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A28 220f � _ -. z � P�rson County Heaith Department � Sewage System Improvements Permit [�/�/ �, Date:�-� This Permit Void After 5 Yesis Permit #�%l �� Owner: ft: l 1+' " 1 o d,� SR# -�� f' O Location/Directions: � Dr ��// ut / c, wK �s` �� 5� '-'�`u1;� y Subdivision Name: --- - Lot # � Lot Size: � Ty�e of Dwelling: Water Supply: Private: P�blic: Community: Bedrooms: 3 Garbage Disposal Basement Basement Fixwres " ' "" " � INFORMA'L� D BY t_ /_ �1� L� Ir<Y�'6�� SBilltBtlan: �({�,�; ` o a or eatative. ��.. _. REPAIR: REEVALUATION: ' C Size of Sepdc Tank: __I (��C,� gallons Size of Pump Tank: Nitrifica[ion Line: ��n ' x 3 ' Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: ___ . ------------------------- Date Well Approved: �"`�� Well should be 100 ft from any sewer system BY Sanitarian Date ge s pprov • �- 3�- 9/ BY Sanitarian � CERTIFICATE OF COMPLETION ,..3 Contr�tor. � ► "^ A� e . �t � S � ------------------------- � Sewage System location, installadon, and protection must meet state and local � regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public healih hazard. Septic tank and � nitrification line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covered and put into use. If � the site plans or intended use change this permit is subject to revocation ( (G.S. 130 A-335F) � Location of sewage disposal sewage system sketched on back. i (OVER) � Iii�r�l' �� wiririi��. m��.� ii i '��Il�si �_ �� . r�.:.��.', � - Person County Heaith Department Sewage System Improvements- Permit , Date: -��' � ZThis Permit Void After 5 Years Ovmer: � Location/Directions: Permit # � �D �rS�� " / / S�i z � Subdivision Name: �t # O Lot Size; Type of Dwelling: � Water Supply: Private• Public: Community: Bedrooms: ..�— Garbage Disposal Basement Basement Fixtures INFORMAT�1 C�tT�� BY . C%L��i �� c.___.____. .,. _ A w.., n ownu a entauve ,� REPAIR: ALUATION: Size of Septic Tank: _7,�� gallons Size of Pump Tank: � Niuification Line: D �X �' Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: ------------------------- Date Well Approved: BY - � Date S age y rov ' I BY Sanitarian ,�. CERTIFICATE OF COMPLETION ,.� Contractor. � : w. �, �� S � ------------------------- � Sewage System location, installadon, and protection must meet state and local � reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person County Health Departrnent before any portion of the installation is covered and put into use. If the site plans or interded use change this pemut is subject to revocation. (G.S.130 A-335F) � L.ocadon of sewage disposal sewage system sketched on bxk. (OVER) Well should be 100 ft from any sewer system Sanitarian �� Person County Health Department Well Permit Cp YPlP✓ Q� Date:,�� 9Z'I'his Permit Void After 3 Years Owner: L Locadon/Directions: SR# Subdivision Name: � Lot # Drilling Contractor. WELL CONSTRUCLL�N Discance from Nearest Property Line Distancx from Source of Polludon� Tatal Depth: G Yeld: 20 GPM Static Water l.evel FG Water Bearin Zones: D Ft Ft. Ft. t. 8 �P� Casing: Dapth: From _SL_ �� t F� Diame�te�r Inches T'YPE: Steel Galvanized Steel If Stecl, does owner approve: No Weight Thicdrness: Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: Grou� Type: Neat a�1lCement Concrete Annulaz Space Width �� Inches Wacer in Aimular Space: Yes No Method: Pumped Pr�ss� Poured `� Depth From .� to F� Materials Used: No. Bags Partland Cement Weight of 1 bag lbs. If mixture (sand �a� cut Igso - Ratio: co ID Plates: Yes 4 x 4 slab Yes �— No z � � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THA THIS WELL WAS CONSTRUCTED IN A ORDANCE WITH REGULATIONS S FORTH BY THE PERSON COUNTY D AR . `��(_�Q3 Date lssued Sanitarian's Signature Date Completed _., $ketch well location on zeverse side. � �. : . � • Person County Heaith Department � Well Permit � Date:� G-�l This Permit Void After 3 Years o '� �WIIeI: r� ( $R# O . LOC3[10I1/DiICCtl0I1S: �,%� �Je K Subdivision Name: � t # Drilling Contractor: , WELL CONSTRUCTION ►� Distance from Nearest Property Line Distance from Source of �' Pollution h c��, Tatal Depth: G Yield: �U GPM Static Water Level FG Water Bearing Zones: Dept� � FG Ft-��F4. Casing: Depth: From �� to F� Diar et : 1 �� Inches TYPE: Steel � Galvanized Steel ff Steel, does owner approve: No Weight Thiclmess: Height Above Groimd: Inches Dtive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No ff "yes" give reason: � GrouG Type: Neat S ement Concrete Annular Space Width � Inches Water in Armulaz Space: Yes No v Method: Pumped� Precju,� F� Poured Depth: From co � Materials Used: No. Bags Portland Cement Weight of 1 bag Ibs. If mixmre (sand, grarely cuttings) - Ratio: to ID Plates: Yes �� No 4 x 4 slab Yes �— No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORREGT AND THAT' THIS WELL WAS CONSTRUCTED C DANCE WIT EGU TIONS SET FORTH BY THE PERSON COUNTY TIvIE •�� Date jl6��r'� Signature Sanitarians Signature Date Completed Sketch well location on reverse side. � NOTE: ] " supplies, y •. • at later � � (1) sketch of installation showing lot size and shape, location of house, septic tanks, privies, water Note special problems existing on lot. Write in measurements in order that installations may be located Note location of water supplies on adjacent lots. �( n �-Q � _:� ..,. (2) Agg!ic�tios D�*e: Amount Paid: Receipt #: � Improvement Permit (Site Evaluation) $200.00/$300.00 (if > 600 gpd) ❑ Mobile Home Replacement or Building Additiou $150.00 if site visit re uired ell Permit (New/Re nt/Repair) $300.00/$200.0 $75.00 ��';�)f �1LG��A. �y �='az lYIap: �D �: � � ��,�� Parcel#: ZZ- �' aa�aso��a�aa�.� ��em��n ilication for Services Services Re uested ❑ Construction Authorization Fee is de endent on the e of s stem ermitted ❑ Permit Revision $75.00 0 Repair of Existing Septic System Application: No Chazge/ CA $150.00 or $300.00 r. l) Applicant Inf rmation: � � Name: � � t Y�"� � �� Address: r -�� L �$ ? 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home):��^�99 � �'�'� (work/cell): ��-592-134 Phone: 3) Property Description: Lot Size: �Subdivision: � Lot #: � Address and/or directions to Property: ❑ ye�o Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑.� n/o � Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �o Is the site subject to approval by any other public agency? �s ❑ 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: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Noa-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: 6) If applying for �Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the ' is s uently e' en e ges, all permits and approvals shall be invalid. l� 2I�1'� Sign ure (Owner/ Lega epresentative*) Da e * 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. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC�27573 (336-597-1790) ��. �f �II --��.� �� - � � ��°�� va�a�ramaairuam�tn��o.�. ��Il¢4a Tax Map: �� Parcel: ��D Subdivision: WELL PERMIT (New_ Repair�) Lot: Applicant's Name: �G/� Mailing Address: � .� Phone Numbers: - e ,, 9Z-��DT (�'��1J Location of ProperEy: ��i � ,�p, Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Coarments: Permit issued by: --�'—�� Date: � �Tew Well: EHS/Date Location: Grouting: Well Log: Wetl Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comrreents: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxbaro, NC 27573 Certificate of Completion �iner: • EHS/Date Depth: Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 Application Date: i I a9-0 7 Amount Paid: �a:s•� Receipt#: � 0 38 �' ? � �,�� S f �1L_'e�� }� _ " ' � �=- c� � �C.7 .�" �I" �" -� 7L..:rn.w�i.n: a.a�rn.:izaa.a.s.�iaQ:.rn..Il. ��Il.ra.cn.u.cL-.�Ea. Application for Seryices (Sentic Svstems and Wells) ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit cement) $225.0 $125.00 Tax Map: /��g Parcel #: � `� Services Re uested ❑ Construction Authorization (Fee is de endent on the e of s s ❑ Permit Revision $75.00 0 Repair of Existing Septic System No CharQe � �t p�� 1 �O �rp ;�i �Ya` � �� l � � �e°.� /' , . �O. , � Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then tlze Imnrovemeiit Per»:it and theAuthorization to Construct shall became invalid. r 1) Services Requested by: Name: C.%� f %�'�dY�IeOV(J Address: �� S yP S` Phone # (home): �� — �yv � (work/cell): S9'7— ��5` 2)Name and address of current owner (if different than applicant): Name: Address: � 3) Property Description: Address and/or dire�tion Lot Size: Subdivision: LOt #: 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 _ Approximate size of building foundation: Length Width 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 completed application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): Date: � '- `^ d 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ...��;�'� } . .. ': ..�'� :.�'...' ��: .. .'. �:: y..... . :• :..'�� v�'�:::}••�r'�J::��.� ..�• :.. . � ,... ., �. .: y .:.. ...,.:.... . ... �:i."J.F�.:••••••�� ...•' . . �.,�^ � . . � . •:s.2 �;�:�.. . .. '.: . �T.�.� . �Jm:?.�9:?3:`]L^��'^.� ;��31�i1'�'..i�`:1L'�;'�.�'��i1.l�L'�'�� ". �Yi JL'J�lU �.;L' SOlI'g.H. S . ��Y�t�YY:� �� 3 i l'iV. � �.� � u 'ra i V �1 �� 1 dJ.9J �H S 1G . n 'w 3 `LY m.J $ Taac Map �/ Applicant: _ Subdivision: Location: / _ Parcel # �� Township: � Lot # �y�e mf �atea- Se�pp�y: �/ Tndividual _ Community Public �ea�uir��nents: Site Approved By: �1' Grouting Approved By: j Z � 7 Well Log. � Pump Tag: � � Well Tag: � Air Vent: ` � Hose Bib: � � Gaeing Heigh� � Concrete Slab: � � � Well Driller: � �/ o� _S o/\ Well Approved by: ��**See.At�ac�aed Sate 5k�#c�a*�*� Liner: 'Installed by: _ Depth set: _ Grouted• Date; 9�Tater Sample: 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 canditions: Date:, � PCHD rev Oi!27/04 0 •��J✓� ��. y • ! ~ � � �� .a'�'a��l'T �!'1YT O�.W�OYi ��7�j� � SIZ'E SI�ETC�i : Nazne ' Taa Map # A 2$ � Pa:tcel #� 1 Sub ' ' n _ � Section/Lot# . . f � "�'�— . Authorized State Agent . - Date . sy� ��,o� �,�s� �pro��tou� �y: The contmctor must, flag the system�irior to begi�g � i�talla�n to insKre that pmpergrade is n:aintained —� � � -� 1�� r� � BI�(o� �� q s _ t �e s9�-�79a, / 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: ES032515-0079001 � �� (�� U �� u�u �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: CLINT MORROW 3561 LEASBURG RD ROXBORO, NC 27574 Col lected: 03/24/2015 10:15 Received: 03/25/2015 08:17 Sample Source: Well Sampling Point: Outside spigot P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htt�://sloh. ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Derrick A Smith Angela Heybroek Well Permit Number: A28-19 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Denise Richardson 03/26/2015 E. coli, Colilert Absent Denise Richardson 03/26/2015 Report Date: 03/27/2015 Explanations of Coliform Analysis: Reported By: Susan Beaslev / � '' 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. North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: DERRICK A SMITH PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: CLINT MORROW 3561 LEASBURG RD P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slph. ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES032515-0067001 Date Collected: 03/24/15 Date Received: 03/25/15 Sample Type: Raw Sampling Point: Outside spigot Sample Source: Well Temp. at Receipt: 2.5 Sample Description: Comment: Time Collected: 10:15 AM Collected By: Derrick A Smith Well Permit #: . A28-19 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 8 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 0.56 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 1.20 10.00 mg/L Nitrite < 0.10 1.00 mg/L PH g,g N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 6.50 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 36 mg/L Total Hardness 35 mg/L Zinc 0.13 5.00 mg/L Report Date: 03/30/2015 Page 1 of 1 Reported By: Arno/d Holl :`..:�,`�`�.5..� ��.�.� �� I � .a�..aa-om.�..da�.�.�Il IE'3l��en.Il��a ��d�� aam� _ N u �I � � �.� �-� �. D�► [� [ - �o - o ,p.��. �� Well Log Lc�c$i�oa: � S -� d r t^ o Tax Map � Pat�cel # S�:bd1Y18iur: �°C L� i r ►� � vd rC �; �,o t,ot ��" Well Conttntction Distance Frc�z� n�xaresi Pruperty Line (Mini�num i o feet) ` r,� Dist�ce from �aptic System (Muumum 60 feet) _ r� �y � Tota1 Deprh: �� ft Yicld: I GPM Static 'Water I,evel: __�IO +, ft Watcr Hr.aring Zor�es: Dcpth 375C?fi ft fi ft C�aslo�: l 0 5 Depth: From ,�1 to 1¢ 4 ft. Diamettr: �, in Type: Ga�lva�nizoci Stecl u �� Waght: �g 'Ih�ckn d•� Height �bove Cmound: __l�,___ in Dsive Shae: __ /Yes I�o Any problerr� arcountend while set�g casing? �Y'es � �f "y�s" giva r�e�san� Grout: Nr�t: Saud/Cesnent Canc�ete GraveLCameat Annular S�racc Width �_ inc�es Water in Aanular Space � Yes No ?wlCthod of Groui: Pwnpsti �_�_. Pt�ssur� Poured Dtpth to ^ F� '_�+��etrrisla Used: + N�. Bag� P�ortlend cemes�t Wcight of i Beg ,_,_` Pound� If mixtwe �saad, grav�l, cuttings} — Ratio to ID plaus: � Y� ____ No 4 x 4 slmb �, Ycs � No Drillin� Lc►g Lacxtion Dsawtng I hereby eenir'y th� �s� above informs►tian ia eorr�ct and that this w�ll was constructed in accorclance wzth regulations set farth by �he P��son County Health T,epartzncnt, Si�xture nf l'uatractor �c/2.�-� IIi * o� �02 Dste ��, 2�____� ��.,.. PcxD n� {�ln s.roF