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A29 289Application Date: %— I � —1 �} Amount Paid: 0200 .OD Receipt #: � g (0 ��°�"`� �� d �0• � c��' ll� � Il�oco I�,[mprovement Permit (Site Evaluation) � � $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 ('J— ' ��, f I�1�I�.��T ��p��.7f�p�7� If�.rzav-nn-KD4T.II.hAaB.8T9:.t0..lt II 1L1i..91..11.�2T. Services Tax Map: �.% q Parcel#: —�,�6� �� ( ft' d` ' ' for Services ;equested ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Informat'on�� Q Name: Address: O x � 2) Name and address of current owner (if different than applicant): Name: �i✓'/� �.�%✓�'li/��iYi: �9. �-� Address: ' l �/ � , - 3) Property Description: Lot Size: �i ��vision: Ad ress and/or directions to roP'� e: , � ,. , _ _ , , P rh' . , �. � Phone e): '' �f ��- (wor cell): — � C �.l 1 Phone: �p µe� OrJ S i � Lot #: ❑� �=no Doe"s the site contain any jurisd�ctional wetlands? �yes ❑ no Does the site contain any existing wastewater systems? ❑ yes �-`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 �o 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: ❑Residential ew 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 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 properiy? ❑ yes O no 6) I, f�pplying for `Authorization to Construct', ptease indicate preferred system type(s): ��onventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the 'nformation provided above is complete and correct. I also understand that if the information provided is inaccurate, o' the site is bsequently altered, or the intended use changes, all permits and approvals shall be invalid. , ig re wn r egal Representative*) Date * upporting ocumentation 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) ��.s� ��.�� ][�s��au-��„-,�,. ��Il IE—��.Il�I�. Applicant: WA`� Address/Location: Improvement Permit Permit Valid for: Five Years i� Non-expiring Type of Facility: Ste�o� t-Ar.��t 1?�s►Oe�-� New � Addition _ Number of: Bedrooms �/ Occupants�"�' Employees / Seats: Proposed Wastewater System: i�crs,� w a'S7c � Proposed Repair: �c�p;Ep w da� �10 Permit Conditions: � � Tax Map: �_ Parcel• Subdivision Phase/Section/Lot # Water Supply: �►v�tr W��•�- Projected Daily Flow: 3b0 gallons/day Type: � C� Type: S� G �v —1�1 q Authorized State Agent: '�EQRtc��. 1� _ Date: �{y (X) Owner or Legal Representative: �� Date: �. ZR .� The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicant/property owner to insure that all Person County Ptanning 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 Carotina `Laws a�rd Rules for Sewa�e Treatment and Disposa[ 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: Acc,E�f] w) aS `�c � (*)Type �� Design Flow 3b'd gal./day New j� Repair _ Expansion _ Soil LTAR: �5 gal./day/ftZ Type of Facility: 3--'C�R �1SF. Basement: _ Yes _ No (*) System Types IIIb, Illbg, IV, and v, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank IL1��1 gal. Pump Tank � gal. Grease Trap ~ gal. Drainfield: Total Area 10$Q sq. ft. Total Length 3�00 ft. Max. Trench Depth �_ in. Trench Width 3 ft. Min.Soil Cover td in. Min.Trench Separation 9 ft. Distribution: Distribution Box� / Serial Distribution� / Pressure Manifold Specifications: Authorized State Agent: DE�c�1.. A. 51'�t� Issue Date: Permit Exp The system permitted is: Conventional /Accepted X/ Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: ='� �� i�„ _ Date: -L •/ � Person County Environmental Health, 32S S Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12) / w! � �. � �`' aG � LC � `' � ^ � _ �, �� : . E� n ia �t,,,". w Zib ��°p 9 � ` � � �' m N n �' �-�+ �� . �� O �� h � N' � � �•b 6 Z � � `y �.a _-----_ � �� a �. � j . - o Q �+ j/� � p, rJ o q . � • � p � � � � y � � a � � f� � 5 � � ro �� p�� p � �� . ,b � � � � y �� , n. " I�" � ,� � ♦ ♦ � � \ n � � � � �. � � � � a� 5 a � PROPOSED DRAINFIELD a� �� i� Ai iJ�flax Ta MF1�Y. lFi�i417Na�► �lF �"i�i'•�7C, PROPOSED DWELLING ��o W E�l. �A PROPOSED ACCESSORY BUILDING D. B. P. C. 713, 15, P. P. � 784 7Q3 S`is�t� 3K 3b0 6�D ; 3-�� o.