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 �
