A29 288� �ZSd �a� w��l
��s � ���aR�
i' � Q
Application Date: -( 2� -1S
Amount Paid: � Ztb� o�
Receipt #: �Z2KsS
3���6 aPP��c� �we���, �we1l�
i'0 �.l�i � z �Gr'�`
`.-.����3 f�Jl.���'iJr�. V Taz Map: �2� � F
�5
Parcel#: �_
�OQ,Oo � �—.t ^ �C � �CT�T�C�Y
! `o'� 3 q IF anviin�onnu:ra�r.�cn�du.11 _IH[�-.�IL�7�
........ .....
e�:�=
Aaalication for Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Services Re uested
Construction Authorization
Fee is de endent on the e of s stem ermitted
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor ation: i
Name: ' �`�
Address: i
o`�
2) Name and addr s� curre o� er (if different than applicant):
Name: �� � �f �A
Address: r�
Phone (home): ���D� � o�lo�,c7
(work/cell): �� � 1 �3- alo� c'�
Phone:
3) Property Description: Lot Size:A���. 7(3cre�ubdivision: N o Lot #:
Address and or directions to Property: I�I C-'-I�q Sou�li. ri a �� n_
�--- 1 , _,_, , _-, _ _� __ _,_, T
❑ yes ;0'no �Does tHe'site contain any jlxfisdictional wetlands'! �
❑ yes � no Does the site contain any existing wastewater systems?
❑ yes ,,0'no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �"no Is the site subject to approval by any other public agency?
❑ yes �'no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure;
�tesidential i1
New Single Family Residence Maximum number of bedrooms: y�Qr y
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building: _
Maximum number of seats: -
5) Water Supply: �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 ❑ Any
1 certify 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.
�ature (Owner/ Legal Represer
upporting documentation required.
Permits are valid for either 60 months or are non-ezpiring 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)
��, ; ,�� ���� ��
�, � � ����
?Cs �-yn �- � �:����.�.11 IF-7I � �.11�l�
Applicant; �Q Sd� � d-�)a✓�
A.1.J...�..../i ......�:..... _
Permit Valid for• Five Y
Type of Facility: . 12
Number of: Bedrooms l.�'
Proposed Wastewater ys
Proposed Repair:
Improvement Permit
� Non-expiring
S New ]�—Addition _
)ccunants / Emolovees / Seats:
Taz Map: � Parcel• 2g�
Subdivision
Phase/Section/Lot #
VVater Supply: w'Q1 �
Projected Daily Flow: � gaIl s/day
Type: � _
Type: �
Permit Conditions: S-Q2 ��� �ZQ ►�
Authorized State Agent: �'+-� �c �-� Date:
(X) Owner or Legal Rep sentative: ,� _��ppy.� � 1 Date:
The issuance of this permit by the Health Depard�ent does not guarantee the issuance of other required permits. It is the responsibility of
the applicandpr�perty 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 compliaace with the provisions of the North Carolina `Luws
�r�rd Rules for SefvaF� Treatment and Disnnsa! Svstems'(15A NCAC l8A .19U0). Neither Person County nor the Environmental
Health Specialist svnrrants that �he septic system will continue to fanciion satisfactorily in the future, or #hat t�e water supply witl
remair noiable.
Authorization to Construct Wast��vater �ystem
See site plan and additional attachments (_).
A
Proposed Wastewater System: — �' , (*)Type�� Design Flow �� _ ga(./day
New � Repair _ Expansion _ (, Soil LTf�R: >�l S gal./day/ft2
Type of Facilit-,�: `t�� f�S� Basement: _ Yes _No
('�) System Types Illb, Illbg, IY, and V, re�uire perioJic system inspections by thz Person County Health Department.
Wasiewater System Requirements
Tank Size: Szptic Tank ���� gal
Urainfield: Total Area 32.a sq. ft.
Trench Width 3 ft.
Pump Tank � gal
'fotal Length `f 4a ft.
iVlin.Soil Cover � in.
Grease Trap '— gal.
Max. Trench Depth 2o in.
Min:Trench Separation � ft.
