Loading...
A29 276Application Date: 02- �0-d q �#(3U � Amount Paid: 0200 . 0 CJ ��2 6 7Ll �- a� q 0� Receipt#:� •4�j(S 3 9�-�' S'0 .D0 � � �a �� �1��: � ���'�� T�� � ��� I�.navn�r¢�a�ra�cnca� � ILJ�� L � 11 Application for Services (Sentic Svstems and Wells) Services Requested Tax Map: �'�" a-9 Parcel #: �-1 � � Ca�l jlj ei 1 be�oY e q�` � a,��e �" � o w�� � .� _ r � Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 d) (Fee is de endent on the t e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision a $I50.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement) ❑ Repair of Existing Septic System $225.00/$125.00 No Char�e Important: If t/:e information in the application for an Improvement Permit is incorrect; falsifted, or t/te site is altered, t/ten t/ie Imnrove�aient Permit and t/re Autltorization to Construct slia[l become invali�! � ) Servic�s R: q�es.e� �y: Name: { j7 18� � Address: s G�� D Phone # (home): �%p(o '36% �i�l,3 (�k/cell): �`Z.3 -35�/ - 07 S'I 2)Name and address of current owner (if different than applicant): Name: S�ME _ Address: 3) Property Description: Lot Size: 2;4 I Subdivision: �1 �p� Lot #: ►.� l� Address and/or directions to Property: S EE i�"�`Z'Ae�� 6=5 mQ, P 4) Proposed Use ar d 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 5) Water Supply: Private �Vell ✓�(Yroposed Existing � Community Well: Public Water System: Are there on the adjoining properties? No ✓' Yes (please show location on site plan) Note: A completed application must also i�iclude: ➢ A plat/site plan of the property that s/iows property dimensions and t/ie size and location of all proposed structures. ➢ A signed copy of t/ie `Lot Preparation' form verifying tliat tlie property is ready to be evaluated. I am submitting this application to request services from the Person County He�lth 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 : Z - -� a 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �� �� �����`� , .��� ��� � ' � y � � I � �-r-'�_'�`�° �, � �-��� i� ���-3..s<o „-�, �-n--, �e��.,�..1 �"-+� ��.�.� Anplican� Location: ����a��G�� �7� 00 0 �� e a o o � ��rove�aent �sa�it it ���# 4��ad �0��`3�e �� _ t�% �i�aon �p/`� � �.%e Tyue �of Fa�ity: 4 6 FZ S � ,� New %� �ldsiition �ate� ���gsiy �1 P � � # of Oc�upants _� # of Be�rooms � Proje� Dai3.y Flow �{ R o g.p.d. �� Propos� Wastewater Systen3: /'a.► �� CY GGP �. � Type: Propos�d Re}�air: fJ ��-•�p cc�.-, ,,.,� �� i o-t � Type: �'�' Permit Conditions: �P -S � �'Q � � Owner or Legal Represe r�uthorized State �Agen� Date: 0 2- �-S o 9 T'�.e issuancs of this pe�it by the Health De}�ar��ent in does not �axautes tELe issuanca of other pezmi�s. It is the responsibility of the' aPPli����P�Y owner to in suze tfi�at all Person County Plannmg and Z�ning and Bn�ding Iuspe�tions. rec�ui.temeats are me� Tlais �pro�iement ��rmit is snbjest t� rs�ocation i� the site p�an, plat or t3ie intended use ciianges. The �mprovement P..rnait is not a�fe�terl by a r3iange in owrnership o# the �rope�ty. �3us �ei-mit �as i§sm� in c�mplianca.