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A28 211� �,:� � �; �' 1���..� � ,�\� . �� �y1�� . I �' � �^' �/ � � _d.. ' V � 3 �.m.-si��o„-� � «��.a.�. ��.m�,�� rl�olicant: ��� ����� �� I 0 DI 0 �°r�'�llc��r��S�Q� � �a�r��e�esa� �'�r�a� ��.:� �T�llad i�r X �i�e j�ca�s _ �% �sa�a�a�n / Type of Fac�ii�Ly: � � # of Ocaupants�(ita 1� Proposed Waste Sy Proposed. Repair� . New � A�di�i�n . . �T�� �aa�p�y "�,L �= Proje�. Da�y Flow ��� g.p.d. .. " � Type: • T��: Fexmii Conditions: � �2 Si�� ��C� � . . . Ownex or Lega1 Regrese Authorized Stat� Agee� Dat�: s��o The issuancr o� this p�rit liy the Health Departme� m dnes nat gtaara�ie� �e i�c� of other permits. �� is t�e res�ons�iiity of the aPPli���Y owner tm in s�e tiaat a11 Pezson County Plaunin.g and. Zaniag and Bn�g Iasp�tinns re�ufremeats axe me� � �ga��v��a�s ��..�'a# is s�j�xi tm re�►�nta��a 9� #�e sa� pl�n; �jpl��'�`• t�ae 'vmtestdesL aase e�a��.s. '�3ae ��r��ee��t �er�ma$ is na�� a�%� i�g* � c�ags in �wrss�iuys of ��a� �nropes t3i. �s �es�it �sas i��aed �aa c�aa�s7ianx� �#�a tla� p�vi�a�� �f ti�� I�To�tla ��l�mm�: .: `Lrasv$ asad Rua�s f�� 5ea�,ce..ee ?'re�3sraeaat ared �isasosad S�stesa�s' {���1 lYC �.� 1�A .1904�). I�eat.�e: �a.a�n ��uaaty.: �ame~�-'r.��.'� '= ;���nt� ���189i Spse�i��sstr �►ars-.�t� ti��t taae se�stis �k �y� � c�n��ae t� f�ss#ion sa�ia�a ifly im t��e fapi:mre � o��t�#. t��-wa�s� sn�n�ly wiIl re.�aasa ��ie. � • • • �uat�aoa��i�'i�n t� �r�ns�a aae�'��..��ew��5��a (-��s��� �o� �a�a�� ���.�� � �. Ses site plar� rznd additional attac3iments (_�. �'Z � . � -� . . �9r � - Fropo e3 SrVaste4va#er Syst�m: � �C'�n, �%+� Ty�p�� Wast�e�vcater �lo�,w �.p.d. � � New �air F�,pansioaz � . - ��a� ��� • Z,S� g.�.si.! $ Z Typ� of Facility: �' S• ' � Basement �C Yes ! No � �'�����a�� ��� ������� � . '�'� �: ���c '��: �� m� '�� �����: '�m� �,r�� � �i�0 saq � i�� L�ngt�a �� � ��e�asbn �a�a � � �3�a�a��ion: 33��aa�aa� ��� ���i�#im�• -. -��rP� � �� �i.� ���ver �,r, �a � �es� ��a�n�a��a �i ��e ��p: g� ' ' �a �� ��s� ��� 2 D �. � '���a ����o�� � #$ �• C . �re��e �o�d �ia�9a��� S�� �e�� /�ui`-t `^ Date: ( Z? o P�srrit E�nirationDate: //23 /� 3 The tyne of system pe:�i��u is Coa�.ven�ionai �_c��tasi A1t�n�.-tiive. 1 a����t �.e �e��ficatios�s oi the ��f� �� ���¢s�s�t.��a�tQ. � rate: 7�a�— � � ' rC�'� �c'�. i i, i410�._ ,. .. . .. . � _ 9i'�1� � /� � `'' � �/ .�_ 12—�� PRPOSED 15' � " � ACCESS EA►SEMENT � FRANK WILSON WAGSTAFF �L 8—E-108 IS NO2'21'S4"E 512.4 _. 1'���� p,,((a( . SC¢l�e .. � r� = l �c� � � P� �p'�' i yt S�t �� Sc�S�P/y, �r' J w�e� C+��%�'en S . . � �cr.S�� � Scl$,�,°rti f}✓t C��r, � � � -------� IS '� i�lot�h%'n Q�� 4 �'�� se�-baeKs. � '� N�lq�����1 t�g�� r �'°� �� � �aech�,�, � J S.1. 4''—� 5�--�- fl-�� Uv�►; v� �'t(C� �C ��1✓����) . a � IS � � ��a � ►o � � �� f�o�_ �" `"� . v✓ 5c� . Cwooded� �' f 512.47 , S02'21'54"W - S — Zoo' � ' � �,��,�j ���.��� � . CO�JN�'� �iaviroaaffiexaE�e.l �en.�ih SITBr SBETCH � Nazne f�'� �.