Distribution: Distribution Box / Serial Distrinution �/ Pressure Manifoid
Specifications: _ S � _ � ��✓1
,�uthoriz:,d State t�gent: " � Issue Date: l (— �O �L `�
Permit Expiration Date: r �—((�-Zv
1'he system permitted is: Conventional /Accepted V� / A ternative / Innovative . I accept the co�iditions
and specifications of this permit.
{X) Owner or Legal Representative: Date: 3(•
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
��,�.s� 1�I�I�..���T
������
]Eaav.'asoaa�-^�oa��mIl' ]E31Cmm�Il�71a
SITE PLAN
Name ►"� �/` i�^+R'�� Tax Map# �` Parcel# `� ��
Subdi i Section/Lot#
Authorized Stat gent `� Date '�
System components represent approximaee conlours only. The contrar.tor must flag the system prior to beginning (he
installation to insure that proper grade ts rnaintained.
Note: An Accepted system may be used in place oja conventiona! system withou! permit autharization or modification.
�v —� cp cp oo w v u�
in in i,n oo i�+ bo i�+ iv = D
000a000.Prn�c.+
�
r
�
Z ZZ �,�
Z� �i � � !� yy �
�N���,;ytn� Z
�cfl�000NW�s G7
� m
v cND �I �� IV OWO W
SCc�` 1 ''- � 0� �
-....�, , _ ,__... _
�_.<; r.,�-
M� � `�9 �g 1,1. �S /
3��d NHor)
�a� N
--- � � 41 �� oro /
---------- 1 :
���-1 �� 5r°� -
1tl�a�, sT
(�c.� ' Qcc��d�-� o�'a�� 11 �
v
2��r ��� ����
£� ',7
1l�'D �R ? � ✓�u s�- �
� �
� n�--l-e,� b-e-c��, �T a►�
'�,`.i�-- a � VC►"'` � �^ '��'Q "�'C •
�����
C %%2r ci�
r-
� �-�-e� �� � (, �Q s � s �+. o ��
c�rQ � � �
rr � N M
7 ���s-��Ks �. c (
�-,��N �-eo,,��-� ��7�('720 .
�d
l�o' �'�� �,,,:
1
1
O
�
� � n
0o m
w cn � �
. .� .
�
,.
��,R�"
C�
�
r
:
�
a
� �
Z I'*1
��� m
m
Z�vv
��
���m
w�� �
.� _
� O
v �
O
Z
Tax Map:��
Subdivision:
���.Sf ���$.���T
- c� � ����
��ra�vn�r��auaa¢3�rn.��.Il g 3C��.Il�11�
Parcel: Z�
WE�.,L PERMIT
(New '� Repair_ )
l' -�/_ '
Applicant's Name: �Qsav, �?�►�
Mailing Address:
Phone Numbers:
Location of
r� . q
Lot:
ll-� ,�Q. � (v-�
Permit Conditio�s:
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:
�Tew Well:
HS/Dat�`r
Location: �r
Grouting: ��(�
Well Log:
Well Tag:
Pump Tag:
Air Vent: _�1�.-((Q
Hose Bib:
Casing Height:
Concrete Slab:
Date: � �^ �'�S
Certificate of Completion
OL,iner:
EHS/Date
Depth:
Grout:
DAbaudonmeut:
Date: _
Method/Materials:
Well Driller: C�,� ��i,i(q � License #:
Purnp Installer: � License #:
Approved by: Date: —
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
♦� L+-ii-/ \..V1�1,711�V�\„11V1� 11L� <,V�11
'ttiis form can be uud for singie w multiple wells
1. �?Y�II Contractor Infomutlun:
Dennis Cummings
w�u co�wrx�o '
2537A
NC Well Cono�actor Cutification Number
Cummings Developments, Inc.