�viti� the provisions of t3ae Nort� Car�ISna `��aws a�ed I�ules for Sewage ?'rem�tzent ared �isuosal Svstems' (35A NCAC 13A .1900). Yeit9�er P�ou �ounty ffimr t�te �nvia-anffieutal �ealtia Spes.ialist'-�arrants ti�at tiae septic tank syste�t w�1t cont�ue tu fmnc�on s�4isiactora�y ia tiie future or'tha# the water supgly will reuiain�potahle. � ..� � � A�at�aox�zataon � C�rastruct di�as�#ew�ter Sps�e.m (�.ies�u�r� for ��ding �er�nat) * Ses site pdan and additioreal attachments (_�• - Propose Wastewater System: � r4 � i f� �GL P ZD ��d 'I�pe�`' 9' Wastewater Flow �g:p.d. New Repair Expansion _ � Soi� g.TAit: ,a-T S g.p.d1 ft 2 Typ f ac�7ity: S F�_ Basement Yes _,No � � , . . �7ast��at�r S�te� �.��aa��ffie�$s '�� �ize: Se�tac '�ank: ��� � �am� 'Tanlc: � gati Ggsase �xa�c `v �� gai �rai��eid: '�oial �ea: 1 a— Os� � � Total ��eugt� �t0 �t � 14��iffi� �s��c3a 13ep#�a �_ � T�em�'�Vid#�a � fi 11�'sninaus�a Soii C��er: CD � in �istrs�aaataon: � �as-tribu�iioa �o� Serial �ist�i'�antaon r'al �peci�ications: � �e � i `�'f � }� c /L1 v � qc3� jtii-iU� ar So1 CovP /�,_. �}__� inFS Q�' -- �u#�aori�� State Ag�t �..,1r�4�.., �/�-c� - Permit E:tpiration Date: o � a The rrpe of system permitte3 is Con�rentional Ac��te� P�� . �o����� ���������e: 10�1iniffi�am Tre�c�a Se��ratiom: � � � � �essure ,iia�ifoid � / � J � �-► � �P ' I �-+ C �i S a� !lo p4c , Dat�: C7 � a- d - . _:3lteznative. I ac��t the �ecifications of the � ��: �-1-a �l I,/ P1.11L� r�.S%. 1 1/1 V( Q1 Hs �� w a � i l , � I J�? °e �1 � Nso, Ta � � I 1 �1 Q 4� �S `Ac `�' '"1 �� S �� 110' 2 � . Pa G�j . � � � -� � ���es �-f aa� ���-��/ - S�� I Co r► �s� � ��„le� i�,, J P� Must install septic system on contour. � SPP�< < S�S�'-Q„�, /►-� vS% � o� � Must not install septic system during wet conditions. W��� �� .� „ Septic system must maintain all proper setbacks. s � � P e�- o� p o� � � l Any questions call Environmental Health Dept. Se t; G 336-597-1790 P S�S �"�' '� �S`t �6�'- �� w ► �'� ►�► I S -F�Pe �-- �` 1 � �ui/r�! �i �� v� rJ 4% t v,-, o l � J S82'13'40"E ' Ig � `S �e� O� Q 352.60 TOTAL � �.QP�- ^ � A RT v E v f'r�-i C,� J � r-o r -- ,� ToT'4� = L�.� O' ��Z. , :�' Low � ��� G�+.4ti,QER. J� , � I!�l �P M uS� r?a�' Qncr'a q� � ' V� o� S�' � S !'PP���- Qr,P9, ii s � � ���,�� ������ . . -� ���.��� ]Em.�u-d,...,�.,,��¢.m.l ]C-33C�.�H�Ila. SITE S�ETCI� Name��t�id �/'i �a � � TaxMap#_n�'Pascel�7(o Subdivision Section/Lot# �e� 9'�,a�--'l� c� 3 a�fo 4 Authorized State Agent Date System components reprerent appmzimate�contours only: The contmctor must, flag she rystem prior to begim�ing the i�utallation ta insure ihat propergmde is maintained {� �' � �� , � �°'02�� S6'� �$ ` IS UN Su�TA��L E S C�Z �. � 1.