�A,bSV�►�"� T �� 3 �� l as Map # Pa�el # Su 'vi ' Sectioa/I,ot# 23 0 Authorized State Agent Date System components represent apprnximate contours only. Tbe cnntractor must f lag tbe system prior to beAlnninR rbelnnallation to insure tbatOroperArade �s maintained. �.-���, ) f ���� �� � � ���� IE��aa-��.-rt-„-n ����.Il ]����,I1�I� Applicant Location: Tax Map � Z� Parcel # Z I I Subdivision Phase/Section/Lot # # of Bedrooms Operation Permit System Type (From Table Va): Product (IIIg): �Z- This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment nd Disposal, and all conditions of the Improvement Permit and Construction Authorization. � � � l� � � 2 �L� (Date) ID-IZ-10 (Date) Scale: Dk pQ�� '�� - . i �� •� ., �����'�� �� � Tax Map: �$ Parcel #: 21( Septic Tank System Checklist (Type II-I� Notes• System Type: �� L Z) Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: :� �� S �I�1�.�����T : `-.. ... � _ .�: :������ �7L'II.YRa1;,�7CII.�L�KD,4B�.71.�.�-.14 �a0�.�1�.�'�� WELL PERMIT - PLEA�E SEE ATTACHED PLAN FOR WELL SI.TE LAYOUT Tax Map _ Applicant: _ Subdivision: Location: Pazvel # Township: Lot # Type of Water 5upply: �, Individual _ Community Public Requirements: Site Approved By: Grouting Approved By: a We11Log: �5 �2-�c,-�Z Pump Tag: � Well Tag: Air Vent: 1 D� f Z� l� Hose Bib: Casing Height: � Concrete Slab: / Liner: �Installed by: _ � Depth set: � Grouted• Date: Water Sample: � � '�� Well Driller: �ft 4 v1�5 Well Approved by: �� ^ Date: fZ ' l� �l� / ****See Attached 5ite Sketch**** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD rev O1/27104 North Carolina State Laboratory of Public Heaith Environmental Sciences Inorganic Chemis#ry �Certificate of Ai�r��l�rsis P.O. �ir�x 28047 306 P�J, �Imington St. Raleym,�l�, NC 27611-8047 http:Lf�::.lg�h. ncpublichealth.com Phonia: 919-733-7834 Fax: 919-733-8695 u��„ ���_ Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH JENNIFER �.�JNSFORD 325 S MOAGAN STREET RED FOX LI�. ROXBORO, NC 27573 Courier # 02-33=�15� EIN: 566000331 EH _., ,��.�� �..-- StarLiMS ID: ES010611-4032001 Date Collected: l;i1/G+4/11 Date Received: �,11/f��/11 Sample Type: Sampling Paint: Well her:.ucV Sample Source: New Well Temp. at Receipt: 7A Time ��ollected: 1:2�D PM Colleck�ti By: J. �rnith Well P��mit#: A2�-211 GPS #: Sample Description: Comment: New Well I (ProfiVe) _� A�,��u Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < i�.005 � 0.010 mg/L Barium C 0.1 2.00 mg/L Cadmium � 0:001 0.005 mg/L Calcium 70 mg/L Chloride 6.20 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron 0.33 0.30 mg/L Lead < 0.005 ' 0.015 mg/L Magnesium 6 mg/L Manganese 0.84 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 < U:05 0.10 mg/L Sodium 13.00 mg/L Sulfate 10.00 250 mg/L Total Alkalinity 215 mg/L Total Hardness 200 mg/L Zinc < 0.05 5.00 mg/L ��,r,� ��_ Report Date: 01/22/2011 Page 1 af '1 Repork�rl By: �e�te �ia�ecl 12/03/2016 11:04 4347973442 HERBERT DAWSON PAGE 01/01 � � . . �. . � � . � , . � ; � . �� � � � :1 � 33 �� :��� � �� .� � ��� . � � � � . :� � . .,��.. :�� {� ��::[��1�:���:.:��:.