Company Neme
2. Wdl Cunatraction Permit #: TA�X n�,4P �9-�9 f"L�Q[ r a$'�
IasraA�l,ca6le wellpcnniu �.e. Cao�ry. SYatr, 6artmue.I�jection, e:c.l
3. Well Use (check well use):
OAgriculUual
❑Geothermal (Heating/Cooling SuPP1Y)
OIndusbriaUCammercial
❑TrriRation
ivon-Water Sopply Well:
❑Aquifer Rccharge
�AquiYer Storage and Recovery
❑Aquifa Test
�Experimcntal Tcchnology
❑Gcothcrmai (Closed Loop)
OM ipal/Publio
csidcntial Water Supply (single)
OResidential Water Suppty (shared)
OGroundwater Remedia[ion
❑Saliniry Bazrier
OStormwater Drainage
DSubsidence Convol
OTracer
OOtha (exnlain uttder #21
a. vac� w�u�s� compi�r�a: " �� w�u iv�
Sa. R'eU Loatioa:
✓1 S'}G ! -�'
FacilitylOw�xr Name Facility IDt! (ifapplicable)
.�akn F�-Ileri �! �e,cbn� a7S� 3
Physical Address, City, nnd Zip
�C�''SOYI
CouMy Parccl Idcrnification No. (P1N)
Sb. Iatitude and Lot�itnde ia deg�eea/minutes/seconda or decimal degrees:
(ifwell IIel� one ladlong is suffict'�ent) r
3G°Zo• a 2G N 79°d `�:35� _ W
6. Is (are) the weU(s): 03rermanent or ❑Temparary
7. Is this a repair tu an ezfatin� weU: �Yes or �o
Ij�his is u repair, ftll mt1 known we!! conrlruclion iryformation an4 ezplain the n[uure ajJhe
repair under tF3l remarkt aection o� on lhe back oJ[hiaJornr.
8. Number of wells constracted: One
For maltiple injicrion or non-watsr supplv w�lls ONLY with the soms construcdon, you ton
submit oru jorm.
9. •7'otal �dl �epi� 6ilwv lstbtl sul�fs¢et �Q � ([t.)
For mulh'p!e weps lirt a!l depth.t �jd(�'erent (uampfe- 3Q100' and IQI00')
lU. Static water level below top of casing: "`�-� (f�)
ljwakr leve! u abose cosing, use •'+'•
11. Borehole dfameter: 6 (in,)
1�; WFu cuaaa��aa mcchQd: Rotary
(i.e. suga, rotary, cable. dircct push, etc.)
For Imcmal Uso ONLY:
wi�h !SA NCAC OIC .OII10 or !SA NCAC 01C , 0200 WcA ConNrucuon Srandardt and that o
copy ojthis record haa bten yrovided �o the well owner.
23. Siu dlagram or additlanal well details:
You may use the back of this page W provide additional wcll site details or well
construction details. You may also attach additionsl pages ifnxessary.
SUBMTTTAL iNSTUCTTONS
2Au. For All 11A"ells: Submit this form u+ithin 30 da3�s �f compl¢don af w¢II
consWction to the following:
Division of Water Resources, InforcaaHon Proceuing Ua1t,
1617 Mail Scrvice Center, Raleigh, NC 27699-1617
24b. For �njection Wells ONLY: In addition to sending the fam to the addcess itt
24a above, also submit a capy of this form within 30 days of compl�tion of vuall
gons�ry�Eion �Q 4hg folloyying;
� Division ofVV�ter Resources, Underground Iajtcdon Control Pro�m,
FOR R'ATER SUPPLV WELLS ONLY: 1636 Mail Service Center, Raleigty NC 27699-1636
13a. Yidd (gpm) Method of test: Air Rotary 24c. For Water Sapply & InjeeNon Wells:
Also submit one copy of this fonn within 30 days of complotion of
13h Dtsinfectioa type: HTH Amoant: ��%Z • we�l constr�ction co the counry health depattment of the counry where
constructed.
Fom� GW.I Noeth Carolina Dcpartmcnt of'Firvironmcnt azd Natural Resotaccs - Division uf' Water Rcsotuccs Rovised August 2013
���.ss ���.� ��
�� � � ����
I��n.da���„-„-„ ��n��n.Il IL���.]L�I�n.