�� I� l.. a j/i� � �/ / � ���� J �.� �J]�L.J � �/ �11• V l � � ^` � � ���� �.33�7L7P a@ �]1"IL"1 cC� ]l.a¢.SLJL 1L .11 � �Sl.�l ¢.:t'� ����, ��+ �11�I�� (Ne�v�%�epair� '!Cas Map: � � � Parcel: a 7� Subdivision: Lot: Applicant's Name: � a v ��J 7/� �`��� P ilRailing Address: !f-`� 7 S�-r o �Q! ��P /'. �'e � d-, (� v � 9 Phone Numbers: 7v �-3 � 7�'�l � � a�3- 3�- ��5 7 �ac�tion of Propert3� l� �5-�- �i P%� s --� (.o�-- �-, ln_�__� a��e � �'ermit Conditions: 1) See attac�ied site plan for proposed well location. 2) All applicable State and County regulations governing const�^uction and setbacks apply. 3) Permits expire .5 yerzrs from the date o, f'issue. � Other Conditions/Comments: ��'P S � � P �S � � �"� � - �'�s�sni# �ssued by: � Date: � a' a` ��� � ��R'�'���A1'� i�F+ Ci�l'VIPL�+'�'IOl�T New VVell I�aspection: EHS/Date Location: Grouting: -/ `� "� Well Log: Well Tag: ' Pump Tag: Air Vent: �� Hose Bib: Completed: Casing Height: Method/Material(s): Concrete Slab: Weil �riller: u�rrt�� Pump Installer: � ` � , Well Approver� by: r`'� L�er �nspection: EHS/Date Installer: Depth: Grout: We�l Abandonment: EHS/Date Date Sample Collected: Person County Environmental Health �25 S. Morgan St., Suite C Roxboro, NC 27573 '�,icense #: License#: Date• � �Z �� Date Results Mailed: ' � Phone: 336-�9^-1790 Fax: 336-597-7308 3/1/08 7'� �� �, /�is Pa�� 1 �' � RESIDENTIAL ��►�BLL CONS'CRUCi'ION RECORI� NoN► Cazolioa Departmau af Envuoiuneal and Natural R�ccouccts- Oivision ai �Yatu Quatit� �i'EGL CON'CRACIbR CERTIF[CATION # . ��6 ( t_ VYELL COM OR f f L 70 ^ k we31 c«, ' uai) aame - Barnette Wei[ Drilling Inc. Wep Cotriraetot Campa�y Name ��,�,�5 611 Bamette Tingen Rd. Roxboro NC 27574 • City a Tam Stat� 2� Code � 336 � .599-0015 area coae- Ph�e nwr�e� F;`.'i�� r�4_..:i�•I:�il;�7;: strE wat. w ata�+�> N/A STATEWELLPERIN'f!{'dappr�aWe) wA D WQ or OTHER PERM[T 3('d �e) N/A - WEII. llSE (Check AppGcable Box): Residentia� W2tef SuPply � nAr�«uu� 'l -' �Y� 09 TIME COIIOPLE7ED L LOO A!N Q PM � 3_ WELl. i70tN: CITY:�,YLR7D�7 COt1NTY ��a��_ '�W' � K�l 7D� �� (Steet tva�r�e, si�m�ets. .. 4y, subd'n�sPon, t,ot tio, P:stei. T�P �? - TOPOGRAP!-qC! SEiTtNG: ns+� o��r � n� oo� (c�,edc app,opda�e oao4 - TAay 6� ia d�ms. i�i�V� � _ I[ii(M�[Q.9000Od50[ IONGITUDE � �' � � Laritude/iongia�de socu� ❑ GPS oToPo€�'aP�� �P (location af wel mrut be sla.m on a USGS topo ma,� and a[tad�ed b Vris tarm inot usirg GYSy 4. WELL QYYI�ER ow�as wunE �c.v�l c� �'r ! I� ia l� REET ADDRESS _�y.I � n n ok 1��> �. C. 2�5'� y ciq, or rown srace z'�p coae c'.i3L � 5 t7-S2�9 - Area code- Pha�e txunber . s_wc-u.�ra�Ls: ��D f� a TOTAL DEPTtt b. dOF.S YYELL REPiACE EXISTlNG iNELL7 YES Q NO E! � WATER LEVEL BdawTop d Casing LrJ i-T. (tlse't' � Ahowe Tap d CasL�9) a. TOP oF cwsi� �s 1.5 �_ n� i.