�� � . u�,��� � �� � .�/-� � �.� . � � �� . � F�... :�.-,., << � � -:��:;�;�`�'��� � � � � � � � � � � . � � � . � � ��-;�,�;m:�.���..,��:.. �t���,�. o� � .� . � . � . ��. � � : . ,..,. . . � . .. � . � -� .. . ,. � . � .a ,�L'��.� . � � .,► , . ; .. .� . '•. �. .. . Gra�t Lag � � � T�i Msp , � � . � —�..� � � � � � � '�'� Co�tru,�iou .�„ . � Dist�co Fi+qm, n�arest Propr,rty Li� (Mirumtun• 10 i�,t) ,�,_,� �' _ �. � � . pist�noe �om 3tipt{o SY�m 4��� 60 ffat) . . . . . �•� Fotal �DGpth: 1r,� $ Yi�ld:� C�PM Stati� W,�i �v�l: � i� � . Waier B�rI� �na�: Depi� �,�, ft ta �! _ $ �` g �� g , , +Caaiag: � . � : . � . .� • : . � , � . . . � . � �� �� � m �.�:�,,.,._ � . ,� �amct�r: �� w . �. . . � � � . � . . . Type: C�alvan' Stc�I �,�[�_ � . . � , . � . . � � : , �. . . ��� 5�..���: ��.L.. �ai�ht abttve Cirou�id: �[�, in � � , . �/ � . .. . Drivc. S�ne: Ye� N'o � '.Any. prablems eaGo�mtarad �o eatting �cssing� �_Yea ,�,�./`l�iq � , � �f "yas" g�ive r�asaau: � � . . . � . . . . � . . � ,. . . . ... � � . �rou�:' • � ., . � . � ` . . . • ' , . . � � . . . . . � Nea� �_--.. - �3$adl�# ,� Coricxete � Gravel/Camart � � � . � � , �Atmu}as Spaoa'Widtti ��„_ �r,� �Wat�r in A�aula� �ace Yap ,�o � . . � Il���ad ofQxout: pumpod � . �'raes��e . Pou�,d ,.�]hp� � ttt __ - I�t, � . 11+Y�terl�ie IJoe�i: ' . . . . . . .� . Na. Ha�s Portl�ad c�rtic.nt 1�,,. ,,,,,_ 'GVcig�t of 1 Bag ,� Pouads �' . . Tf mix�'o ( . �-�ta'vet, ct�inge) — �ti4 � to��' � . � . �. � . . � . � ID P1at�: ;_✓Yes ,_,_, No � 4 R 4 sleh .�Gs ,�,_, Na � . � . . : . l'1ner: � . � .. . . a �p� Detc lnstalled; �� Crtout: . � � �d by,� � � . ' . ��5�� � • � ' YnnitFnn h.•4mi...,� • . � . , . . . . -._._, . I heroby o�ttify tbat itie abows ip.formN�tion ie raorrect m►d tha# #hi� vrrell v[�s con�u�@ �t1 acc�rt�a�� wlth x�gulations �t fari � . by thc �easab Counry Hes�ffi �apar�nent. � . � � . � ' � . . , f . . . . . . .. . , � 51�matare o� �vnts�clar � ' Yb # � DAte • � � � ' � � . . � . . . . �amp T�tail�n�n►t . . • � . � . . � . kum,p in�tatlxtio� C�intractQr: ,�-,.a�..�� ll, £72� �,� : .,�ea. �ttiibe It,egistr�fi� Nuxnbes: ,_,;� ' : . � �� ��� �,�ft Statt�atcc�vel�`�__ ft . -�--W--�^ � � �ump Maire & 14[od�l: � � � ' ' � Ptmip SiTe and �ting: � � � . � . � . . . . . . � . . . . .��F �� �� . I heraby oerti�y that thi� pump rw�a in�tafled arid t#�e waillioe,d capmptetcd a�aorc�i� t� thc P�rsozi. �ounty Well Rules in affaat on tl�tia dat+� arid that a copy Qf this r�aard has bc�a pravidac� to ti�c well. oaincr. . . . . . n.��... *.��i.u-- `�"�--�--- /' i . . 1 . .%%/7 . ... . _ � • 0 �2?��a � � d ���s. `� � 5 �e "' C �( , .� �?s-�� . -� ��Q L �P�� � au sQ y� �`"'r� y / p � '�,e ��,�2 . �' C'a�,t,�� v`'��.9� �, ,��; 5 Wd � � r � .Q�q� -� q a^T �`�`l �- ''� � ��� � � �'' �Q�:^-�� �.�, - �t� � � � , .� �a�� � � � "� � � N c.� � pcC �l ; �,,c,o'�,. �iK� G' �f' ��i � � _ a � �'6.�� C�4 -� �p-\� - '�� `f6g�3 � '7 �G-[0 � � � � � � � a f�. � i( S��'� ju.� �,,,, �. � `a �r� l� � j�,,, � r � �S 1r�- �� �� "C s �� s �