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A29 40;. �� Person or firxn doing installation: �'� �� f �j ��t �, Address r,� �a 'Q"}—� No. of persons to be serve� bedrooms 1,�3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine � � M "� ' i Minimum Requirements: Septic tank � . � �/ � Nitrification line: .� �� '1 �� Septic tank and nitrification line must be inspecfed and approved by a member of the Health Deparfinent sfaff before any portion of the installation is covered. Date Approved: �'kr l�-' M � P Sanitarian By; � �.v�v .-, � ' �� O. David Garvin, M.D., M.P.H. District Health Officer Countersigned (Over) NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. f� .�� /`_�� ' � ., Application Date: � V � � `� ( Amount Paid: 3 d 0�(� 0��t Receipt#: �(S9 �{ �a 6 � Tax Map: /� � � Parcel #: LF 0 �---��,� f �� _ _ �`_"� c� � � � � `� �1 � �rn^�n. u .cn ga uzti-a �cy, �rn �..�n. ll ��T <e-, aa. � ti�n Application for Services (Septic Systems and W Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile Home Replacement or Building Addition $ I 50.00 (if site visit re uired) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 � � C�`� � � o �`e� ❑ 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) Services Reqi ted by: Name: � �� Pw Phone # (home): Address: (work/cell): 33G �'DY /%9y << � �� 2) Name and address of curr nt owner (if different than applicant): U�" ` t�7 al 6 w u e►- Name: M a1r � � � Address: }�-o``x�'rd 1Jet�-�'� /�-11 �-- 3) Property Description: Lot Size: Address and/or directions to Property: � Lot #: Does the property have previously identifed jurisdictional wetlands: Yes No 4) Proposed Use and Type of Structure: �� i Residential Business/Type: Oth r �f1i�, � � Number of bedrooms , or Number of people served (seats/employ es): Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No 5) Water Supply: � Private Well �/(Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A compleied application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated. I am su6mitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals sha116ecome invalid. Signature (Owner/Legal Representative): Z, Date :� r�`I �" l 08/11 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � - ) � � �`�, � ��` : �, a d ,/ ' . � � � � `L:� � �L� � Ya � 1.l.�.'.�r1C�t9"Tt1L"<!m?.%i71^.ill<Ca:1Z73.t�..`�'t.�l �9. Jl.cf:::c`1L1L'1{�,1iA, Rs1 �u��aa� �s��a��a�! P✓��fl� �f��a� ��c��n��n�� Tax Map #: ii Z� Parcel#: ��_ Approval ReqLested for: 1VIobile Home Replacement �_/Building Addition Applicant Name: 1�. i G K /�Y��P h Address: I o(, �d c5(.e,(' S 5-Fv rQ �. Phone #'s: 3 3 cp —�0� —( ��q Pernut Located: Yes �/ No Insta.iiation Date: �-_ Design flow: ? (Dpd) Current Contract with Certified Operator on file (if required): Water Supply: " Well Public or Community Wastewater system shows no visual evidence of failure on: �-� 5- ( � (date) (Applicant's signature if site visit is not required) Comments: s�� A��fln�ao��pYa�� o�� q-uo-=�!-- Enviro ental Health Specialist Date 11/15/OS Application Date: � ' � �;� �,,.� Tax Map: � Amount Paid: 0, `�D 9_�q -J � Parcel #: Receipt#: 1�dT G,vO C�'edi'� CQ►� � �o � s �� ._.��, s�- �I�I�..� ��T '('��^� - � �� 1L✓�rn-.vuv-<enixa�*��e:.ica�..mll �IE-�Iue-�,.za.Iltil�n.. Applieation for Services (Septic Systems and Wells) 1) Services Requested by: Name: ��ir/r /��P�� Phone # (home): ,3�j - �- S�6 Z Address: %�U v -Z (work/cell): 33l3 -� U�/ / 7 �x6�� . � - C _ .