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A29 273
� ���� Aaalication Date: � 'i �� �',�i Tax Map #: Amount Paid• � l�" Receiat #• � � 3 Parcel #• �� ��� S � I��IL-�.� �1�T ,q � 3 - - : - � � ���� �11 7[ : ,:,.-.�n,.r .,.,..�-,�.,..<<Rll 7E-3[.�.,��.11.t:llr , � � APPLICATION FOR SERVICES a ��y ����� � _ � 1) Permit requested by (Owner/agent/prospective owner): �� ��a� �, �� i I � Home Phone: 33�%5qY- ySS7 Address: S�a 1 Bw.��►+,�►+. lfd.-. Business Phone: 919 383 -�50� Qo,r6b.. Kc. �75 7y � 4 So9 ��-6 � Z) Name and address of current owner: $0.^c� rt- �w��v4��- sa� 8�.��;� � Rexba�o c.. a15�4 3) Property Description: Lot size: � Township: Subdivision: Directions to the property (Including road names and numbers): `i9 Sew�N..—� _ . � � .� A. � _ � r �. t 1 _ 1 J Lot # �; � �� h�r��s M�Y� h pu�' ��� ���:sioh ..�:v�S . 4) Proposed Use �td Structure Description: answer each of the followin� questions: a) Proposed ✓, Existing , Type of Structure: St�,lc Fa.•�:1., R�s�J��« Width: Depth: b) Number of Bedrooms: � Number of occupants or people to be served: S c) Basement: Yes , No ✓ Will there be plumbing in the basement? d) Garbage Disposal: Yes _, No ✓ 5) Water Supply Type: Private ✓(new v or existing� , Public , Community� Spring _ Are any wells on adjoining property? Yes ✓ No _ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No ✓ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. 1 agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. `� /�y o Owne or gal Representative Date PCHD, rev. 06/27/02 Ba►►r►it, � ��� �� � ���� � -� � �. � � � , -.� �.J ��-� � ��.���-n-� -,-�,-� ���:�� I����,:Ii� � .. «. . tea:Lr ....� '' �d f.� -. u..• .• � Tc�7{ �Wr i�J Y � � ' �:PC��{ r � �u,'� diivi�s�ian �h.�s�e:'S c �t+i o,n: L � �t : Iffiprave�eut �armit . �'�at'�alidfor��+ve��ar� _�do��ir�tioa ':. . Type of Fac�ity: S� M 1e -�c�n;,1�.,. �� 4 9.� r�_ _ �ew ,� Addition _ �ate3 Sa►��ly � �c l� # of Oc�auts �# of Be�roa�m.s �-1 Proje�te3 Daily Flow � g p.d. .. Prapos�3 Wastewater System: P�('�P�e 1�z �F'lo.., �� C'hczrr�he�: � Type: � T— PzoposedRepair. �cCPr-r�cl C7 F1��1> ,� Chc.cc,l�e�� Type: �— � Permit C�nditions: -��� �iJ ��i�e �\a� � Owner or Legal Representative Signah Aut�horize�. State Agen� � c Date: The issuance of this pe�t by the Health Degartafeat in does not gnazantee the issuancs af other permits. It is the respon�b�7ity of the ��PmP�Y owner to in sure that alt Person Couuty Planning aud Zo�iag and Buiid'mg Inspecbions requiremeats. are mei. This �srove�ent PSrmit is subject to revcacation if the sife. pL�, plat or t�e mtended use citanges. The �mprovemeut Prsmit is. not :<;-:._� arffes#ed liy a c�auge in ov�ner�3rig:o�ttt��tsoperty. Thi��pes�mit�vas�:ssued in_e9mpliance witti the p�tavisions o£the.No�tS�@ar.aIina • �=;�:,; :F�aHrs��=and .