A29 254Appiicar,l��n Date; �'OS iax il�ao �:
�mou _-'af� �✓�d,� �UCP�D�L�C#�✓dZ�
l�e��i # a4 : _ � , O d a ' � �' � � �rc2i �•
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�� / � �►PPl.tCz4]'lON �OR SERVIC�S
C01VS"i'in;i��CT SH�4L� B�+COME tNVALID. �
�} Penn:rt r+equest�dl l�y: (flwnerlagentlprospective owner): ��� �,
Hom::� F'hone: -� Address: 3��� /l�
Busir►�:.s Pho�e: � - D �o S
2) M�ri�3 and arldress af curres�t owner. .ts�i'J�
, i he �'rirm
3�j Pra�.��r��fij Description: Lot size: cre� Tawnship: ' e % ubdivision: Af �S'�S�vi /%. Lot #�
Dir��c:t9�ns to ffie propefij (Including road names and numbers): �W �
t;' n'fl)r�4 .�/ll��r d).51�n_ /?1.r3 )Ch ___
4:j Prei�.ased 13�e �n Strcaciure Description: answer ach of the following questions:
a) f�rc�posed , Existing . Type of Structure:�� i.c'��i �i-1 Width: Depth:
b) �d.wnber af 8edrooms: � Number of accupants or peaple to be served:
c) fcasem�n� Yes,,;� No Wiil there be plumbing in the basemerrt?
d) ����cbage D��posai: Yes �. No _, .
a) Wa�F:r Supply. vype: Private �(r�ew ,� or existtng„�, Public_, Communiiy_„J Spring �,,,
Ara any welis or� adjoining property? Yes,_ No _ If yes, please indicate approximate lvcation on the
�sit� plan.
!i) Doe.:� your pro�e�fij cantain �reviausiy identi�ied jurlsdictional wetlancls? Yes_, Plo �/'
f3l.E4,i#:: t1�+�'il� Ti�9E FOLLOWING:
➢.A Pl..AT a�' `i�iE l�R�PEiZTY OR SI'� PLAN MUST BE SU19NlITTE3� WITH THiS .�►PPL9CAT9�OA1.
9��f�OPERi""Y LIAtES �4ND CORNERS t1AUST BIE CLEARLY MARKED. ,
�'i'i�E PR�POSE!? LUCA7IOM OF �1Ll. STRUCTURES MUST BE ST�►6CED OR �LAGG�D.
9'Tl�E S6TE li�ilST BE 3i�ADILY ACCESSiBLE �OR AN EV,4LUATIO(d BY i�lE HEALTI-H �E��RTMI�NT
� iAF�.
i heren��� rnake appiicaiiorr ta the Person County Heaith Department for a site evatuation for the on-site sewage disposal
:sysierri fa• the atrove-described property. I agree that the cantents of this applicatfon are true and represent the maximum
�aciliiic�a tu be piaceti on th�: property: I understand if the site is aitered or the intended use ci�anges, the permii shall
�ecom�: ir�vafid. ,r �
� � DS
��; �� - ,� �� 9- i
� Cwner ar Laga{ R resentativ� . Date
�. PCHq, rev. 06127/Q2
��� �� ���.����
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Applicant:
Location: 9 5 �
T�x M.��'/' Parce�l #
Suibdlivisian ,t� ;�� ;� :��
Fh�se Sect+ion`Lo�t #
Improvement Peranit
Permit Valid for ✓Fiv�e/Years No Expiration
Type of Facility: -�1��KrG New ✓Addition _ Water Supply J/��
# of Occupants # of Bedrooms 3 Projected Daily Flow �?� g.p.d.
Proposed Wastewater System: .t f. G✓/�v.yD Type:
Proposed Repair: •i Type: ��
Pernut Conditions:
Owner or Legal Representative
Authorized State Agent: �
0
Date: � � � 3
Date: 7 L
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure 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 Permit 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 and Rules for Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construct Wastewater System (ltequired for Building �ermit)
* See site plan and additional attachments (�. 7aT/i'L
Proposed Wastewater System: y����i��,0 Type;��G 6� Wastewater F1ow3GD g.p.d.