�a s�rao� -rap at c�g t�mi�+atea avor betow Iana suraoe rt�r �eq�e a variatioe in a000rdawce w�h 15J1 NG1C 2C AilB. e, ylg,p (8pta)_ �o METHpp �TEST Blow 20 min L IXSINFEC7tON: Type ��"� Amount .25 CUp g. WATER ZONES (depth)- From�„ti To1 t7 Ftnm / L5� To 13n Fcan To F�om To Fram To From To 6. CAS[NG: 7hicknessJ Oepih Oia�nete� Weight Materiat Ftam�_ To O 2 Ft� _�� � Fran To F� ��4� SD�-2 t� From To Ft. 7. GROUT: OePth Nlaterial iWethod Fcom_sZ io t � �'c GraveUCement Poured From To Ft F� To Ft a scREEPk Depth o7ameler Ftnm To FL in. 'IAF� To Ft in_ Ftom To Fl in. Sbt Size Matecial in. in. �. " 9. SANWGRAYEL PACK: pepth Size Materiat From To Ft �/�wtn To Ft From To � ft '10. OAILLING LOG From To � [O � i l. REMARKS: Fo�mation Oescr�tion N �' ti� � no �r �r nu�r�tas w�t�. was coNs�uctEo N nccoaw�ce wm+ �S�Nc'.Nc�.watcorismuc��oasT�r�aas. ae+a�►►uracoProFn�s aFcaanrus � atovn�o Tu � vv�.� owr�t � , � �'��-� SI R F CFR 1 WELL CONTRACTOR OATE �p 1/l /1 �L I� ��/�t •rli�n PRM(T�D W�ME UF PERSON CONSTRUCTI THE W ELL Sttbmit the u�igir�al to the Division of Water Quatity wiihin 30 days. Attn: tnformation IY�L, ! 617 Mail Se�vice Centec— Raleigh, NC Z7fi99-i6tT Phone No. {919) 733-7015 ext 568_ Fmn GVY-1a Rev_ 7/a5 li� I ����� �� ; � � � � � � ( ) � `;r . � 1 , \ 1i. � ���`-� . � � ����� �� I I� � 3'�"Sr�3" �O -r^� �"'�'.� ���. ��i.� J.l. ! L � d...��:i� Applicant: J�4vi��' i �I�i Location: �{�i S �,- �r� a��r� �� ���c�� N .a � tv ���Sl�rti�60� �����,p � � � �� �a oo y �� ���� �` �� � 2 <<°,�) Syst�em Type (ln Accardanc� Wiih Table Va):���__l_ �`� . — J . i�:fS ���"���fi 9��� �E��i l�S"�,��L��J 9t� Cfl�l9�Ll�A��� �i i H�.t F�iG�.�L� . P�ORTH C;'�R��9�.�:� �=��RE�r�1. STA�fiJT��, �fl�.�S �t)R ��PJ.A.Gc TR�.�i�1lEiVT Ai�ID DIS�OSAL., . �i�D �i��. CG��39�'a0i�5 t�F � i�3E ��P40i��1d�E�T P���ti(�' �►�ID Ct�i�S g RUGTION AllTei�����i0�. . � ����c • 1�� . Auihorized State Agent f nstallec! By: � l-P,�� � � gla�l�, � GBte , Date: a�24-�c� �� _ �5�{'� I—y = I 5v �a. L3: IU��- � N4O -�- �Si cx� , ���tZ a-13� 'C; :'� r��� . � j /^C�(}.i y ��� � 3� �'.�,,�� �������a�� �°���,���� s { � ��� �8 � ���� Tax MGp � A�q rarc�! � d71� Sy�i�€� Typ� (T�b�e Va) �, i 2 Ow�e�lA�plica�f `�vi d i r i bbh � St�bdivisior� Address/Loc�¢ior� SE�IPf�ass �ot � � � �����c �'���5 �ea��p��l���� �a�r���������a ���� ��s��� �.�� � Siate�iD/datz ���� a.- Cz acit � .c.� Tee and F�iter � � Bafffe Sealae�t � Riser iz a licdble) ' T2ilk OUiIa t ��a� P�rmane�f iVlarker Pa�m� �'�n6� Water r�or /S��iant Riser Wa��r i � ht � ��era� Chec3� ValvelG�t� �lai�e Anti-s�p on oie Alarm (visable and aud'¢ble) ElectricaE Compo�ents Raie (9�m) Approv�s� i�ump �o��! B1ock Urd�r Put�p. Pum� Removal R�pe/CY�aan . �i�as�a�abaa�6a��. ��+���s� �e�i�l Dis�rib�tion Pressure (�a�r9 od �ow Pressure �ipe Anar. Pic�e M��ePiai and Grade U� � i r�nc� V�iid#h 3�t. • Trer�ch D� th i� ia�. ✓ T.r�nc� Len th y�l � �. ✓ �"re�c� Grade � Tr��c� S a�in Rac:t D��fih and t�uaiet Darns/Sie dovv�� ��c. �ii'�S�UY� ii�$�P'�l� � Hole Spac»g � i7 2 iZ@ Pi e• S1��ve Turn-� slP.foie�i�rs �equa��d� �������� From� UVe�9� F�om Prape�ty l9n�s Structures/�as�ments � Star�ac� Vlf�i�rs Pubiic Il�la$e� S�p�aie. �Lertic�i Cuts (>2 �t.