�rcC�s foY Ses+�rrs$= Tie�t�a�nd'.�isnosal Svsterns' �35A.;N+��i�::=1:$�•� :1900). Neither Persoa �:�oun,�" "���e:�;� •�:;��no�e�tal �ealtiL .��.gsri��:��e. septic ta�k.s�em. �ctien'satisfacto� `� - ::th�¢ater:snpply will3:emaia.patahIec.>~;�.�. _ _ . . _ _ - ~:<_=_�w�._ . _ . _ :�:V._ - �.�-�}.�..*�.,:;a.-� �.° .�.�:.r�;::i;�::��:��,:��: � Amtlioa-ization to �oB'struct Wastewatea SYsie� (Requ�'e��;���ding �e�uitj- . �. ,j .7. �.,". _ - * See site plan and additional uttac}�menis (_ j. . . . . . . . ..'.. �- Proposed Wastewater Syst�m: Ar'r� � E2._ ��a�� �C_l�nmher� � Type Wasteyvater Flow �.p.d. .-. New �, • Repair_ Fx}�amsion � Soil I��� � Z S g.p.d./ ft 2 �. Type of Facality: �c'�2 ���� m 0,� , A, 11�Q i'►�z Basement _Yes �C No , ��5$���$�3' ��3$�39fl �1�'�lII@5R$3 • 'iaa� Size: Se�t,ic'Tank:� u�� gal Pnmp Tani�: — gal G�ease Taa�: — gal ]3r '�f'ie�d: 'Total ��a: �� � � sq � To�al g.ength it � lYla�inuffi Trencl� �th / 'an �a�ac3i �i� � ft 1V�i�nm So�1 Cover. "'iu" ��imnrn'I`rench SeparAtion: �i ft a a . �_ , �ist�ii�ntson: � �i�il�utaon �ua . . . Stpe�cations• S L�r,cr'� C� 910�-� dnt�orizesl St�ate �ge�t Pezmit E�i Serial �istributio� Pre.ssnse l�ana%ld Date: The type of sysiem permitte�' is C nveutiona.I � Ac��ted �11t.�znative. I acc�t the e�ifications of the P��- �e�f�,�l ��r�santa�ve: � Daie: Q . PCED r�v. ll/14/05 � " ,: ����, ��-� I�I�I�.� �� - �- ������ .�aaoras�anan.�n..eaa*�m� ��m.mIl.�Jia SITE PLAN Name ��flC�iZ4.i� ��� Tax Map #�I'arcel # a � Subdivision Section/Lot# '�"�i w�s �� � 20 �oR Authouzed State Agent Date System componeats represent appm�mate conmurs on/y. The rnnmacrormust}lag t6e system pdor to beb_ifn�g the tnstallarion m insure that propergrrde is maintained. �flX-bo'Ct� . _y ------ _. __ _.. , ...__... ,..._.._..._... , ._. ,.__-_._..7f_.��,5 � . ..__._.__ �� ,q _ ._......---......_ � ._ , ;,....�.�.L �f,� .. - :_�..:.�..a,_. ' � ` �' - --.. . .U:. - •.: , cc:i ._.._.... _.. Cq�9 ..._ ._.__.... � _ _. _ ....._....-,, ... �;� �-- _. _ _ -- .. _ c,, ,.., ._,:, �;, _ .. _ , :.;'� ;> �> �� _? ,�� .�... �� � ��t� -�r �i :a� � ,, , Sc�-' `� � � ui 1�i"�� �� � 5 +�k- , � 5se � �rp � �_. � ,., �,�� �za' 1) p} <n ' 1 N G� u� L�� L r� � n 0.pp�o. c.�� , ca � .._� � i,� �a�� e> ;s� ,+,r ,�.► ._.� . �,ep_ y= rn r— io ,.��,�`�� � � P '��� t _ �, � ���` � , � ' ' %er�c� �e\�5�� �3z s , � l3J`-i�;� i �;:�;u :3.5�; , f�'� ;:�_ '� c`�n �e-�►1 a.s� Se�4l�cks �t 1q''`-�� d �n s-1-al� ��er�r, �1 ���� `'� � n�-�- ��5-�69� S�S�-n� Un � c�y �-Ei �r,S -� mus�- hc�S��. ``r, la - `d u, � ��\ cs� -t� c�.reY e�F;re dra�c,�,etd � �„� Q�s� �s c�ac� Lr,v� N,2 "h � ��-1�9t� -rn{�;a9 << �� ��� �, �aS��A�. �t&��-� � Accep�d l�ne ��z ( tow �� Cix�.mixr> �2 l!1 �{'�2f'C-h �1� 1j�s-�-;bu-4-ion boX- t�ce��d � Ci�rarr�-"r ) (�z � �� � ��� �'� ( s7 s�e�, a� �� �� � � S � ��� �� '�� •.