A29 283�"�g��� : q�R
Application Date: � G"Iy Da J,, ��� SS' ������T Tax Map
Amount Paid: �(00 .OU �6 � �G�` ,_,., ."� � �� Parcel#: 'vt�
Receipt #: �!� �{63 � � �� � � ����
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C�-i� I I a2� A
�l Improvement Permit (Site Evaluation)
� $200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
0 Well Permit (Piew/Replacement/Repair)
$3 00.00/$200.00/$75.00
tion for Services
Services
0 Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
�plicant In ormation: c� L , ��
Name: Yl � 0 2r <<� h
Address: ��p Nu�Clle �t�'�l5 f2
Hurclle luills NC �:�5�(
2) Name and address of current owner (if different than applicant):
Name: j H O Vt�'Yl
Address: Se �
/� N
3) Property Description: Lot Size: `.�, l( AC � Subdiva
Address and/or directions to Property: �11
�?�hn /�lleh �2c1. �n �a�a�
Phone (home): � (� ` �0�'-a��Slv
(work/cell): - 5� �P
Phone:
Lot #:
❑ yes ��f" �o Does the site contain an`y jurisdicti�Onal wetlands?
0 yes �Q) o Does the site contain any existing wastewater systems?
❑ yes �"90 Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C�'�o Is the site subject to approva( by any other public agency?
❑ yes L9"no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
'l�s
4) Proposed Use and Type of Structure:
❑ esidential 3
New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of be�dr�o°ms:
❑ Repair to Malfunctioning System Will there be a basement? � yes E7"no With plumbing fixtures? ❑ yes �o
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: L�'New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring �
� Are there any existing wells, springs, or existing waterlines on this property? ❑ yes �'1 no
I�f plying for `Authorization to Construct', please indicate preferred system type(s):
' 0a Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the info�mation provided above is complete and correct. I also understand that if the information provided is
inacc e, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�c;�-� � � �Df�
ignature Own r/ Legal Representative*) D e
*S
required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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App(icant: ��i.1
Address/Location
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4
Improvement Permit
Permit Valid for: Five Years X I�'on-expiring
Type of Facility: ��� New � Addition _
Number of: Bedrooms 3/ Occupants�,�`/ Employees / Seats:
Proposed Wastewater System: w �.S �o �uc�.-�-u�
Proposed Repair: j�c�'4�fl �+ �t57a cx�o
Permit Conditions:
0
Auth�rized Ctate Ageni: pE.4.1�c� A_
(X) Owner or Legal Repressntative:
Taz Map: �_ Parcel: a$3
Subdivision
Phase/Section/Lot #
Water Supp;y: ��� 1�3EU..
Projected Daily Flow: 3b� gal(ons/day
Type: 'I13 6
Type: TiSE
Q��.�c�a
Date:
Date:
The issuance af this permit b r the Health Department does not guarantee the issuance of other required permits. tt is th� resFonsibility of
the applicant/property owner ±o insure that atl Person County Planning and Zoning and Building Inspections requirements are met. This
improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance witli the provisions of the North Carolina `L�ws
and Rules for Sewa�e Treatmen: and D�snosal Svstems'(15A NCAC 18A .1900). Neither Persoo County nor the Environmental
Health Specialist warrants taat ��e septic system wiil contjnue to function satisfacto. �iy in thc future, or that the water s��pfy witl
remain potable.
Authori�ation to Construct Wastewater System
�"ee site plan and additional attachments (�.
il
Proposed Wastewater System: /.�c,�.p�ep �I :�5?3 �4/ (*)Type 7�jC� _ Desigr! Flow 3W'O _ gal./day
New � Repair _ E:cpansien Soil LTAR: Q� 3�5 gal./day/ftz
Type of Facility: 3-��c� i��f. Basement: _ Yes � P:o
('L) Sys� Types Ilth, Il�bg, iY, trnd V, require periodic system inspectivns by the Person Cor�nty Health Department.
Wastewater System Requirements �
Tank Size: Septic Tank j�o� gal. Pump Tank "� gal. Grease Trap �"' gal.
Drainfield: 'Totai Area I D�O sq. ft. Total Lengtl� �b'a _ ft. Max. "french Depth �$ in.
