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A29 197._ � Apalication Date: 3'-1�-60 �Amount Paid•�-� b. ;o -U Receiat #: __��,�c�a . �'�-#37�� a �o '� �� ` _0 � D'� Person CountY Heaith Department Environmental Health Section Tax Map #• � �'� Parcei #• � � � � '�� . APPLICATION FOR SERVICES . IF THE INFORMATION IN THE APPUCA710N FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED. OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME 1NVALlD. 1) Pertnit requested by: (Owner/agent/prospective owner): f��'j+'�w �� ` 5- t q Home Phone: ��l q-.5� �'— �/7� Address: 3 0 � W . ��^w �, ��.r� �, . �.0't- � Business Phone: 9I9• 3�-z�i�y tir� e a.., �� c.� z y�c� 2) Name and addcess of current owner. �lwr-e� pc�ri'.' �- :30�. Lu � ty'f �,r �, �,,, �}, . w,�l�a�,R�1r � �'7� �_ 3) Property Description: Lot size: Townshlp: ��e d%11 Oirections to the property (Including road names and numbers); �.. 4) Proposed Use and Structure Description: answer each of the foilowing questions: a) Proposed (9!Existing 0 , b) Stick Built 0, Modular �ingle Wide 0, Doubie Wde � c) Number of Bedrooms: � � Number of oax�pants or people to be served: e) Basement: Yes �, No �Ifi'yes, # of basement fixtu�es: fl Garbage Disposal: Yes �, No � g) Oimensians of Proposed Structure: Width: � Depth: � 5� Water Suppiy Type: Private°6'(new Q oc e�asting �), Public �. Commun'�ty Q, Spring � Are any wells on adjoining property? Yes � No 5�-iYyes, loca6an 6) Please fndicate Desired System Type: (systems can be ranked in order of your prefere�cej �,%Conventionai Modified Conven8onai _ Altemative Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATION 1 he�eby make application to the Person County Health Oepartment for a site evaluation for the on-site sewage disposal system foc the above-cfescribed property. I agree that the contents of this application are true and represent the maximum fadGties to be placed on the property. I understand if the site is altered or the intended use changes, the pertnit shali become invalid. i understand that as applicant, I am responsible for identifying and marking property lines. comers and making the site accessibie for the perso�nel of the Person County Health Department to condud therc evaluations. I understand that I am responsible for notifying the Health Department if my property contains any wetlands as designated by the Army Carps of Engineers. � /�^ O� ��.�,.� r �-.-� 3 � Owner or Legal Representative Date . PCHD, rev. 10M 2/99 , � , , ' PLEASE SEE Tax Map #: � D PLAN F Parcel # LA Zoning Township ll/�1�1 l/l c1 v�ii Applicant: ' f - � �l/ . -j�i" � l' ► fp I /1 /1 � (� -t- _ e� �'� � � t, ��t/ v r�� Locatlon. � U � � j P � �/ �{� Subdivision: � 1' � SecUon: Lot: �_ ! V � � �. �� l• Improvement Permit A buildina permit cannot be issued with oniv an Improvement Permit New ✓ Repair _ Addition _ Type of Structur� Water Suppl�,1'� l 1� � � wc;�� # oi Occupants # of Bedrooms � Other • Basement? Basement Fixtures? 1� ��o f�/�' J r � �� Projected Daily Flow: � g.p.d. Permit Valid For. GYFive Years ❑ No Expiration Proposed Wastewater System Type: � � � Pump Required? Yes ✓No � . Permit Conditions: revo Authorized State Agent: _ I v� v��V�� U� (CVlc�vv�l�es� ) ��st�w��r�) _Hs�rcor C��, � � cG?�v�j�s. Date: '� — � _ The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. Thts site is subject to revocation if the site plan, plat, or the intended use changes. The tmprovement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance wiih the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinq Permit) Type of Wastewater System �V stewater Flow: ��g.p.d. ��\ ��. _ CV�a�w�� Facility Type: New fsY Repair DExpansion ❑ � �—� � Basement? O Yes o Basemen t Fi x tures? O Y e s 0� �—�� Q��, f �� Wastewater Svstem Requirements Septic Tank Size: �_ gallons Pump Tank Size: , I%� �r 9allons Total Trench Length: � feet Maximum Trench Depth: _� inches Aggregate Depth:� in. Maximum Soil Cover: � inches Trench Separation: � Feet on Center Other:l iiT 1;771i(L,I,V 1(. (� ( �t U�V YdlcV �� / �/ � �� u r cn�t .�i; � � r.� iwa �� Permit Expiration Date: � � 1—l/-7 Authorized State Agent��.e�.s, �.��[�csv� � Date:�� The type of system permitted O does Q does not differ from the type specified on the application. I accept the specifications of this permit. Owner/Legal 12epresentative Signatu Date: �� PCHD, rev/ 10/12/99 Application #: Tax Map #: Parcel #: Person County Health Department Environmental Health Section SITE SKETCH �� '(w►�v �c,ui� ��u��I� (;tY��,l� I ,� ��C QpCplicant's Name Subdivision/Section/Lot# c�Y4� �. , uthorized State Agent �� I �-o b Date Svstem components represent approximate contours only. Tlie contractor n:ust flag the system Scale:�/�,('I� `i'D ��.