� �s� � �tsst Q v1 �4� � 2)Name and ddress of current owner (if different than applicant): � [ Name: �/¢e ,�f ��Prr �o�`� U�-`T� � Address: � PLJ (J,e_f a� ov..d N� ��57'� 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: f��'n� �" % f � s Does the properly have previously identified jurisdictional wetlands: Yes No �l_ 4) Proposed Use and Type of Structure: � � �J Residential Business/Type: p� �� d Other ��I�pn /J a �/ ,�� r Number of bedrooms /y!�' , or Number of people served (seats/employees): /�s/�' Basement: Yes No � (with plumbing: Yes No _� Garbage disposal: Yes No �_ 5) Water Supply: Private Well � (Proposed � Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No _ Yes � (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properry is ready to be evaluated. I am submittiag this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): --� Date : 08/11 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� S, f� ��$.� �� ' � � � �� 7CILQ'']L7L'2DIt1L71'IL]L<C��Ita��A.Jl �Q��iL�1�11� T�x M�� P�rcel # � Suibcl!ivision Ph�se Sect�ion Lot # ••� . �Il��a�l'� , . , , r��:� � ►. :�: . . r.�. -�w!��= Permit Valid for Type of Facility: _ # of Occupants _ Proposed Wastew Proposed Repair: Permit Conditions: Owner or Legal Representati Authorized State Agent: � Improvement Permit Expiration New Addition Water Supply �_ Projected Daily Flow �� g.p.d. � Type: Type: / Date: �� Date: � The issuance of this permit by the Health Departxnent in does not guarantee the issuance of other pernuts. It is the responsibility of the applicant/property owner to in sure 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 Permit 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 SewaQe Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental �Iealth Specialist warrants that the septic tank system witl continue to function satisfactorily in the future or that the water suppty will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_J. Proposed�astewater System: d r✓1 �'4V2 Type � Wastewater Flow �g.p.d. New �� Rep�_ F�xransion Soil LTAR: � .p.d./ ft 2 Type of Facility: RrryL (�ui r�l�Q.�s�o �J Basement _ Yes o Wastewater System Requirements Tank Size: Septic Tank: DO o gal Pump Tank: gal Grease Trap: '� gal Drainfield: Total Area: .3Ce 0 sq ft Total Length �2 6 ft Trench Width � f Minimum Soil Cover: �_ in Distri6ution: V Distribution Box (/ Serial Distribution Authorized State Agent: � Permit Expiration te: �) -G�l— Maximum Trench Depth �(„� in Minimum Trench Separation: � ft D• C, : T�" I��, Pressure Manifold Date: �— ZS'�� The type of system permitted is � entional Accepted Alternative. I accept the specifications of the permit. • r�� ! Owner/Legal Representative. � Date: � �9� PCHD rev. 11/10/OS ! . . � -�-��..;,�� `LJ'�.. �1 `" � ' "�'� � � �.J 1V � �L lE�•�y�„�.�,. �,m�.11 IHi��.fl� ,�� . ,.�- � � i '� � � ► � ` � � �- �, � ��/ ��■ -� Y. � �"� Tag Map # Z'f � Pa:tcel #� Section/Lot# �-2�1-�� ' Date System com�ios�ents r+e�iresent a�i�firoaaiimate �contours only: The coniractor must flag the system1brior to . beginning the instaAact�ion to i�srsre that propergrade is nrainttuned � —; J _ - �Z� � ,�I /� ,g�' � �� l / 6 �.N/ � V G� V/ IQ f L `3l�'` �i'e�c�i 1�a�am �oo�� °` 1 ��,sf� ��.� �� `._., � �-- ,{� � � � � � � IE�ra�a- ��.�c�cn��.