�,s �.-�� -�c 3��" �,.>E Y�.�� t'. �k. -2�`�� `�'°��'D�tSI+�.� �t, oc� i�A� �r>►s�v.. �� w�T ��. W�. � � o� � �w�, �. s��. c�►a•Po.�E,�s • :7. 35 S88' 10' 31" W _. --- 11' 40" W ___._.._... __ SG��. : �`� = 1�4 F��r 385. 00 D. B. 569, P. 154 1 �" P-- — NF'41� Tax Map: �l� Subdivision: ��,sf ��.�� - � � � �� I��au-��.��d�,Il IE3I��.11�7� WELL PERMIT (New� Repair_) Parcel: �_a�g 9 Lot: Applicant's Name: �nlAlft,E 'QoSS Mailing Address: o x 91�j � c a� � Phone Numbers: 33 - SOy- a91 33�0- Sry`1- 80pa- Location of Property: Permit Conditions: � -t�alt�.1 �i�'�fL h��,t"c 1� 1.) See attached site plan for proposed tivell 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: ��P wev. lco �`'C �(�+ S�c.. CAri'�+�c� 5��4 '1��i ��. �s�. Permit issued by: �4WG�, i�. �►S�C� (�Tew Well: Location: Grouting: Well Log: �{��Well Tag: �Pump Tag: Air Vent: Hose Bib: Casing Height Concrete Slab: EHS/Date SS -'Z�'l'� � Date: 8 9 ►`i Certificate of Completion Ol,iner: EHS/Date Well Driller: 2 Pump Installer: Approved by: w-t.� Additional Comments: Depth: Grout: QAbandonment: Date: Method/Materials: License #: License #: Date: `-� �( Date Sample Collected: �4 ��— � 5 Date Results Mailed: EHS: Person County Environmental Health 325 5. Morgan St.,Suite C Roxboro, NC 27573 Phone:336-597-1790 Fax:336-597-7808 11/26/13 WELL CONSTRUCTION RECORD 'Rus form an be isod fa siasle or multipte wclls �1. WdI ntractor Intormalloo: d !� OlJ i`[� � �,� L,L / �- WcU Confnctor Namc �� NC Well Coatractor Catificatian Number Barnette Weil Drilling, inc. Cou�aay Name 2. Well Constmctioa Pcrmit #: J7' 2/ LisJ a!/ appliarb/c wd( consvvuron pertniu (i.e. Cormty, SlntG �'oriancw uc� 3. Wdl Use (check wdl use): ❑Agriailhual ❑MunicipaVPublic• ❑Geothamal (HeatinglCooling Supply) ORcsidential WatuSupply(single) ❑IndushiaUCommcrcial O.Residential WatrrSupply(shaced) Wdl: OAquifer Recharge OGcoundwattr Remediation �Aquifer Storage and Recovag ❑Salinity Barriu OAquifa-Test �Stormwater-Lhaimrge �F�crimental Technology �Subsidence CoNiol �Geotheima! (Closed L.00p) OTracer �Geothexmal (HeakingJCooling tietum) OOther (explain under �2I Remazics) 4. Date R'ell(s) Comptcted: Z-�/1�'dl IDN �� Sa Wctl Location: � A �//U2 � c�SS . . Faw�� F�a�eyms ��t�� S� «�H � � i�%Q. s`f'niuF' --S'/'l.s '� � Physieal Address. CitY. and ZiP �'e�5 ��v , � c`�D.� Counry Parncl Idcntificatiarxo. (Plt� Sh taatudc aud Lone c�a«n a��rm;oucarsrcona� o� a�amat ae�«: (fwcll ficld, one latlloag is safficimt) -� - Z-v --Cv z N 7�1 — G 3— Z 7 w Fa to� uu orir.v: 22. Cvrifica6on: � .� /� �=a� � .1N..� . ' � v / Si�Oan�reofCettified Well'ContratWr� Dau: 6Is(are)thcwtll(sj: [��rmanent. or �Temporary BY rtSr+f� ihis jorm. ! lxreby cur� tlmrt Ihe meU(s) was (wereJ cvnstruded in acco� ��/ wiilr !3X NGIC OZC.OIOO.w ISA NCAC 02C .0200 {Yell Cons[ruction Standtrrdr aad tha! a 7. is this a repair to an uis6ng:wdl: OYes or [9iYo copyojthu ireadha* be�+pmvtded ra rhe well o,.ner. !jtl+it is a npat ,/'rll out brown wel! constrruvion iRfamatiar avrd eiplcin rhe natioe ofrhe repairuRder �'21 rrmarl� sectian w ore rhe baui ojsJrJsfom� 23. Sibe diagr9m or additional weU dettils: ��f You m�y asc die back nf this p�e to ptrivide: additiona� we[l. site ddaits or wetl &:lYumbv of weUs constructed: �-+� construcfion ddails. You may atso.attach additioeial paDes if ner.c,ssaty. For rrsultiple injection ar ieon-iraru ny�p[y wells ONLYwi�h the same eortsdue6oa, you cnn svbmitoneform. 