Trench �Nicith 3 ft. Min.Soil Cover � in. Min.T�rench Separation 9 ft. �''q„
Distribution: Distritsution Box� / Se� ial Distribution ! Pressure Manifold __�_ '.7 �$�1`� �
Specifications: � 1.taEs 90� �C�� SI.CEVE S�PP�-� l.�aE L1a0�R. �t�A �Oss+r�b•
Authorized State Agent: f��RR.sC�- A• Sh�.\ fssue Daie:
Permit Exp
The system �ermitted is: Conventiona{ /Accepted X; Alternati��e / Innovative . I accept the conditions
and specifications of this permit. -
(X) Owner or Legal Representative: Date: %' � g- �
Person County Envirortmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Authorized State Agent
SITE PLAN
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Secrion/Lot
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System components tepresent appmxrmate conrours on/y. The coatraaormustllag tlre sysrem prior ro begiruuag the installation ro
insure thatpmpergradeis maintaiaed.
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WELL PERMIT (1rew�Repair�
Tax Map: � Parcel: o� �
Subdivision:
Lot:
Applicant's Name: C N��cS�t1�. E LA�►� W��tJ
Mailing Address: $yq�� 1���� 1���5 �O
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Phone Numbers: 33b- 3by -�`�� 33�- �`1- fly�b
Location of Property: NwY 49 S• �� 5�+� A��. R'0 >
oa � ^-1 •5 �-►��s .. # I��lo -- --
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and Countv regulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments: �,��P w��. loo �-� � Av.. s��. Cc�t'�a��s .
Permit issued by: I�Psac� A. Sr�-rn1 Date: y t`1 i�
CERTIFICATE OF COMPLETION
New Well Iaspection:
HS/Date
Location: � � ���
Grouting: D- -(
Well Log:
Well Tag: /D �!o !c f
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Conczete Slab:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Methad/Material(s): _
Well Driller: --r2i�'o -,�es+�l,r o�( License #: ��
Pump Installer: —T� License#:
Well Approved by:
�P S S�r2 �; ,r-P
e
Date Sample Collected: 1-.�(,,� IS �� �►� aW
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date•
Date Results Mailed: 02 �3 -15
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resowces- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2481 A
1. WELL CONTRACTOR:
Joshua N.Robertosn
Well Contractor (Individual) Name
Triad Drillers
Well Contractor Company Name
8228 Kerrs Chapel Rd.
SUeet Address
Elon NC 27244
City or Town State Zip Code
3c 36 � 421-3513
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# �� / " Z(��
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #{if applicable)
3. WELL USE (Check Applicable Box): Residential Water Suppiy�
DATE DRILLED – � "
TIME COMPLETED J'� AM ❑ PM �
4. WELL L A N:
CITY: COUNTY �('i�.S(7!/�—
O
(SVee ame, Numbers, Communily, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETfING: (check appropriate box)
�Siope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 °,�'JQ_" DMS OR 3X.XXX�(XXXX DD
LONGITUDE 79 °�`I'��" DMS OR 7X.XXXXX)ocXX DD
Latitude/longitude source: �GPS Qfopographic map
(location of we/l must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL WNER
tl ��7 f l� �645
Owner Name
? c.�SD l� (',f1(� Y,� �S�
SVeet ress
I/r 27 %
City or Town State Zip Code
c.��.� Z , ��D�e�
Area code Phone number
6. WELL DETAILS:
a. TOTALDEPTH: �Z�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �
c. WATER LEVEL Below Top of Casing: �t[/ FT.
(Use "+^ if Above Top of Casing)
d. TOP OF CASING IS �_ FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): � METHOD OF TEST AI�
f. DISINFECTION: Type HTH Amount /Ga z
g. WATER ZONES (depth): , i
Top��� Bottom� Top �� Bottom ��/Z
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom �2 Ft.� ,��/ �_
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material � Method
Top 0 Bottom � Ft. � �� �
. �,��..,
Top�_ Bottom T Ft. �� /
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
o i�_
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/
�l 5�
/
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/
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12. REMARKS:
� Formation Description
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COP IS RECORD HAS BEEN
PRmVIDED TO THE WELL NER _
N. Robe�tson
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CONSTRUCTING
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DATE
Submit within 30 days of completion to: Division of Water Q�ality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. vo9
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Tag Map � Parcel # �$3
Subdivision
Phase/Sectian/Lot #
# of Bedrooms �
Applicant: C;�1P-�`�'P�.�. � t�aU� w�..,�,�
Lacation: �l9 S • � � �A "30�}..\ �:.�, � � 6�v ^l .� r��s �o
����°at14�1 �G�°lili.t
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System Type (From Table Va): �II6 Product (IIIg): �►�C��.�zoR..