Applicant:
Location:
��i��'dtl�ii �i�l'Iili�
Tax Map �� Parcel # 288
Subdivision _i�
Phase/Section/Lot #
# of Bedrooms �{
�
System Type (From Table Va): Product (IIIg): P�ia��us�r (Ck�,.1,i„/)
Type V& VI Expiration Date: ^j Type V& VI Renewal Date: �_
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Seevage Treatment and I2ispasal, and all conditions of the Improver�ent Peimit and Coustru�tioa
Au�horizat:on.
. -
( thorized Agent)
.
�r �
(Licens Co actor)
'
y g�
H���
��- ^l _
�cale �
PCHD, iev. 1�./1�"r/12
. - • R—I�1-14
(Date)
9 - (�t —Ile
(Date)
�
� �� i (b� _ �
\
�u� ����
���
�
Tax Map: �GL Parcel #: 28g
Septic Tank System Checklist (Type II-I� System Type: �
Notes•
Pump System Checklist
�um T3nk Initi�L�Date
Sta I� & Date:
Ca acity.
Riser (6" m
NEMA 4X Box
1�1ode1:
Piggy �ack plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
1�.Tumb�r of taps:
Size an� sch:
Contracted Certified Operator (Type IV Systems):
Notes:
�� . � � i .. „, .... t, .' , ' _� • ' ^ } .� ... . } - ' � e - ' '
� :r �t,` !iT L' a -'�`� LY'^`,-{, .� 'i .r :�� d` �ss>. i� `Y �
re...� � �.-x,'! �j :�M ] ;1: :f Y � � � �
.j� �� ' � :�`F e.l C .1` ' l, ` . a L.�syf� .-. j ��.d
�� I����� U �r, .
nc departmeat , _ =`� . _ > •;, :-. _ _° _ - . ,r-• -.} ��:� � �.., ,.�
of health and ,s I . •: •,,� l�•_.�; - �3 - _�i ='�; �_ k _.� � -
human sarvicas .. _ . . «t . ._. ,�. ��.,..•' . . . . v. . _ . . . . -, . _ , v.;- � - _ . _ . ..
For lno�g�nic �hemical Gonta�vrinants
County: � I� Name: �A.��ot�1 �� o A.Q-t— I
Sample 1D #: � Z�� Reviewer: _ L
TEST RESULTS AND USE RECOMMENDATIONS
1. j�Your wel i water meets federal drinking water standards for inorganic clremicals, Yaur water can be used for
driuking, cooking, washing, cleaning, bathing, and showering based on the inoreanic chemica! results onlv. You may
have other water sampling results that aze not taken into account in this report.
2. � The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
Ievels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used far
washing, cteaning, bathing and showering baseci on ti�e inor�anic cl:emical resu!!s onlv.
Arsenic
Ma�iEa��
Barium I Cadmium 1 Chramium
NitrateMitrite i Selenium I Silver
Fluoride � Lead � Iron
Ma�nesiurn Zinc �H
3. [� a. Sodiurn levels exceed the U.S. Environmentaf Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/I. The North Caroiina Division of Public Health recommends that on[y individuals on no or lo�v sodium resvicted
diets aot use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on
the inor,�anic �/temical results onlv.
❑ b. Levels over 30 mgll may pose aesthetic problems such as bad taste, odor, staining af porce[ain, etc.
4. ❑ Re-sampling is recommended in months.
S. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and i5 minute sample inside the house (preferably
the kitchen) and if possible a frst draw, 5 minute and a 15 minute sample at the v��ell head to determine the source of the
lead and/or copper.
6. ❑ The fo[fowing substance(s} exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inor�anic chemrca! results only, but aesthetic problems
sucl� as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment s}'stem
to address aesthetic problems.
Barium � Cadmium Chrom�um Fluflride Iron Ma nesium ;
Man�anese Selenium Silver pH Zinc I
For n:ore informatio�r regarding your well water results, please ca!! 1lte ;Yort/t Carolirta Dirision of Public Nealth a1919 �Q =5900.