�:}%..'.�';:'.': :• �...•`"� �•','r>:�'�;:: � , t:..; :'.. .:•:, :.... ; ._' .� . �,� :::: ::: , ,'. :'�.:._�:. , �'; : �.' . . .��� �� ���� �.� '�� . ��,� �.: �' � < < .. . �,. (�(� <:•:?:�r:':,._:;Y..��.� �� .. ............:..........: •.� •: ::;•.;::,-.� ,,.,.;,;:... . . c :....: . . ..: .. .: :...... .:. .. . : .. . : ,.;:.. � . :: : � ..: . . • —•�- ' � . ...: .. " . . ... - ., ` '. . : . . .. . . ..: � �r.ri.,��•rm; . � ...::,...x��v:n._�s-4x:::.—.-�.-.-.ca�:�.;as:71�'.'.=3�����.��76i . ��1'� ���.$.�1�� ����lE �ut'E� F�'��'!t��� ��.t'� �'�I�'�%��LI� ��iiL�' ���lU�' Tax Map �� Parcel # � .. Tot�rnship: Applicant: _ �,-�y-�,� �,�� Subdivision: L�t # Location: �-lq S � (o-i- ��-,� (�'�S-} �ielcl�rP �hr��� i�icti�--. , '�y�e �f �l�$�x 5����g�: � Individual � Community �ea�uf�eanen�: Site Approved By: '�r l�l ��� Grouting Approved By: (� � � ly �� Well Log: ��- � I►4� Pump Tag: ' _ 22, 09 - �JVell Tag: � Air Vent: � � - �iose Bib: � Casing Height: ^ Concrete Slab: � ' Well Driller• (�C Well Approved by' �����e� Attac�ae� �i�e ���$�h�"�;;;�; Public Liner: 'in�talledby: �arn� ' Depth set: � Grouted: l -/5 - 0 `1 CS I�ate: � �tiate� �ample: Wells must be 10 feet from property lines. '9Vells must be 100 feet fram septic systems. �Nells must be at least 25 feet from any building foundation. Other conditions: Date: �-�2 'D� PC�-ID rev Ol!27/0�� ;�_� '�� 4'��'ftM^••�_'4J.�.�.�w:j _�•i -..y...��.- � "+i�n �f����'�` � ..�.:-� �r� �s _ ' � . : •-� �.;`f..� �-' =; : �<` , ' Oo. �l0-�� � � z 6 �` . . .�: . . . ��:� ,� � � . . 'M � . tii..1 t _ f�,^. ^ i * f 4� �. �n•, '�� . .r�+... . . /�jJQ� �� .q� ��"`►-.�Y`:.�Y.:�,: - f..�� 1 � � Y/`i �B�N7�� (J�( l( A✓R/ � � ! �- _... - - - � ..� �:: ":=����✓����`=` / ��� "o``�`�"�,m����.�t:•:: �;�,-�� . 0�o Da�l _ %`� 3 -- n �'-. - . crout lLog - Owner- �% a� �t f�+s'1,+J %Z�l - Tax Map,Q� Par�cel # Z�� I.00St101L' �PI s0 t! � h S1I�IP1S1�1' �.Ot # f �Cu �.'O�QCEIOII Distance Fr+om nearest Pmpexty Line (]Minimum 10 feet) _�t� Dis�taace from Septic SysLem (Mminunn� f0 fe�t) lo-o Total Depti�: OD $ Yield /3� GPM - Stahc Wat�r LeveL• Z S ft WafzrBeariagZ� Dep@i3� so fi.�8�' ft ft ft i 5=— �(� � � -� �i �1-�- ` Zl�-Q. n�s� � F��____� ��$ Diam�t: vl -2Sia � . Ty�e: Galv�ui�d St�l ✓ . Weigh� z! Thic�rnesx _ Height above Cmound: ./_ �" m- Drive Sho� e� Yes No b� ' �Y P� enco� wh�e se�ting �g? Xes �o � `�j�GS'� $IV6 I�SOII: F ��ri . N� Saaa/C�t C.oncrete GiaQeUCemeut � • ' = � ��'�h _ '�.__ inchcs Water m Annular Spac� Yes �o " ' � �- Pwmeci v� Depth � to Ft rrl�terials IIsed: _ No. Bags Part]and cemeat ' Weight o� 1$ag ��Pouuds . If mndur+e ( grav+el, c�gs) —Ratio tfl _- ID p1aL� �es No 4 x 4 slab �� No - Liner_ - . F�rom � DePtiL _ ( N ��i'' _ Date Installed: " /S Ginput {1� 7ns#alled by: �,Q'riz,�� . - To Dniiing Log � Locittian Drawiug � � S'v �.