A29 287Application Date: e2 � .1�
Amount Paid: l5 0 • ��
Receipt #: q 3�1 Io2
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tion for Services
Services Reauested
Tax Map:
Parcel#:
��
Improvement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 if> 600 d (Fee is de endent on the e of s stem ermitted)
Mobile Home Replacement or Building Addition Permit Revision
$150.00 (if site visit re uired $75.00
Well Permit (New/Replacement/Repair) Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Info�'mation: � ' �
Name: -{rs � • �� v� v Phone (home): _� 3� -� 9`7 � y,� 3
Address: 3 � (work/cell): y� y� �% S'�_919 q
2) Name and address of current owner (if different than appticant):
Name: ('h �a � �� ►� P l�i . �'io w'� �� Phone:
Address:
3) PropeMy Description: Lot Size: a, y'r Subdivision:
Address and/or directions to Pronertv: R,. .1. ,. .-�-_ .
O yes
O yes
❑ yes
❑ yes
� no
� no
� no
(� no
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other public agency?
Are there any easements or right of ways on this property?
(if `yes' is checked, piease provide supporting documentation)
4) Proposed Use and Type of Structure:
�Residential
� New Single Family Residence Maximum number of bedrooms: �'
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtvres? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
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 ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional � Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ pny
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
* Supporting documentation required.
y-��-l.s'
Date
• 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.
(1fl/lli PPrcnn f�'nnntvFnvirnnmantal �Taalth 27G C l�iTnrrran Q+ Q�,;*o!' n„_.L____ �rn..-.�-,� .....� ..._ ._..-.
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Applicant: ��
Address/Location:
Permit Valid for: Fiv�
Type of Facility: f�
Number of: Bedrooms � /
Proposed Wastewat System:
Proposed Repair: �����
Improvement Permit
� Non-expiring
S. New �—Addition
�cc�upants / Emptoyees / Seats:
Tax Map: � Parcel• �g �
Subdivision
Phase/Section/Lot #
i `L�
Water Supply: W � �
Projected Daily Flow: �'o gallons/day
Type: �
Type:
Permit Conditions: � SI�-t� S,r-�t' �
Authorized State Agent: � Date: _ �"S� /s
(X) Owner or Legal Re e ntative: ,� ,� Date: S'l- �v - 1 S
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure 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 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 SewaFe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �Q'P{i�� ��.5� �V (*)Typ� Design Flow �� gal./day
New�_ Repair _ Expansion Soil LT� 5 gal./day/ft2
Type of Facility: �1� S- Basement: _ Yes No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank D(% �i gal. Pump Tank � gal. Grease Trap ` gal. '� Yl�
Drainfield: Total Area [��� sq. ft. Total Length �i �� ft. Max. Trench Depth 3 i[J n. S�4`l�W�
�--l�an
Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft. 3 0«
Distribution: Distribution Box / Serial Distribution i� / Pressure Manifold
Specifications: �e� �t�Tc ��� �
Authorized State Agent: h-, �1 ''''�^� Issue Date: � S--1 �
Permit Expiration Date: � 'S —Z 4
Tl�e system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: C,� � Date: �- ��/�
Person Countv Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev 5/ 121
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Autharized State Ageut Date
Systeni coixp'mrents �pverent a�i16mxinurte�eo�rours on1y.' The contnrc�br �nas{Jlagthe systen+prior�to
begrnningilrs r�si�rllatian to i�si!t� �hdepro�ergrade is n�aintaiited
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WELL PERMIT
(New� Repair_)
Tax Map: A°�� Parcel: 02 g
Subdivision:
Applicant's Name: ���� ��tP✓4�c1�'
Mailing Address:
Phone Numbers:
Lot:
Location of Property: �� 5- � , ) p �+h ��-e�t �aC. � !�d � � (�
^' � 5 /� �' s
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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.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�'�
Certificate of Completion
�ew Well:
�� HS/D t
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
ae
i-�-c4
� -i��i�
Well Driller: � r��i'�
Pump Installer:
Approved by: �„� �
Additional Comments:
Date Sample Collected: � 3'2�'ll�
EHS: �S
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: � �� �
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date: _
Method/Materials:
License #:
License #:
Date: - -
Date Results Mailed: �-l`i�il�
Phone:336-597-1790 Fax:336-597-7808
11/26/13
Barnette Well Drilling
WELL GONSTRi3CTION RECORD
71va fortn can be tstd for siagie or multiplc we'Js
I_ Weif ntractnr InFormatioa
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WeU naactor Name
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NC Wcll ConCaaorCatificatian Nunlxc
Barnette VYe11 Drilling, lnc.