5UBltilfl'fAI,INSfUGTIONS 9. Tota1 weil deplfi below I�nd sadaee: �� (ft) �a- For Ali Wdl� Submit Wis focm within 30 days of mmpldion of tivell Formul�iptewe!laGstal[deprhrld8rrem(umnyle-3@Z00•�z�tao� o�swaiontathcfotlowieg: � I0. Static Water level6dow top oiasiog: � S �[r;� Divisioa of Water Qualily, Infurmation Processin�g Unit, Jrx�a[er level is abare auin& rese '+ � • 161711'[sil SerYia Center, Italeigh, NC 27699-1617 11. Borehote diameter. � (in.) � 246. For Ioiectioa Wet[s: In addition to sending the form to the addr�s in 24a [f/ above, aLw iu6nrit g copy of thYs form withirt. 30 days of aompietioa of well 1ZWellrnnshvction.method: /Z� � �C�'t'ARS� rn�[uctiontoi6efollowing r�a e�b'� :+�a�Y. cable, dicect pash, etc,) Divisiod of W�tv Qoalily, Undeigcoand Injcelion Controt Ptognm, FOB WATER SUPPLY R'ELIS ONLY- 1636 Aiail Servicc Center, Raki�6, NC 27699-1636 13a. Yidd (gpm) � 113ethod of tat B�own20 mi�ute 24e Far �Yater SuablV & Tniatioq 1Vellr. In addition to sending the form to the addicss(es) stiovq elso submiC one copy of this form �ridsin 30 days of 136. Disinfection type: HTH ��o�t '�%2 CUp completion of wdl coiuWction to Ehe eounty hcatth dcpaztmrnt of th� coucdy wt�e co�istrifcted. Fum G1Y-I North Carolimi Depumrcat of Fmuonarnt aod Natiaal Resomces— Divisiou of Wa� Qaaliry Revised Jan. 2013 _� ��, sf ��.� �� r � � �� '.' �n.�na-o�n.�act��a.��.Il ��.��Jia Applioant: W a o s Location: , _ Operation Permit System Type (From Table Va): r Type V& VI Expiration Date: a z�q Tax Map � Parcel # � Subdivision Phase/Section/Lot # # of Bedrooms _�✓�lC Product (IITg): � �� Type V& VI Renewal Date: �g_ 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. f'� � '''�/ (Authorized Agent) � C��a�4 � �a�,-t�� (Licensed Contractor) Scale b"� PCFID, rev. 12/14/12 � Z'��15 (Date) `�'Z �( -1 5 (Date) ��o `� ��c, , . C��K� ��.q� �r�'�� O Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� Notes: System Type: c� �Z Pump System Checktist Pum Tank InitiaUDate State ID & Date: Ca acity: Riser (6" min.) NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on �ost Above grade {12") Conduit sealed Pressure Mani%ld Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes• � North Carolina State Laboratory Public Health Environmental Sciences Y�li icrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 Name of System: WAYNE ROSS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slah. ncau blicheaith. com Phone: 919-733-7308 Fax: 919-715-8611 FIELDSTONE FARM RD ROXBORO, NC 27574 StarLiMS Sample ID: ES060915-0039001 Collected: 06/08/2015 13:35 A Sarver (IIII'IIIIIIIIIIII�II�IIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIII'III�IIII�IIIIIIIIIIIIIIIIII�II Received: 06/09/2015 08:05 Angela Heybroek ES Microbiology ID: Sample Source: New Well Well Permit Number. GPS Number: Sampling Point: Well head .A�93 /j oZq�� Sample Description: Comment: Environmental Microbiology - Colilert Profle Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Susan Beasley 06/10/2015 E. coli, Colilert Absent Susan Beasley 06/10/2015 Report Date: 06/10/2015 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. North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: WAYNE ROSS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sl�h. nc�ubl ichealth. com Phone: 919-733-7308 Fax: 919-715-8611 FIELDSTONE FARM RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES060915-0022001 Date Collected: 06/08/15 Time Collected: 1:35 PM � Date Received: 06/09/15 Collected By: A Sarver Sample Type: Raw Sampling Point: Well head Well Permit #: ;�J! G Sample Source: New Well Temp. at Receipt: 6.5 GPS #: �-a `� '�8 1 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 37 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 1.40 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 9 mg/L Manganese 0.07 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 1.60 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 8.1 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 17.