A28 219�0-3-� 3
Application Date: � ' � -� 3 �L 0 a `��+5 �" ��q �% ���
Amount Paid: a� T�� � , � ���l�
Receipt #: S 3 4 6�7 '� N�t q�� �'�����
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Application for Services
Services
g�'Improvement Permit (Site Evaluation)
� � $200.00/$300.00 (if> 600 gpd)
� Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
C �Vell Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Tax Map: ��
Parcel#i 4��U.q.
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❑ Construction Authorization
(Fee is dependent on ?he type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1 Applicant , ormaYon:
Name: �'jp; �' , �orr�s ��r'
Address: -
�Xbn�oTNG ��5��{
2) Name and address of current owner (if different than applicant):
Name:
Address:
�
3) Property Description: Lot Size: ��� Subdivision:
Address and/or directions to Prooertv:
Phone (home): �.3(0 �59'q - �i"]�q
(work/cell): _� 3(o - a'7 9— O l� O S c�!(
33�P—J�/�-73��' Worj�
Phone:
Lot #:
�
❑ yes 1�no ° Does the site contain any jurisdictional wetlands?
❑ yes J_��° Does the site contain any existing wastewater systems?
❑ yes H no Is any wastewater going to be generated on the site c,ther tnan domestic sewage?
❑ yes �o Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this praperiy?
(if `yes' is checked, please provide supporting d�cumentation)
4) Proposed lise and Type of Structure:
�'Residential
ew Single Family Residence Maximum number of bedrooms: 3
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Wilt there be a basement? ❑ yes � With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
T}7�e of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Vb'ater Supply: �New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, spruigs, or existing waterlines on this properiy? ❑ yes �o
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided ubove i.s complete and correct. I also understand that if the inf'ormation provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invali�l
Signature (Owner/ L�egfal Represe�tive*)
* Supporting documentation required.
3 ��2- ti 3
Date
Permits are valid for either 60 months or are non-expiring when accompanied by au 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, Roxboro, NC 27573 (336-597-1790)
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Applicant: _R+c'c3�t' !�_ tJp�R.ts �Cl„
Address/Location: 1 Qt a��ocu- QA�K.`( f�
� Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: 3 Btt S�,�d� ��vt KFs. New � Addition _
Number of: Bedrooms �/ Occupants b""�/ mployees / Seats:
Proposed Wastewater System: c:c.s. O �+ o1Sh. REou�-c����
Proposed Repair: w a5'2� ICr.nuc.-cw
Permit Conditions:
' S9�!- ►�1
0
Authorized State Agent: ��,,,� {,�
(X) Owner or Legal Representative:
Tax Map: A�S ParceL• � ai5 '�
Subdivision
Phase/Section/Lot #
Water Supply: PR.�v�. W �,,�,
Projected Daily Flow: 310-ct gallons/day
Type: �5.�_
Type: �_
A� S��c
_
Date:
Date:
,�,�., w4tE. r�
The issuance of this permit by the Health Department does not 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
Improvement 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 the provisions of the North Carolina `Laws
n�rd Rules for Sewa�e Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�
Proposed Wastewater System: _Accs.v�� �.,•� �s�i S�a,���j (*)Type�_ Design Flow 31�4 gal./day
New x Repair _ Expansion _ Soil LTAR: O• 34 gal./day/ft2
Type of Facility: _�(StL S,�t�t� �•��� �ES�tt�i,C� Basement: _ Yes � No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank ��a'v gal.
Drainfield: Total Area O4 sq. ft.
Trench Width 3 ft.
Pump Tank '"" gal
Total Length 3a � ft.
Min.Soil Cover � in.
Grease Trap "' gal.
Max. Trench Depth �] $ in.
Min.Trench Separation � ft.
Distribution: Distribution Box�C / Serial Distribution / Pressure Manifold
Specifications: 3 L�ri�.s � lep f��T ��4G�1
Authorized State Agent:
Issue Date:
Permit Exp
The system permitted is: Conventional /Accepted X/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: �v 3
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Applicant:
Lacation:
System Type (From Table Va):
Type V& VI Expiration Date:
��eratio� �`erm.it
�_
Tax Map � Parcel # ��
Subdivision
Phase/Section/Lot #
# of Bedrooms �
Product (IIIg): �7i
Type V& VI Renewal Date: �/�
G'
This system has been installed in compliance with applicable 1'+Torth Carolina GeIIeral Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization. �
( thorized Agent}
�nm��ro✓► l�v��t Z
(Licensed Contractor)
�'25"�`�
(Date)
_ 3 � ZS-�
(Date)
Scale � 5Ca �
PCHD, rev. 12/14!12
� Line Length
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� 2 Qo
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Total '
Tax i17ap: � Parcel #: Zf9
Septi� Tank System Checklist (Type II-I� System Type: �
Notes:
Pump System Checklist
Contracted Certi#ied Qperator (Type IV Systems):
Notes:
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WELL PERMIT (New�Repair�
Tax Map: ��5�_____ Parcel: _�:��`►
Subdivision: Lot:
Applicant's Nam�: R�c� A. I�vzus 'S"�.
Mailing Address: 19� ��c�� oa��-�e 4-�
c�a�� �.a�. ��s �4
Phone Numbers: 5� q- g qg q 33b- a� q-.��,cb
Location of Property: p�.,�.�.a� �ou4� @��`�� a'��� ���� Qn �
�ti.ww 'OR�vE txiwrl► -so �t' Srr�.
Permit Conditions:
1) See attached site plari for proposed well location.
2) All applicable State and County regulations governing constructior� and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit is�ued b�: a�.,,,�.Q, Q. ,�,.�Q� Date: aS 13
CERTIFICATE O�'+ COMPLETIOi1T
New `�ell Inspection:
E S/Date
Location: l .2�,��
Grouting:
W�,yrWell Log: � -
Well Tag:
Pump Tag: 1j
Air Vent: -2�'��I
� Hose Bib: �
Casing Height:
Concrete Slab:
Liner InspectiQn:
EHS/Uate
Installer:
Depth: �
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/1Vlateriat(s) :
Weli Driller• R Q n� i� Licensc #:
Pump Installer: � � License#: _Y�__
WeII Approved b;�• Date: 3-2S
Date Sample Collected: s`1 1
Person Coanty Em•ironmerital Health
325 S. Morgan St., Suite C�
Roxboro, NC 27573
Date Results Mailed: S� 1'�
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
01/27I2014 13:37 4343745376
PAGE 01
W, ELL CONSTRUCTION R�CpRb
�or�h Cnrolina • Dcparcmrnt oPEnvironmrnl and Naturel Rcsourcrs . D;viafon of Water Quality - Ciroundwater 9cction
���et�L Co`TR,�CTqR �i�vlY�pUAW NAME (prin�y
�►'�LL COA'!'Ii,�C7'Olt CO�IPANY NAM� �ER'TIR[CATION II�,Q9.. j1�
-wBA�`IKTrL�I�.L'Li�iIB�N...1'.13��`. �,, pHon�e r L 1 -
STATE �1'�LL Cp�S7KL'CTfON p�Rhl�7'M
fiPa licable) OCIATL*D W� PEitM1T�
c�r�val;c.bta�
►- ��'ELL USE (Check Applieabla Box); Resider►ti8t Q MunieipaUPublic O lnduatrial � A�rieulturai O
,�ioni�orin� C] Recovery p Nrat Pump Watcr Injectipri p Other p!f OthGr, I,ist Use
�
_. WEI.L LOCAT
Nrar s o��• • �+ �o���
�Succ� !��me, w umpers, Communisy, Subdivi�fan� L,ot Np„ Zip Cod�� .
�. O�vNER; S VV � �
Address
a p�.} .t � �r
�"_"`i- ' ��� �1.�"..3e�!�.,,�
ti�y Or ToM�n Swe� Ziy Code
��.�)�.�" �
�. bATE DR�ILL�D�� ~ �� . y f
5. TOTAL DEpTtl:
6. 170ES WELI, R�pL,,qCE EXlST1NG WELI,? Y�S Np E!�
7. STATIC WATER LEVEL Be1ow Top af Gasln�: ��,
8, TOP OF CASING !S 1 FT. `u�~+•��Abov�ToqOiCuie�
•Top o� c�stn� �errr�ln�tad �V—or bejaw 1� d t���� r�qylMd; UIfOCC�
v�risntt In aeenrd—�� wlth �5A NCAC 2C .0! {�,
�. Yl�LD (�pm): ,� M T pp OF T�ST
10. �1�ATER zONE5 (depth): � t�q� , _
t 1. DISINFECTIpN: Type Amaunt�
13, CASiNG: Wall Thickneu
��P�h Diamelcr or WcighVFt. Msloriat
_ F�om�, 0 To„� Ft,. 6,� f 4 ,�g��� _�VC
_ Fr�m��,'i0. „ Ft.