New �/ Repau_ Expansion _ Soil LTAR� � 3 g.p.d./ ft 2
Type of Facility: Basement _ Yes _�1Vo
Wastewater System I�equirements
Tank Size: Septic Tank:1000 gal Pump Tank: 000 gal Grease Trap: gal
Drainfield: Total Area: DD sq ft Total Length 30 O ft Ma�mum Trench Depth � in
Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Separation: 9 ft
Distribution: Distribution Box Serial Distribution ✓Pressure Manifold
Specifications:
Authorized State Agent: Date: 7/ L_
Permit Expiration Date: ' ��' � �
'The type of system pernutted is Conventional Accepted Alternative. I accept the specifications of the
permit. p2 � �
Owner/Legal Representative: Date:
CHD rev. 11/10/OS
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Tax Map: Parcel #: Date:
�or �3
�,� f�',� �,'
/�p5ij/iGG�
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) ( m) : (ft)
1 3/ -$'o /o ./ Aa . �o
2 3/ go � io •/ oo -io
3 3 v io� � oo •��
4
5
6
7
8 �• 3
9 f- Z i�
10 Z-
DD ft of line x,65 g. per 100 ft = _ 100 =/9�ga1
75% x� ga1= �L� gal per dose 3Z- �i- gal per minute (gpm) = Flow Rate
Friction Head
Loss: �• 7'� ft per 100 ft of supply line x! � ft of supply line ; 100 = • 7� ft
/• 7 ft x 1.2 = 3.� ft of friction head
Manifold Size: _�" Force Main Size: z' " PVC
Total Dynamic Head =!D ft of Elevafion head + Z ft of Pressure head + 3-S, ft of
Friction Head = ��TDH = �y��,���,s�
Pump Requirem nt: �z• ?i GPM @/� � ft of Head .
Drawdown: ��al per dose = 21 gal per inch =�_ inch drawdown per dose
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6" Cover •
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Inlet Fmm Septic Tank
4" SCH 40 PVC Pipe
NEMA 4X Simplex Control Panel
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4" X 4" Pz�essure Treated Post j
�2" Separation � �
Electrical Con�it �j
�• ` Acca� Cover• •• , ' . . � 1 �,
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�� ' � s .• ; �t•` '� . :
�,. Openin= Filled With Anti Siphon Hole `
Portland Cexnent Cmout �� g��
Check
, Valve �
High Water Alarsn Level
" (6" Separati�on�
�. , Hi�lt Level- Puxnp On -•..��
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Duct Seal Both .
Enc3s OfThe Con�it Concrete Riser
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Threaded Gate Valve ;
Union , , • ;r • ,
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Zip Coxd . � Opaning Filled With
T�� Supply �' portland Cement Crrout
Line ••
Outkt To D'utnbution
.zN„L,n 2" SCH40PVC Pipe
R°pe Float Wire� � �
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� F7oats ..
R �..Removabk '.:'
Float Tree , ,
i'
np . �
4" Concrete : �. '
' Precut Concrete Tank ' r ,
� ;.; (MatezialStrenstk>3500PSI $1ock � 1 "
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Authorized te Agent ' ate �'��5�
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. begrnn�g the is�stallas�'on #o insrsre tlratpmpergrrsde is rsiaintaine� :
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WELL PERMIT (New /Repair�
Tax Map: ���_ Parcel: ,��
Subdivision: y�`�'r�tl�.��j/!!�!F Lot: ��
Applicant's Name: �,�/�/ � r.2�
Mailing Address:
Phone Numbers:
Location of Property: �q S���Dt ✓5�a�/ o��a�T
T � � �,�, an r�-
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.