� �, �; - � ��Y c�y �a.t the abov+e� iafomr�ti� is co�xt ana. that this �v�dl was •ca�s�racted 'm � with iegulatiams s�t fa� ►y the Person Cu�untygealzhDe�, . �ce °iCo�cbor 1e��-���%'��.+Y�f -�Z'' ID # ? E� `? i?aie _ � `- / 3 — c°� �' _ • . PnmP Ia�Itmmt . . � ��mv� c�: ,�3���P,� �.� /7� � / �..� sr���x�: /�d�- "''�Y �: / ✓_ $ s� w� r. .��: � s � .. . -r— u�up Make � Ma�eL• ���.�C�P � Pu� s'ru and Ra�. �2 hp �p � ��bY �Y ��s pump was mstaIIed and t�se well he� cx�leted a�d.ing io the Pcr9an Couniy Well Ru%s in e$ect n t�is date and that a c�py of tbis �ooid has t�ca p�ovidod to �the weII owne� . °mp ieslaHa' �a�e��Za�i� '�� l"�°G �` • . Dat�: �� - c� r PC�D rev Ol/27/04 � � �����;���;;���j�, � 1 � �'���' 1 � � ��Q � � � �-�. �- m �. �--�. � �. �. �. I �-� � �..1I � �. Applicatlt: � ---;:__. V�t a��r� � ���� N .��3_ ���ao� ° �^'�s�ca�L4��� � �ofl °�o ao � � . ������� � ' �'� _ System Type (ln Accnrdanc� Wiii-� T�ble Va): �iT �tZ �I�w� 1 rdl� � i���1V1 ���J ���7°C lfi9�-d i'�LL.i� �/V' L�i&lII��Y1i"��� Y19��� ���i�t.+���� . t�1�R !� CARt�Ll�l�, C��E3�.�+1. ST��lT��, �UL.�S �flR S�Js�.G� TR�T�BI��lT AND DlS�rO$AL, . .�ND ,4�� C�i�t3iTd0{�5 �F � i�3E IEi�P�'cOi�'�s�liEi�T P�3�il�' �►�8D CC�i�S'�UGT10N At]�fl-iOF���T'IO�V. . . � ���� �� . Authorized State Agent � . j __. ; Installed 8y: Jtn�.�.,.� 1p��5 I r � � , : 2, � t5 � � � WS � 1� �yO 5�� : �,,� `° � �,� ss IZ�Elo��3 � Da#e Date: � � 2 �ib ��a �w I s�2 � ,�, � ,. , �. � $ �" a,,,, � y -� �, �" ,y�. ,, �+,y,. G� �f '�Z�� � Za � (c?� 2��2 �• � �O � , � ����'�� '�'.�,�t� �����s� i ��� �°����.�� � � � ��e �9 � ��� Ta„ 11/1a� ��,0'�1 Faresl # a'73 Sys�E� Type (72b�e lIa) 1�i c� OwnerlA�piic�nt J�,r, Yt,ll � Subdivision Address/Loca#ion Se�IPhass �ot � ����c �'��� �a������l���� �6�a��c��ora �n�� ������ a�s State�iD/daie WZ -25-0� i Ca aci �� . �l. ./ Tee and ��lter � / Baffie / Sealant / Riser ifi a li�able / �''2t7k Outl�t S�a! / Perm�n��t Nlarl�er �'aam� �"�nBs � n 1Naterpr�of /S�alar�� Riser Wat�� i � ht �'�r�ap Cneck ValvelGate �Iai�e : � Ant�-sio ao� o e a�d audible Rate (g�m) Approv��i Putnp i1�s Bloc;� Ur�der Purnp Pum� Re�vv�! R�6 . � i3is�abu�¢o�a. i-�i'�SSUf� IV�att9SOaC1 �.ow Pressure Pi�e Apq�r. Pipe �riat��iai and Grad� Valv�s � � ?rer�cf� V,lad#h 3 �. � .� Tr�r�c� D��th �-Z in.� .� ?renci� Le�gth �I�� �✓ Tr�nc� Grade Tr��rci� Spae9ng Roc� D��fih and t�u�is Darns/S#e�dov�� ��e. Pr�s�ure Later�l� � Hol� S�acing � m e �ze Pipe. S��sye �equaa°�d� Se����� From� 1lVell� Frarn �'ro�e�iv lan�s ' iv Su�fac� 1/�Aaiers Pubiic Wa#�� Sup��ies Vertical Cuts (>2 ft.