From_.._ To Ft.,� � �"'
l3. GROUT� pc Maicrie! M��,�
From_`_,� To� fit `�ON��E�+� ��
From To�„� Ft.
Ia, SCR�EN: Dcp�h piame�er Slot$i=e M� aceriu!
From_� Ta Ft.�in. � in. ,
From�_ �oi,_� Ft. in, �n `
15. SnNi�iGRAVEL PACK: —'—"
Depih Si�e MBteria!
From To p�, �,
From,�„_To� Ft.,_,_
TOp08r9phirlf. and c�tting
�t�idgc C751opc OVsllty ❑Flat
(Ch1Ck appropri�tc boa)
Latitade/longitude of wo11 loca�ion
(de�reeslmiauiey�xond�)
Latitudcltongitude sourca:OGPS(�ropogr�phic map
�� ' (chock box)
� �}/� n �p �g�,_
����_�. w�y
Show direction and distance in milea from at icast
two 5tatc Raads or Couniy Roads, lnclude ihe rppd
numbers and epmmon road names.
f 6. REMARKS: �
1 DO rIEREBY CERTIFY THAT TEtlS wELt, wnS CONSTRUCiPD �N wccorw�Nce wrr�[ asn Nc�C zc, w�,r,L
CptiSTR�f��pN STAtiI]ARDS, AND T A COPY F THIS RECOitD i{A5 BE�t� PRaV1DED Tb TNE WELL OWA1�R
1�^ Ly� i 4
51GNATUR� OF P�1�ON CONSTRIlGTiNG THE W�LL DATE
Submit the orl�in�I to the Division of Wator Quailty� Croundwater Sectioa, 163b M�il Servlce Ccntrr - Ralclgh. NC
27699-t6JG Phunc Au. �y19) 733-a�zr, �Ytthin ao dar:. GW-1 REV. 07/20Q)
North Carolina State Laboratory Public Health
Environmental Sciences
iViicrobiology
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: ES050814-0088001
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ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
ROBERT NORRIS JR
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sloh. ncaublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
233 BLALOCK DAIRY RD
ROXBORO, NC 27574
Col lected: 05/07/2014 14:09
Received: 05/08/2014 09:10
Sample Source: New Well
Sampling Point: Well head
D Smith
Angela Heybroek
Well Permit Number:
A28-219
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present DBLYONS 05/09/2014
E. coli, Colilert Absent DBLYONS 05/09/2014
Report Date: 05/16/2014
Explanations of Coliform Analysis:
Reported By: Susan Beasley
MAY 21 2014
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
Name of System:
ROBERT NORRIS JR
P.O. Box 28047
4312 District Drive
Raleigh, NC 27671-8047
htta://s�ph. ncpubl ichea Ith. com
Phone: 919-733-7308
Fax: 919-715-8671
233 BLALOCK DAIRY RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES050814-0070001 Date Collected: 05/07/14
Date Received: 05/08/14
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 3.4
Sample Description:
Comment:
Time Collected: 2:09 PM
Collected By: D Smith
Well Permit #: A28-219
GPS #:
New Well I (Profile)
Analyte Result Allowable Limit Unit 4ualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium < 0.1 2.00 mg/L
Cadmium < 0.001 0.005 mg/L
Calcium 66 mg/L
Chloride 21.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.21 4.00 mg/L
Iron 0.97 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 15 mg/L
Manganese 0.59 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 8.2 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 14.00 mg/L
Sulfate 11.00 250 mg/L
Total Alkalinity 218 mg/L
Total Hardness 230 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 05/16/2014
��' ��Y�%��
r�AY � 12a��
BY:— _
Page 1 of 1
Reported By: Arnold Hull
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