Other Conditions/Comments:
Permit issued
Date• �
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location: s s ��}
Grouting:
Well Log:
Well Tag: t�s s�v j�
Pump Tag: �5 - -(
Air Vent: 'DAS Ss �3
Hose Bib:
Casing Height:
Concrete Slab:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: ,1�,1��tJ License #:
Pump Installer: License#:
Well Approved by: Date: � ��� � 3
Date Sample Collected: �0-'(5��(3
Person County Environmerital Health
325 S. Morgan St., Suite C�
Roxboro, NC 27573
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/ 1 /08
_.-se'""�v �
-�c r.,..`�,
��{� "�� _ �. r �:� RESIDEr►�TIAL wEr.�. coNs�uc�rioN xEcoxn
n� �Y rk�'`. �i
''':•`� t. � Nortr� Carolina Departmart of Environment and Nahaai Resouc+ces- Division of V�ater Qualit}'
3.� <• ., � �
��''�e ,.s''� �' TIFICL�TI�N #
�;.,,�,,; �- WELL �ONTBACTlR GER
� J`lGt • o� 7J �cl�
� � State ZP C�
��, � -3�0
Ar�ea code Phone n�nber
2 WELL WFORMA770N:
WELL CONSTftUCTiON PERMIT�
OTHERASSOCIA7°EDPERMfT a�ppGcabie) .
SITEWELLID#(d2�P�r�G18i`�.._ /�' %� o r � �y �
3. WELL USE (ChedcAPPticable Bo�_ Resider�ial Wa6er SuPPN fJ
DATE DRILLED r► ' I3 ' �-`� •
TIME COMPLE7'ED � � �`� �.0 � �
4. VYElL LOCAl10N:
Cmf: ��.: � cournv�Pt�
Gl� r t,� �-� � �r
(Street Na��. N�nn6� Sonurusu"q4 S�vamn. Lot No., Paroei. TiP Code)
TOPOGW°�PN�C / LAND SETTING: (d�edc � b�
❑Sbpe OVaUe�r .DFiat ❑Rid96 O�
aU r
LAmU�E � e' . . . pMS 3x�00000000c op
LOI�fNDE 75 �3 _ ' DM$ 7X,�pp0O0000C pp
�ngitude source: ❑GPS C7�opo9�� �P
(lpcatiw� of we!! mustbe shown m a USGS topo maP andaffadted in .
this t,arm �irwt using GPS)
5. YYELL OWNER
owner t�arr�e
Street Address
C�y or TaMm � � �.
U
Area code Phone number -
s. w�.L oera�.s: �
a TOTAL DEPTti _..� .
b. DOES WELL REPLACE EXISTING WELL� YES p NO �
c. WATER LEVELBelo�er 7ap of �: �� FT-
(Use `+' i� Above Top of Casir►9)
d TOP OF CASiNGaS �� Above L.and Sudaoe`
"'T'op of casie9 term� at/or beiow land sarfaoe maY recNire
a variance in a000rdance wilh 15A NCAC 2C .0118.
e. YIELD (9Pm� �Q �d��D Of TEST I r
f. DISWFEC710N: Type
�� �
g. �1YA7'ER ZONES (de�th)= ,
Top� � .2--� T°p B�tom
T� gottom _ Tpp Bottorn
Top Bottom ToP �
71�iclu�essJ
7. CASiNG: DePth 1 Q L� D/�arty�� Weight Naterial
TopJ�_ �_LaZ- �-..]t_-�— �� �v�
Top � �-
TqP Bottom Ft' .
s. �Rour: �tn � �
Top O Bottan o� f�t. a
T� �„ Ft, sf%/1%a
ToP Bottom F�-
9. SCREEN: Depth Diam�er Slat Siz�e
��
y'ouR
_�. �>., 1
Top Bofto:r� Ft m- �' -
'f� 8ottom Ft in. �- .
T� g�m FL in. in.
i0. S/1NDIGRAVEL PACIC:
pep� Sae �
Top � �-
7op � �-
Top 8otbom �ti
11. DR(WNG LOG
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OL /
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/
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�z �nn�wcs:
Formation�ia�
O
�
0
(�/ Gr �1 , .�
�r /c> il �,-�-
1 DO 1iEREBY CERi7FY TFWT i1i1S�111ELL WAS COhISTRUCTED 1�1
ACCORDANCE WITH 15A NCAC ZC, WELL CONSTRU�fION
STqNpARDS, AND i'i1AT A COPY OF THIS RECORD HAS BF�N
PROVIDED l}iE VYELL .