��.I1 IFZI � �.Il�IL� Operation Permit Applicant: Location: Tax Map �R Parcel # �� Subdivi on Phase/Sectoin/Lot # # of Bedrooms �� wt�n, 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. System T e: (In Accordance with Table Va): �Q Product: �( Initial: � Repair: Expansion: .._----. _ . . . .._ . _. . . _ .. .--�- - --- ---.- _ .....-------_...-- - - -- �, � ,n•�e,�.- - . . . HS/REHSI �� Licensed Conh actor � Kal � %1' u� �4�` S � . . _. . . - -- ---. _.� _. . . . . 1 l r ._ _. Date (a t lr Date V 6,�,, r� �� > ii . _ �,Q ll'/t'� Ze � �r S 5�� 1j1D S�o� �Y r�ik.�g�,�� Y+eS-� � �1 P �� Cc,�— S�-a,�� a� ( . � Scale ��- a� ��2 c� � ;k �. Line Len d� 2 60` Total � lSo � Tax Map: �( Parcel #• y6 Septic Tank System Checklist (Type II-Vn System Type: �°I Se tic Tank InitiaUDate State ID & Date: ��=3-/ -S i/' �� Sfir3 3Z �' Capaciry: �� ✓ Tee and filter Baffle f Vent Riser — Outlet boot ,� Perm. Marker Distribution - --- — - - --.._ - bX - - . . ... �__ e_v_e_s_set----- - .. __----- .... Serial Pressure Manifold LPP Notes• Pump System Cliecklist Pum Tank InitiaUDate State ID & Date: Capacity: Riser (6" min.) NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (if applicable): Notes: Tank Com onents InitiaUDate Pum model: Block (4") Nylon retrieval rope Float tree and attachments On/Off float swing: in. Ala�rn float (6" separation) Anti-siphon hole Check valve Tl�readed union Gate valve Conduit sealed Outlet sealed Approved and secured riser Su ly Line Size and material: in. sch. Length: ft. � ��1y{�� J1�.�l�� `�' � C� � �T�� 1�.��a n- � ��. � �.. �.�.11 .IHC � �.11 ¢]�. � W�+ �L PERMIT (New�Repair� Taz Map: Z Parcel• �d Subdivision: Lot: ApQlicant's Name: 1�G e��" � � Mailing Address: Phone Numbers: Location of % Permit C'onditions: 1} Seg attached site plan for proposed well location. 2) All applicable State and County �egulations governing constructaon and setbacks apply. � 3) Permits expire S years from the date of issue. Other Conditions/Comments: , � . , - ,r P�rmit issued by: New Well Inspection: Location: Grouting: Well Log: Well Tag: Pump Tag: A.ir Vent: Hose Bib: Casing Height: Concrete Slab: I)ate: q- �(� - � � CERTIF�CATE OF COlV�LE'I'IION Well Driller: Pump Installer: i . _ Well Approved by: Date Sample Collected: �2$r' Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC ?7573 Liner �spection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: I)ate: D 7 l % Date Results Mailed: 2' Z.f1 '� Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 t. wELL �ESIDENTIAL wEi.i, coNsrRucriorv �coRn Notth Carolina DepaRment of Enveonment and Nahnal Raourca- Division of Wata Quality WELL CONT[tACTOR CERTIFICATION � � I Z G� �/'°S/ � ( ��S � W aM Can (kbividual) Nam� . E-iurlac�n W� 1 I_ Co. Zi�1C„ ' . W aM Contractor Cariparry Narns �• t' ' STREET ADORESS ,� ��G� , !' � I�c2i14 aT.�i�� S 7'�- �? � ��Y �$1� ��7- 37�$` Area cods- .�hans ntxribar 2. WELL ItJ�ORMATION: . A SRE W �:LL ID s(u STATE W ELL PERMIT�I(If appRcabM) ' DWQ ar OTHER PERMIT �{if app�cabb) WELL USE (Check Applicabb Baotk Residentlal W ater Supply � DATE DRILLED I D'� b"'� O Z � TIME COMPLETEC c3 • d� AM p PM � S. WELL LOCATION: cmr: Rox,�� couNrr�� (SW�t Nartt�. Numbws. CammunUy. Subdivision. Lot No.. ParcN. ZJp Cod�) TOPOGRAPHIC / LAND SETTINfi: ❑ Slops O VaNey ❑ Flat p Ridfls p Otha c�.