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2. well canstruchon Temoir#: �, � /
Ltu au appHw6tc wrl! corssuauian ncm,rrr p.e. Cmony, S+ore, Yarience: ercJ
3. wdi uu ��nKk W�� �5��:
Water St�ply� w�i:
❑Agricu7Wral �MunicipaVRt6[ic-
❑GcolEietmal(Eieating/CooiingSupplY) L�R�dantial WatcsSuPP�Y{�8��)
Dlndus�iallCommacial f]Rcsidwtial WatvSupPlY {sharad)
Supply W dL-
For fatcmai Use ONLY:
lnjection R'dL
OAquifc!'(ect�arge ❑Groundwa2rr Remcdiatim -19
OAqsiifa'Staa�eand Rccovay {]SatiailyBarricr �
OAquifrr Test QStormwatcr�Lhzinage
OTi�erimentalTcchnabgy �SubsidenceContml _
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4. Dste Rc1I(s} Comptctcd: �6w�u m� 9�} 2- �
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FacitityfQane Name � Fa�iliiyIDB (ifspplicablc�
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Caunry Puod ideati6ca4oal�to. (PIN)
Sb. Tatiludc aad Longitudc ia.degrceslmiuutr,s/a�conds:or dcars�al degr�rs: �y ���maox
[�fwei36dd,oaelsc'IongissotLeiwt) C�
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st�oEc�;s� w�u caa� nm.
61s(arerthcw�3l(sj: ��trmaaeat pr I7Temµoraiy�
�3' �8�+� �++sf rm. � herebr art�� thm tAe well(sJ wac (aerre} mnsrructrd "ue aocordence
.aitlr ISA NC4C 02C.OI00 or ISiL XCAC OlG AS00 We(f CcnshsrcJtoit SYax�r�s tmd lhdf a
7. Is 3tus zrepair to an a�isbing,wetE OYes or C3i�f6 aopycfdttrRaxdhar baurgravlded ro ilce �rrllonuo:
Jjrhis B a repe7r, fi!! or�rbrow�r wd( torttmmea�e ir far»ahon wad.�rrin t1u npaar ojthe -
repav Lnder 82l reraarla secrion or on,tHa 6act. of th�s�arm_ ?3_ $itt dUtgrJttlOi' addl�ioual wC1i dGEuls: ,
Yau may use the bact: of tftis p�e to pmvide. addi�onaE wdJ. site ddails or wi�fl
B.: l�iumbri of iveils construcied= � canstrucDarc details. Yon may alio.attactt addifional pagcs if necessaty.
For vn�f�iple ir.fection or rron-water sa�fy xells ONLY wifh riie Jwrte eoruprtqYoa, yor� azn
s+divrilanejomr. SUSLti�I3'�ALIIVSTUCf1014S
9. TotalRdldept& balawlandsadace: ��'� (ft) 7�ta Far All 1�Ve11� Submif this-fotm witiun 3Q days of. eompleiion df weil
,FormnlfiplewelLtfistalldept/Lttfd'�ferPiu(ei�ple-3Q200•cr,a1(�too7 conscuctidnta�cfottow;ng.