� UVater Lines Ve�iicle�Tr�ffic . Ea�er�ents/Ri��t of i/� ��er �ase�ner�is Re�ard�d �r� e ��ra�or on Tri-Partate AQs��rnent . ;� / / i i �r;i� ic`/. �/'�v/Q"i Report To: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Name of System: Jonathan Hill Past Fieldston S/D P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://slph.state.nc.us Phone: 919-733-7834 Fax: 919-733-8695 StarLiMS Sample ID: ES022009-0018001 Collected: 02/19/2009 15:30 Jonathan Wiley IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Received: 02/20/2009 09:00 Angela Heybroek ES Microbiology ID: 1977 Sample Source: " New Well . ' Well Permit Number: GPS Number: , Sampling Point: ' Outside spigot ,= ,; A29-273 Sample Description: �� � Comment: : - Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte _ Test Result Date Total Coliform,Colilert Absent . Joy Hayes 02/23/2009 E. Coli,Colilert Absent - Joy Hayes 02/23/2009 Report Date: 02/25/2009 Reported By: Susan Beasley ,��� � � ���� Page 1 of 1 � Explanations Coliform Analysis: If coliform bacteria aze Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hazdness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits � Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 North Carolina State Laboratory of Pubiic Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Hill, Jonathan Address: Past Fieldston S/D Zip: County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street Ste C Roxboro, NC 27573 Courier: 02-33-15 (336)597-2371 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Collected By: J WILEY Date: 2/19/2009 Time: 3:30:00 PM Location of sampling point: Outside spigot Remarks: Permit # A29-273 Parameters Results Units =- s Date Analyzed: Silver <0.05 mg/I ` = 2/20/2009 �.. . Alkalinity as CaCO3 68 mg/I 2/20/2009 . Arsenic <0.001 mg/I 2/20/2009 Barium <0.1 mg/1 2/20/2009 Calcium 37.4 mg/I ' 2/20/2009 Cadmium <0.001 mg/I 2/20/2009 Chloride IC <5.0 mg/I 2/20/2009 Chromium <0.01 mg/I 2/20/2009 Copper <0.05 mg/I 2/20/2009 Fluoride <0.20 mg/l 2/20/2009 Iron <0.10 r;�g/I 2/20/2009 Hardness as CaCO3 (Ca,Mg) "` 116"'' mg/l " ' 2/20/2009 Mercury <0.0005 , mg/I 2/20/2009 Magnesium 5.5 r�igii, ' 2/20/2009 Manganese ' 0.05 - mg/1 2/20/2009 �,-% Sodium 9 mg/I 2/20/2009 / Nitrite as N <0.10 mg/I 2/20/2009 ' ,� Nitrate as N <1.0 mg/I 2/20/2009 : ��0�' Lead <0.005 mg/I 2/20/2009 pH 7.4 Std. units 2/20/2009 � �`,.�- Selenium <0.005 mg/I 2/20/2009 Sulfate <5.0 mg/I 2/20/2009 Zinc <0.05 mg/I 2/20/2009 Date Received: 2/20/2009 Today's Date: 3/9/2009 Report Date: 3/6/2009 Ref: 2572 Login Batch: Reported By: ��el ..�".�-' ""�'�"" �, Sample Number: A685698 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria aze Present, the water is considered unsafe for drinking purposes. 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. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits e Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 1Z-��o� 1�,e�-�K�c 1..eW�S an 1�k �1�..�ae s�e � C���' ,�-•�-c� 1��- g�ec.� s��e.m o,Yea � c1e`"�.� , c�� �- raeed dave�� d�ach � � 3.1� JS 9 0