} V�ater Lines Ve�icle�Traffiic � Ad�ac�nt Syste�vts ��s�s��r�ts/Rig�# o� i� ��trse� . �asesnents Re��rded e�ii te p�rafor o �'ri-Partate Aar���e�a '��,1L iC�I. vI 1��'1 1 Report To: North Carolina State Laboratorv of Public Health 06 N. W?m�ngton St. Environmental Sciences Raleigh, NC 27671-8047 htt�://slph.state. nc.us lnorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 StarLiMS ID: ES033010-0018001 Date Collected: 03/29/10 Inorganic ID: Date Received: 03/30/10 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 1.0 Sample Description: Comment: Name of System: DAVID TRIBBLE 4095 BURLINGTON RD Time Collected: 1:30 PM Collected By: J Smith Well Permit #: A29-276 GPS #: New Well (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Total Alkalinity 25 mg/L Arsenic < 0.005 0.010 mg/L Copper < 0.05 1.3 mg/L Lead < 0.005 0.015 mg/L Manganese < 0.03 0.05 mg/L Zinc 0.49 5.00 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Chromium < 0.01 0.10 mg/L Silver < 0.05 0.10 mg/L Selenium < 0.005 0.05 mg/L Iron < 0.10 0.30 mg/L Mercury < 0.0005 0.002 mg/L Fluoride < 0.20 2.00 mg/L Nitrate 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L Chloride < 5.00 250 mg/L Sulfate < 5.00 250 mg/L pH 6.8 N/A Sodium 4.90 mg/L Calcium 4 mg/L Magnesium 2 mg/L Total Hardness 19 mg/L Report Date: 04/13/2010 Page 1 of 1 Reported By: �e��ie �%%lc�real � North Carolina State Laboratory Public Health 3 6 N W?m'��ngton St. Environmental Sciences Raleigh, NC 27611-8047 http://sl�h. state. nc. us M i c ro b i o I o Phone: 919-733-7834 gy Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES033010-0038001 � ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ES Microbiology ID: 15247 GPS Number: Sample Description: Comment: DAVID TRIBBLE 4095 BURLINGTON RD Collected: 03/29/2010 13:30 Received: 03/30/2010 08:37 Sample Source: New Well Sampling Point: Well head J Smith Angela Heybroek Well Permit Number: A29-276 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Lyons 03/31/2010 E. coli, Colilert Absent , � Darneice Lyons 03/31/2010 Report Date: 04/01/2010 Reported By: Susan Beasley � ��� Explanations of Coliform Analysis: 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. ��s`° � . � ��� �.��C < <� � � �� �c�- �. c ��,, � . , � �, i � � .�'' �,�`� `�PG..�.�� C.�.S�-� -��n:r.�'iYC�C ,C�'�G'`S`�'� ��1�"�� �' �Yu't.�uA�� Se�1�'R-� �-w (CZvi �.0 c� `�' "}� zl� : �� �.e.v ,�,,,� . `�se ►�-e,z� �t ur,r.�' � ej '"� � 1 , 1 �,u= . ��e� �-- S�� Q+f� �- ;1^�'� �`� 'i�r�.�'`C- � ����5 �� �� � � J Z l D � �,� � i/`7� � l � �