I0. Static water ieve[ bdo�r top of casiag: Z-� ({�� Divisigu oER`�Eer QuaEly, laformafzon Protessiag Uoiy
Ijroterle.eCir cbove msl.rg, cme '+- I6I7 Ms►1 Serv.iee Ca�te , Italeigl�, I�C 27b99-I6S7
11. Sorelwl� diuntter_ 8��'y (in.) 24� Fo rr Taiectioa=N�dlr_ En additioa to sending tho fortn ta the address in 24a
�} f� -) abovG aiio suhuriE � togy � chis for� within.30 days cf comptdion of well
1L Well coas�rucHen.meEhud: 7Y )� f\ O T/'�i ��i e�udiontothefol3owici�
c�.G �a«.�, �br�, a;�i��.�) T
D'n3sivu o[W�tv Quaiilp,. Uadergroand. fnf ectiao Coalml Ptoeram,
FUY2 WATER SUPPLY VYEGTS ONL'it- 153b iHa�7.5trvice Cc¢ter, Raleie4.1�1C 27699-i 63&
I3�. YicEd (gpm) D Mcthod af t� Bb�zO minube 24c For iVster.Suuulv &-�rsicctioa �Vdf� Jn addilioaLo settding the foan m
iho address(as) abavt; alsn submit oac aopy oC this foi�rit wiihin 30 days of
13klAse%c4on typc HTH Ame�t '��� CrUEJ coropiGion of wcli cotubu�tioa to ihc county hcatth dcp.utincnt arf thc oounry
where constricctied.
Fam CsKI-] Nactfa C.aroliaiDcpu�estaf Eavitanmeat and PIalmal Rurnmxc — Div¢im of Wa1a Qiuliry R.evised.Tao. 7A l3
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Tax Map�`� Parcel # 2��
Subdiv�sion
PhaselSection/Lot #
# of Bedrooms
Operation Permit �
System Type (From Table Va):
Type V& VI Expiration Date: _�,/�
C`�`—
Product (IIIg): c �� "� �Pr�"
Type V& VI Renewal Date: h
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. ..
�„� � Yv'2�
uthorized Agent) �
�� �� S
(Licensed Contractor)
Scale �'^-e
PCHD, rev. 12/14/12
_5-1
(Date)
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(Date)
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Tax Map:,�'1 � Parcel #: �
Se tic Tank � C �`a`� �'�
p System Checklist (Type II-I� System Type: ��
Notes:
Pump System Checklist
Contracted Certified Operator (Type IV Syste�s):
Notes:
North Carolina State Laboratory Public Health
Environmental Sciences
Niicrobiology
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: ES032216-0057001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
MIKE DUNEVANT
980 JOHN ALLEN RD
Collected: 03/21 /2016 12:30
Received: 03/22/2016 08:27
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slah.ncaublichealth.com
Phone: 919-733-7308
Fau: 919-715-8611
J Smith
Bonnie Forbes
Well Permit Number:
A29 - 287
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Darneice Owens 03/23/2016
E. coli, Colilert
Report Date: 03/23/2016
Absent
Explanations of Coliform Analysis:
Darneice Owens 03/23/2016
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 3012 D�stnct Drve
Environmental Sciences Raleigh, NC 27611-8047
htta://slah. ncoublicheaith. com
Inorganic Chemistry Fh�ocne: 919 �; �7608
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
MIKE DUNEVANT
980 JOHN ALLEN RD
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES032216-0034001 Date Collected: 03/21/16 Time Collected: 12:30 PM
Date Received: 03/22/16 Collected By: J Smith
Sample Type: Raw Sampling Point: Well head Well Permit #: A29 - 287
Sample Source: New Well Temp. at Receipt: 0.5 GPS #:
Sample Description:
Comment
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 29 mg/L
Chloride 6.30 250
Chromium < 0.01 _ 0.1(
Iron
< 0.20
< 0.10
<
4.00
0.30
Manganese < 0 03 0.05 mg/L
Mercury < 0 0005 0.002 mg/L
Nitrate 2.10 _ 10.00 mg/L
Selenium
Silver
Sodium
Sulfate
Total Alkalinity
Total Hardness
Zinc
Report Date:04/06/2016
< 0.1 1.00 mg/L Fcnl
7.6
< 0.00�
< 0.05
11.00
5.10
90
110
< 0.05
Page 1 of 2
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Reported By: Deddie .�tonco!'