�+�. �,� �A May be in degra; LATITUDE � _ ��t� � a �oNCRuoe �+' a«�.i �� Ladtude/longitude source: ❑GPS �Topographic map (bcatbn of w�e/must 6a shown on a USGS topo map and etteched to lhis /am i not usi�y GPS) �.11VELL OVYNER // OWNER'S W1ME _�� G �C �!` e/1 STREET ADDRESS - Ci1y or Town Stats rip Cods ,•. �� Area coda • Phone number 5. WELL DETAILs: a. TOTAL CEPTF� ��j b. �OES WELL REPLACE EXISTINd NfELL? YES p NO p c. WATER LEVEI. Below Top d Casi� FT, (Uss •+• q Abas Tap d C�) a. TOP oF cn►sarci �s � � �. n� t,.�,a s�r�• 'Top d casig terrNnated at/ar belaw tand swiaa� may require a variance (n axad�ce wilh t 5/1 NCAC ZC .011 S. �. YtELD (9Pmr 3 METHOD OF TEST Q�/l � 0131l�ECTIOl� p. WATER ZONES (depth� From�_To� n r0l`� v� Amount From To Fram To From To Fram To From To s. c.�su�o:65 Tn;c�,�y From�'LDTo��_ Ft� � �� From To Ft STG, From To Ft 7.OR011T: Depfh Matarial _� From � To �'� FL eT_ From To Ft Fram To F� !. SCREEN: Deplh piametx SIo131x� - M�tarial Fran To Ft, q�, h, � From To Fl in, h. From To FL in, h. 9. SANOIGRAVEL PACK: Depth 5izs Matetial From To FL From To FR From To Ft 10. DRIWN(3 LOG From To o� Kc7 �lc� �-t 5 NS 6 S �S �5 11. REMARKS: Formatioa Oescriptbn oa Ror.LG y S l-.ev�C ��rr.� lrl�,-i •� 100 MEREBY CERTFY iHAT 7MS W ELL WA9 COHSTRUCTED N ACCOROANCE Wlifl 1SA NCAC 2C. WElI CONSTRIJCiION STIWDARO3. AND THAT A COPY OF TMS REGO(tO MAS BEEN PROVDED TO iHE WE OW �0. o� �-� �o-d_�.� �� SIGNA OF CERTI WELL C/O� CTOR OATE �/�i�/� ��`� (/vii._ f OF PERSON CONSTRUCTING THE WELL Submit the original to the Dlvistot� ot Wate� Quality withtn 30 daya. Atbn: intormation IrAQt.. F� �.�� 1617 Nlall Servlc� Cenbr— Raleigfi� NC 27689-1617 Phon� No. (919) 733-7015 ext 56a. R� �� North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH RICK ALLEN 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES112911-0048001 � �� (�� ES Microbiology ID: 32274 GPS Number: Sample Description: Comment: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htto://slph.ncqublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 1668 HESTER STORE RD. Col lected: 11 /28/2011 14:45 Received: 11 /29/2011 08:41 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A29-40 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Total Coliform, Colilert E. coli, Colilert Report Date: 12/01/2011 Test Result Present Absent Explanations of Coliform Analysis: Analyst Susan Beasley Susan Beasley Date 11 /30/2011 11 /30/2011 Reported By: Susan Beasley �'��C��I�;"� DEC 05 2011 �X: G�i.��r � . 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: Name of System: PERSON CO ENVIRONMENTAL HEALTH RICK ALLEN P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 325 S MORGAN STREET 1668 HESTER STORE RD. ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES112911-0026001 Date Collected: 11/28/11 Date Received: 11/29/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 6.0 Sample Description: Comment: Time Collected: 2:45 PM Collected By: J. Smith Well Permit #: A29-40 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 35 mg/L Chloride 9.60 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L tron _ _ 0.55 0.30 mg/L Lead 0.011 0.015 mg/L Magnesium 5 mg/L ',Manganese 0.59 ; 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.g N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 12.00 mg/L Sulfate 29.00 250 mg/L Total Alkalinity 104 mg/L Total Hardness 110 mg/L Zinc 0.53 5.00 mg/L . Report Date: 12/12/2011 Page 1 of 1 Reported By: �%1� i�lac