Norih Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN S7REET
ROXBORO, NC 27573
EIN'566000331EH COURIER #: 02-33•15
StarLiMS Sample ID: ES11291fi-0091001
I 111f111 Ilifll111IIIll lllll lllli Illll Illll Illi Illl{I lllll Illll Illll III
ES Miuobiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
JASON STEWART
1030 JOHN ALLEN RD
ROXBORO, NC 27574
Col I e cted : 11 !28/2016 15:30
Received: 11/29/2016 08:32
Sample Source: Well
5ampling Point: Outside tap
P.O. Box 28047
4312 Distrid Drrve
Raleigh. NC 27671•BOd7
h�o�l! !ph ncvuWicheallh.com
Phone: 919-733-7308
Fax: 919-715.8611
H Kelly
Angela Heybroek
Weli Permit Number
AZS-288
Environmental Microbiology - Colilert Profile
Method: SM 9223B
Test Name: Colilert
Analyte
Test Result Da[e
tt �Jr�'6
Total Coliform, Colilert Absent
�� 31201£
E. coli, Colilert Absent
Report Date: 11I3012016
Reported Sy: 5usan BeasleY
i �
��:.LA.�-Ul�
Explanations of Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purpose. li colitorm bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. colr (bacteria) generally indiqtes that Use water
has been contaminated with fecal material. {t must be remembered that a water analysis refers only to the sarnFMe
received and sF►ould not be regarded as a complete report on the water supply
Report To: H. KELLY
North Carolina 5tate Laboratory oi Public Health
Environmental Sciences
inorganic Chemistry
Certificate oiAnalysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27b73
EIN: 566000331 EH
Name of System:
JASON STEWART
P.O. Gex 2G�7
a372 D�sMd DRre
Raleigh, NC 27Eit-84d?
htto'/lslph nCpubE�Ct+eaStt+.�a*!
Phone: 9t9-733-7306
Fax 91}71SSbtS
1030 JOHN ALIEN RD
Courier �F 02-33-15 ROXSORO, NC 27574
StarLiMS ID: ES112916-0062001 Date Collected: �1/28l16
Date Received: ��129��6
Sample Type: Raw Sampling Point: Outside tap
Sample Source: Well Temp. at Receipt: 1.5
Time Collected: 330 PM
Collected By: H KeI1y
Well Permit #: A29-286
GPS #:
Sample Description:
Comment:
New Well 1 Profile
Analyte Result Allowable Limit Untt Qualifier(s}
Arsenic <0.005. -- -.. ----. 0.010 _ mg2
Barium ` - -- - - - - -- < 0.1 - -- 2.00 _ _ mg� _
Cadmium <0.001 ___ 0.005 _ _ mg/L _. _
Calcium - - -•--��-- ..11 --- -�-- mglL
Chloride ---- . 7'10 --- •.-- 250 - - -. -- r?'i9� -
Chromium � .` 0_a� -• --- 0"10 • - - - - m9�� _ . _
- •--- -- �-- �
Copper ._ ` 0•OS - --- -- � -- 1.3 .- m9� -- - -
Fluoride < 0.20 4.00 . mgn-_
Iton < 0.10 -- -- _ 0.30 --- -- �- �- � -- m9� - -
Lead . _. ------• `0.005 -- -- 4.015 mg�
Magnesium -- --� �- - - - . ---- 3 - �------- - - m9�
Manganese -� ----..--- _- .. . - - -� -: - <0.03 .._ -- 0.05 m9�
Mercurr�--• --�- --- - - -� `0_0005- -- . Q.a42 m9n.
Nitrate ..._ 3.30 ------ �0.00 mg�
Nitrite _-._ � - -- - - - - � -- - < 0.1 _ . -- -- 1.00 .... mg/L . .
pH _ � -- ^ �--- _ - g.9 - - - �- - - �-- � .NIA
Se[enium < 0.005 _ __ _ 0.05 . _ m9�
Silver � _ <0.05 ---- 0.10----. mg/L
Sodium � . ._. t3.00 --- - � - - � -- - - m9� -
Sulfate --- � 5.10 __ . .._ _.. 250 .------- m9�� -- •
-•- --
TotalAlkalinity ___ 40 __ _ mglL
Total Hardness 40 _ — _ -- - � - - m9�
Zinc -- �- ---- • < 0 05 5.00 _ mq/L
Report pate: 12/08/2016
Page 1 of 1
Reported By: D��-���f