'�� �r S. '�..3
SI OF FtEQ [�TRACi'OR DATE
�� �
pRU�f{ED E OF PERSON � T� �-�
Submit within 30 days of comPietien to: Div�ion of Water Qua�lhl - U�'onr�on Pr�sin9. Form GW-1a
���.sf ���.���
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I��.�a���.,.-,�,. ��.��.11 I�3LL��.]L�II�
Applicant: " ioN�
Location: aq S. --'�
O�eration Permit
Taz Map Aa�t Parcel # d5�
Subdivision� �i� R�' �s�'��
Phase/Section/Lot # Z 3
# of Bedrooms 3
System Type (From Table Va): Tli L�6 Product (IIIg): ��
Type V& VI Expiration Date: _�_ Type V& VI Renewal Date: �:4
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
Authorization. `�,� � �J��,p> y*��'� �`�� ��
�.�. C¢�R.�c.r�. s� i� �r, 1�1 LM��
(Authorized A ent)
M����� �.Vvy1S
(Licensed Contractor)
�► i�o 4ilY.C� cA�4crl�r�cs
L�tA�£. � CaMP��,t� �'
i S nx- C�� �t�SQ�c,';ZO� .
$ �� � i'3 d�l�
� �����
� �-�,
kw�Lp�N �
� .\v* i flQ�
.�,.�.:�' �=
(Date)
-�_ � ��''�Li�
ate)
Scale ��5.
PCHD, rev. 12/14/12
Line Len
I 1 aa'
2 ioa'
a��
Tntal `3ari
Tax Map: i��q Parcel #: ��
Septic Tank System Checklist (Type II-I� System Type: 1��6
Notes:
�
Pump System Checklist , � ,
Pum Tank InitiaUDate
State ID & Date: p�'- 8 S pp� x� �
�-q-13
Ca acity: i�i'S - io�o
Riser (6" min.)
NEMA 4X Box
Model: ,/ �S _, � - � 3
Piggy back lug s _ �g_� �
Hard wired
Alarm functioning
Mounted on post .�/ s q- i$�� 3
Above grade (12")
Conduit sealed �
Pressure Nlanifold ,� g b 13
I�'umber of ta s: 3
Size und sch: 3 gp
Contracted Certified Operator (Type IV Systems):
Notes•
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES101613-0034001 Date Collected: 10/15/13
Date Received: 10/16/13
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 1.0
Sample Description:
Comment:
Name of System:
TONY WESLEY
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
httq://siph. ncpublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
FARM AT ROSEVILLE LOT 23
Time Collected: 1:30 PM
Collected By: J Smith
Well Permit #: A29-254
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 25 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 0.95 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 6 mg/L
Manganese 0.08 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 8.1 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 8.10 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 96 mg/L
Total Hardness 88 mg/L
Zinc 0.22 5.00 mg/L
Report Date: 10/25/2013
.�CE�`V�E�
OCT 31 2013
BY:
Page 1 of 1
Reported By: Arno/d Hvll
North Carolina State Laboratory Public Health
Environmental Sciences
�icrobiology
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: ES101613-0061001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
TONY WESLEY
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
FARM AT ROSEVILLE, LOT 23
Collected: 10/15/2013 13:30
Received: 10/16/2013 08:50
Sample Source: New Well
Sampling Point: Well head
J Smith
Angela Heybroek
Well Permit Number:
A29-254
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Darneice �yons 10/17/2013
E. coli, Colilert Absent Darneice Lyons 10/17/2013
Report Date: 10/18/2013
Explanations of Coliform Analysis:
Reported By: Susan Beasley
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 r t����rnpJ�-�
received and should not be regarded as a complete report on the water supply. 1€ '
OCT 2 v 2p13
�Y:
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