Type V& VI �xpiration Date: --� Type V&'VI Renewal Date: --�
This system has been installed in compliance with applicable North �arolina General Statutes, Rules for
Sewage Treatment and IDisp�sal, and all conditi�ns of the Improvement Permit and Construction
Authorization.
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�t�. �R�c�� i� . 5r�►
(.Autnarized Agent)
C�1Rt�i�EtzS "%3�+caLt�,� S�R.v��
(Licensed Contxactor)
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Scale n%'S
PCfID, rev. 12/14/12
1� ' Z-" �`�
(Date)
t0 - �-1`�
(Date)
�—' `�lo� S�a44\.`S ►.��a fQ�ih
-c��v.. -�o s�c►�z v� ►.►a�
I Ck�rl�c`� �oC- F�-�
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Line Length
b �
'11�'
3 g�'
8�'
5 bo
Tax Map: Aa�l Parcel #: a83
Septic Tank System Checklist (Type II-I� System Type: �ii G
Sepiic Tank IniiiaUl?ate
State II� & Date: SYp- 3�� Q� �o_�-��
�,�t b �l'�
CapacitY� �S• ioaa
Tee and filter
Baffle
Vent
�Riser r�1 �
Outletboot �q �o.�_��
Perm. Marker
DistributiQn
D-box levels set) ---
Serial c�As io��-�y�
Pressure Manifold --
LPP -�
N�tes: '� i�v �'�U,. wfl5 Ait-�v.�n �, T1'�, �F S�pn L Ta54E�t,oa'� "
P�mp System Checklist
Pum Tank InitiaUDat�
State ID & Date:
Ca acity:
Riser (6" niin.}
NENIA 4X Box
ModeL•
Piggy bac �lug
Hard wired
;
Alarm fltnctioning
Mounted on ost
Above grade (12")
Conduit sealed
Pres�ur� Manifold ��
Number of taps�____,_ __ _
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes •
Tank Co� onents InitiaUDatc
Puiup model:
Block {4'�)
Nylon retrieval ro e
Float irea and attachments
On/Off float swing: in. �
Alarm float (6" se araror�)
Anti-si�hon hole
Check valt�e
Threaded ur�ion
Gate valve ^ �
Conduit sealed
Outlet seated
A roved a�� secured riser
Su ! � Line �
Size and material: _ in. sch. j
Length: ft.
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�3-15
StarLiMS Sample ID: ES012715-0060001
� ������� W��� (U ����� ����� ����� ����� ����� ���� U���� ����� ����� �u�� ����� ����� ���u uU ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slqh. ncoublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
Name of System:
CHRIS 8� LAUREN WILSON
1366 JOHN ALLEN RD
HURDLE MILLS, NC 27541
Collected: 01 /26/2015 10:18
Received: 01/27/2015 08:10
Sample Source: New Well
Sampling Point: Well head
Derrick A Smith
Angela Heybroek
Well Permit Number:
A29-283
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Susan Beasley o1/28/2015
E. coli, Colilert Absent Susan Beasley 01/28/2015
Report Date: 01/29/2015
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
/ � �
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.
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
Name of System:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://slph. ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
CHRIS 8� LAUREN WILSON
StarLiMS ID: ES012715-0032001 Date Collected: Time Collected:
Date Received: 01/27/15 Collected By:
Sample Type:
Sample Source:
Sample Description:
Comment:
Sampling Point:
Temp. at Receipt:
Well Permit #:
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 9 mg/L
Chloride 5.70 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 4 mg/L
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate 3.60 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 6.8 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 11.00 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 35 mg/L
Total Hardness 41 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 01/30/2015
Page 1 of 1
Reported By: Arnold Holl
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