�0, PCHD, rev. 10/12/99 . . ' •. , � • � • '��' �� f .LL ��1/'�� . . � ��+��) 1.4 r ,/�`�� 7�9 �% . _ � -~ �. ��.iJ ��• JL �L. .�..."'_''.... ...' _' "' . . . . lE�m�aa-��* � �eaa��ra.11: ��o.m.Il�]ta Tax Map #: 1� a� . Parcel #: � I I � H��( Zoning: Township: � ( I'U �- � Subd(vislon: ��OSt J ti I I c. e j rG:;�;�,,: Section: Lot: _� Applicant: �� t r j�a � iS . Location: OFF f7 � I J tr �ao p(Z� , � O eration Permit System Type (In Accordance With Table Va): � 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 AND CONSTRUCTION HORIZATI - l� a9�� Authorized State Agent�p�� yLLE G�Q��E Date � �� to � J��3� '��4 ,, ;.Z 1 �-.� ti� ,� 5'`' t�iirL $'�� s , �`3�1z (,`3'�z �n I Z e �+ L� ' Q, � � � 2a� � 9 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATtACHED PLAN FOR WELL SITE LAYOUT f� Tax MaP #. Parcel � Zoning Township � � � V � APPlicanG ,lCyi'-�ts.cK ` �� / 1 � — Locatlon: �'e �� 1 �y�, ) ( � �//��( Subdivislon: ^I /'�J�/ � � l ( l •�I ( ^� � Section: Lot• Well Permit Tvae of Water Suaalv: ,,,� individual Community Public Reauirements• Site Approved by � 7� - Grouting Approved by / 6-�� Weil Log �o - s� o � Well Tag Air Vent Hose Bib � _ Concrete Slab Well Driller: Well Approved By: Date: (�-T�c9 `� C - **See Attached Site Sketch** Welts 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. 11/29/99 Date: /D '��/ o/ ' Owner: t=/H-,�� . Location%Directions: PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG qoz 9-19� Subdivision Name: __ aScv�//� c,,� Drilling Contractor: Lot # � WELI, CONSTRUCTION � Distance from Nearest Properry Line 1 c� Distance from Source of Pollution ( G a Total.Dep.th: /L/o FG Yield: GPM Static Water Level a2.5—' Ft. Water Bearing Zones: Depthf�S ��I F[./txl�Fc. F�. Fc. Casing: Depth: From 6 to � 7 Ft. Diameter: Inches TYPE: Steel - Galvanized Steel If Steel, does owner approve: Y�s No Weight: Thickness:� '� Height�Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . � � Were Problems Encountered in Sercing the Casing? Yes No � � If "yes" gi� e r`ason: Grout: Type: Neat Sand/Cement / Coricrete Annular Space Width � Inches Water in Annular Space: Yes No _ . Method: Pumped � � - Pressure � Poured � - � �� Depth: Fr�m O to � C� Ft. �' Materials Used: No. Bags Portland Cement Weight of .1 bag lbs. If mixtuire (sand, gravel; cuttings) - Ratio: � to ID Plates: Yes � No � � � � � 4 x 4 slab Yes � No I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSO�I C^vui1TY HEALTH DEPARTME . /O - y_- D i Sig ature of C raccor Datc ��`?� ) � �� -: .� � � �C.T�T�� °,.�rn�vnv.-�un�rrca.�sta�.�n:�l �I�t:.tn:�.tE.�-n. Date: �/ 23 /� Tax Map: �_ Parcel: �_ Name: 5 Address: 0 ' r , o �- 1 Re: Bacteriological Test Results Dear �i1�5 , �y�1 Your well water was sampled on �/�/� and tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). The res ts of your water sample are noted below: No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil. Fecal coliform bacteria are associated with animal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliforsn bacteria are present in your water satnple, tlie water may ttot be safe for use. Young chil�ren, the elderly; and individuals lvith compromised immune systems are especially vulnerable and their physicians shoz�ld be notified of the test results. A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department (597-1790) to request a re-sample. For additional information, please feel free to contact Environmental Health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �. �t Ci�\ Environmental Health Specialist Person County Health Department Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808 (revised 07/29/13) PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant i[Gtn� l�ls� _ Address � pq bi j v�.[�oa I�Cl. • Collected Bys�S County PERSON Date Collected /p - 2l -l3 Time Collected l%,�� Source: C�ell ❑ Spring ❑ Other Location: LW�-Iouse Tap ❑ Well Tap ❑ Other 0 No Charge M't;harge �,�,� �,� ...................................L....................................� *************�*************************�***************�**************** Total Coliform FecaVE. Coli Results Present Ab ent 0 ❑ � Reported By . ,I� Date Reported �� 3 Report Called ❑ YES �-�10 Called To: �� ,Q,l� 3 �°°�-�3 �a,ti ��zy� �i Poc�s— /}�/'�o . � �/,�/v�.�,2 �'� ��Sc� 2�L� r% �5 � �� %" 3 ��s .� a�,,�y �a�,^ � �� -� �� 5� � ..��. �L �� ,✓ �5�"'