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 150 mg/L Total Hardness 130 mg/L Zinc < 0.05 5.00 mg/L Report Date: 06/16/2015 Page 1 of 1 Reported By: Arnold Holl !) ` r� � � ' , J \ � . < <t� � \ �I � � � �-� � � �..� I I-1 �- :� I � I � Suilding Additions/ Mobile Home Replacements Tax Map #: O�� Parcel#: Address: J�OGo �,��,u � � � 1��,-�, ? Approval Requested for: Mobile Home Replacement � Building Addition . Applicant Name: -�� W�u,�,_P l�o s S Address: ? IQo,cb� ,t� s?3 Phon�#'s: �,�'ig-Srooz 5�`I-yZ9� Permit Located: %� Yes No Installation Date: -a�1-l.� Design flow: 3(� o (gpd) Current Contract with Certified Operaior on file (if required): k�c� Water Supply: _� Well Public or Community Wastewater system shows no visual evidence of failure on: (date) (Applicant's signature if site visit is not required) Comments: 1(��►'S5� a � i o�-�io� Stit��✓� r� v1 Sr'% ,i�� • Addition/Replacemea�t Appr6ved ,.,,, � �Y�e,/ . E ironmental Health Specialist 2 �� Date a,�- Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.oersoncounty.net ��. �f ��.�' �.� _ �— C��tLT1�T�� IE�.�.a-��.��.Il IE33L ��.Il�Ih� Applicant: Location: S Operation Per�it System Type (From Table Va): _ �.. Type V& VI Expiration Date: ot z�q Tax Map � Par�el # �j , Subdivision PhaselSection/Lot # # of Bedrooms �✓�lC -T Product (IITg): � �� Type V& VI Renewal Date: �_ 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. N� � (Authorized Agent) � C��o�2 � t��. (Licensed Contractor) � f � 3cale �"� /p PCFiD, rev. 1 /14/12 ( l�� ,qo ZZ' .g-, 2�i �� ` �Sc5 L l7 � �/l� /d� �� /��/� r''" � Z �f�15 ma�� `�'Z �(-l5 (Date> C. t2�K� • � 11�9.� ��'r�� J Appl'eea:ioa L'�te: (r�`�� ( Amount Paid: � Receipt #: ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) obile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��?,) f �1l.e�d� �� IE��ns��.Il ]HI��.Il�]]� ►lication for Services Services Re uested ❑ Construction Authorization (Fee is denendent on the type of Tax n'Iap: �� Parcel#: � ❑ Permit Revision $75.00 � Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 �.- 1) Applicant Infor�'o A�� /%„ « / Name: !/�' 1� � Address: O s� a� ., 2) Name and address of current owner (if different than applicant): Name: Address: ✓ 3) Property Description: Lot Size: Subdlvision: Address and/or directions to Property: �0 Phone (home): � pDZ (work/cell): � � � Phone: #: ❑ yes o Does the site contain any jurisdictional wetlands? �es ❑ no Does the site contain any existing wastewater systems? yes �o 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: (/�;'�n �Residential � � ��C] New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? O yes ❑ no With plumbing fixtures? ❑ yes ❑ no on-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well �xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: ,� C� 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative � Alternative 0 Other ❑ Any I certify that the inaccurate, th� � � �nation provided above is complete and correct. I also understand that if the information provided is subsequer,�fly altered, or the intended use changes, all permits and approvals shall be invalid. Representative*) documentation required. �� 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. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) 7I1b11y C,�►'�*��J s� ��ae�\ �� D�.�.�.-vo A�h�.� c} �c�s� � l,�c,,�ECCJ 'i3`� S'Js4�c.'`{ �o1L �► � RlfFt �.�E.�� C�iS 4�.�C �iT� .•�� 2a � �.Pl��- �- C �' �,' ' �� l