be used for drinking, cooking,
washing, leaning, bathing, and showeiing. .
The following substance(s) exceeded�federal drinking water standards. Your water can be used for
drinking, cooki.ng, washing, cleaning, bathing, and showering, but aesthetic problems such as bad taste, odor,
staining of porcelain; eta may occur. You may want to install a household water trea.tment system to address ,..,:._.
aesthetic roblems. .. _::_ . . . �
P. . _� �... . _ _
- -.___-..�.
Barium Cadmium Chromium Fluoride Iron Ma esium
Man anese Selemium Silver Sodium Zinc
. _,__. �-- ..,.; : ......, . _._ _. ....
The following substance(s) exceeded federal drinking water standazds. We recommend that your well
: water not be used for drinking and coolcing, unless you install a water treatment system to remove'the circled
substance(s). However, it may be used for washing, cleaning, bathing and showering.
Arsenic _ Barium Cadmium Chromium Co er Fluoride Lead Iron Ma esium
Manganese Mercury Nitrate/Nitrite Selenium Silver Sodium Zinc H
Re-sampling is recommended in - -- months.
- Re-sample for lead and /or copper: Take a first draw, 5 minute, and 15 minute sample inside the house
(preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to -
determine the source of the lead and/or copper.
OTHER CONSIDERATIONS
Routine well water sampling for the above substances is recommended every two to three years. Sample
- your well water when there is a known problem or contamination in your area, after repairs or replacement of
�
your well, or after a flooding event. Contact your local health department for sampling instructions.
�, ,
; For further information please contact your county health department or the Occupational and Environmental
,�
Epidemiology Branch at 919-707-5900.
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North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: ADAM C. SARVER
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
BRAD MORRIS
721 NOAH DAVIS RD.
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
htt�://slph.ncpublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES082812-0003001 Date Collected: 08/27/12
Date Received: 08/28/12
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Time Collected
Collected By:
Well Permit #:
GPS #:
2:45 PM
Adam Sarver
Inorganic Chemical 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 0.10 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 2 mg/L
Manganese < 0.03 0.05 mg/L
pH 6.4 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 5.90 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 21 mg/L
Total Hardness 21 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 09/14/2012
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"�age 1 of 1
Reported By: �e�ic 7%loKeol
I ti�, r�• !� �r � -c..Tr �
SEP 1 F 2012
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'� � Person County Health. Department
� _ :Sewage .System Improvements Permit
Date:��7 /�=� Thi erm' Voi After "Yeaazs ' �, .Permit # � � I � 3 `�J
. � sx# .���--
Owner: � ���
i:o�auonm�'�t�o�►s:
Subdivision Name: '• ; V r�'� � P. Lot #�_
Lot Size: Type of Dwelling: `
Water Supply: Private: —_/� Public: Gommunity:. —
Bedrooms: 7- Garbage Disposal—�A e�
Basement Basement Fixtures �
INFORMATION CERTIFIED BY �_�
Environmental Health Specialist: , ""'er-°r enrau° �`
REPAIIt: REEVALUATIO :
Size of Septi� Tank: � gallons Size �f Pump Tank: ----
Nitrification Line: �/r`?!�J - �1rZ
Depth of Stone: 12 inches
Max Depth of Trenches: �
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:– ����� Well should be 100 f�_from any sewer system
BY ��— Environmental Health Specialist
Date e a S st A r ved: -
BY � Environmental ealth Specialist
CERTIFICATE �F COMPLETION ,,..3
Contractor. —.� � n , , �1'c �
_ _ _ — — — — — — — — — — — — — — — — — ! — — �
_ _ �
Sewage System location, installadon, and protection must meet state and local �
�regulacions. Sepdc tanlc should be pumped out every 3 to 5 years and shall be maintained
by owner in such-inannei as not to create a public healtti hazard: '�Septic tank and
niuification line mnst be inspected and apploved by. a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site glans or intended use change this pemut is'subjecC to revocation.
(G.S: 130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
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Person County Health Department �
Well Peronit �
Date:�.-�This Permit Void After Years / �j
Owner. _����--�-+� ca� n1._ SR# Il�� �
Location/Duections: _ _ --��-�j'�— �
Drilling Contractor.
Distance from Nearest Property Line Distance from Source of
Pollution�—
Total Depth: 1�_ FG Yield: 1� GPM Static Water Level Ft.
Water Bearing Zones: Dcpth Ft. FL �L
Casing: Depth: Fmm to FG Diameter: Inches ►ti
TYPE: Steel Galvanized Steel✓ �
If Steel, does owner approve• No co
Weigh� Thickness: t Height Above Ground: Inches ; �
Drive Slioc: Yes No
Were Problems Encountered in Setting the Casing? Yes Na
If "yes" give reason:
Grout: Type: Neat Sand/Gement Concrete
Annular Space Width �Z- Inches •
Water in Aimular Space: Yes No
Method: Pumped Pr e Poured `�
Depth: From --�to F�
Materials Used: No. Bags Portland.Cement Weight of 1 bag lbs.
If mixture (sand. gravel, cuttings) - Ratio: to r�
ID Plates: Yes,_�No L
4 x 4 slab Yes No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS COTtRECT AND THAT
THIS �VELL WAS CONSTRUCTED IN CCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY H�I-�`1QEPA�TMENT� � _
Sanitarian s Signature Date Completed
Sketch well location on reverse side.
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