A29 78�� '
, Site Evaluation Application
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Fee Collected YES �
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Date: �/ '��� a �^
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APPLICATION FOR IMPROVEMENTS PERHIT
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1. Permit requested by: owner rospective owne�:
agent:
Address:
Home Phone �{':
2. Name and address of current owner:
3. Property Description:
4 . Tax map �� :
Subdivision Name:
5. Dire,.c� � s to� property:
.L� ..� �'n �a
Busipess Phone �i�:
u
�t size: c/
Township: , /�� i �/
Lot ��:
State Road �� & Roadf�° es, etc/.� �
f— CF� // G Z. : 7/�S � f Sl l � �
6. Permit requested for: New Installation: �� Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: o�
8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? � public? community? spring?
Other source? (Specify):
Are there any wells on a
11,
oinin� properLy:
�s Y fL
If so, identify location:
Type of structure or facility: Proposed: �� Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees: _
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No �If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. A 35(F)
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Signed Owner or Authorized Agent
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Permit Issued �
Permit'Denie�
Plat Observed �
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rACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE �X)
2. SOZL TEXTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTURE (12-36 in.
(Clayey soils)
4 • SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.
(Im�ervious Strata. rock)
6. SOIL DRAIIQAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable _
R �CO2�R�NDATIONS / COZR iIIITS :
�7�TE CLASSIFICATION DLAGRAM (Znclude: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, wells, water bodies, sZope patterns. etc.)
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� PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERNIIT
Tax Map # ,� � Parcel #___ f�
Zoning Township � /- "
Owner/Contractor � Q� �S� � e� .S,"mnson Date - -
Location/Address 1�G c�.... }�-E, rl,_ �-, c� �.;/�, J�.lr� Yr'�l�- z� �
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Sub�vision Name
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" S.R.#
A C�050
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� S' � Size of Tank S
SFD_�, Mobile Home Size of Pump Tank AJ) A
�- --
Business # of Bedrooms�_ Nitrification Line ,(� � X 3
Max Depth Trenches 3 (� 'r
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site +s alte or 'nt ded se changed.
Well and Septic Layout by
Comments:
Date 5_ �^ �i5 Installed by � t�.�1:�,,,,� � s Approved by
WELL SYSTEM SPECIFICATIONS
Individual _Semi-Public Required Slab _��
Public Replacement Air Vent �/
Site Approved Required Well Lo� �/
Well Head Approved Well Tag
Grouting Approved
Comments:
""""r"_'__�'__'�__"'__""'__"'r"._______________ .. . _ . _ . .. .
enduonmental health specialist is not responsible for false or misteading information contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the properiy or for statements in this report that may have resulted from false or misleading
statements provided to him in the applicatioa Neither Petson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will temain potable. c:�amipro�pertnit.sam O1/95 rev.1.0
ORIGINAL
Application Date: 3 � � ) �
Amount Paid: .UO
Receipt #: � � �}b � (
e� '�6 � �.S
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IE."v..�m5 v.n�axaa_mra¢:2n.4:.tn.Il IC�I�c,�.IIQ::LT.
lication for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit re uired)
Well Permit (New/Replacement/ltepair) • l
$300.00/$200.00/$75.00 � �-� N E=� )
Tax Map: �� I
Parcel#c ____�
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 Info ation:
Name: � �� li ��
Address: �ty�ca' �
�p�l�orU /% L �
2) Name and address of current owner (if different than applicant):
Name: C h k��� S
Address: L � . �t
v b /'I .
Phone (home): �33G) S`�g -DDIS�
(work/cell):
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �i9 Se+,.c T/� /''/t��s �fo,r��t�o�+�
/'i�lt.ki O✓1 ,�iQ
❑ yes ❑ no Does the site contain any jurisdictional 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 ❑ no Are there any easements or right of ways on this property? �rob)cm � 6Ct
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
OResidential
O 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 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 ls� Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or f'the site ' subsequ ly altered, or the intended use changes, all permits and approvals shall be i valid.
. - �2 G
ignature (Owner/ Legal Representative*) Da
* Supporting documentation 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)
Tax Map: � (
Subdivision:
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I��.�uu-��.�a���:.�.Il ���.R�:I�
Parcel: ��
WELL PERMI.T
(New _ Repair � ) � r'�'� —
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Lot:
Applicant's Name: Cv(�(C� a'✓'�Sdy+ C�o I�• �'rn'��
Mailing Address:
Phone Numbers: lS _
Location of Property: ( 3% �s� �-� l�
Permit Conditions:
1.) See attached site plan for propased well location.
2.) All applicable State and County regulations governing construction and setbacks a�plv.
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:
Qr1ew Well:
EHS/Date
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Certif cate of Completion
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: Qrn�,;�; �j,f 01 �' W��� �
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: `3 �Z �—1
l�.iner:
� � EHS/Date
Depth: .2� �
Grout: ` �/a yl /�/
/ �
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
CHARLES SIMPSON
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sl�h. ncpublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
136 HESTERS STORE RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES032614-0001001 Date Collected: 03/25/14
Date Received: 03/26/14
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 1:07 PM
Collected By: Derrick A Smith
well Permit #: ; qaq - � $'
GPS #:
Inorganic Chemical 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 13 mg/L
Chloride 6.20 250 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 8 mg/L
Manganese < 0.03 0.05 mg/L
pH 6.6 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.00 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 58 mg/L
Total Hardness 64 mg/L
Zinc 1.80 5.00 mg/L
Report Date: 04/02/2014
Page 1 of 1
Reported By: Arno/d Hall
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�-ir. Charles Simpson
136 Hester Store Road
Roxboro, NC 27�74
Re: Bacteriological Test Results (Tax ��Iap: A29 Parcel: 78)
Dear Mr. Simpson:
�'our ��•ell �vater �z�as sampled on 3/2�/1=�. and tested b�- the Person County Health Department for biological
contaminanu �total coliform and fecal coliform bacteriaj.
The results of your �vater sample are noted belo��-:
_X_ �Vu colifol•m bactericr �a�c�r�� dc�tected in the sumple. Your well water is safe to use for drinking,
cooking, washin� dishes, bathing and showering.
_ TotaI coliform bacteria were detected in the sample.
_ FecaI coliform baeteria were detecied in the sample.
Tota! colifornr bacteria are naturally found in the soil. Fecal �aliform bacteria are associated with animal
ar�d�or human «-aste. The presence of either total or fecal coliform bacteria in well water may indicate that
a neu� or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be
entering the well. If coliforj�: bacteria are presefrt in your water sample, tlre water may not be safe for
use. � i�crng child,�c,�, rl�e elderly, and individuuls tivith co»tpromised immune systems are especially
��irl,�ercrbJ�� ai�cl �heir ��h}�sicinn.s shoirld be notrfred of rhe test results.
�1 �re11 �l�a< <c�srs pc�sitii�e 1vr total o�� fecul colifornz bacteria should be properlv disinfected and retested
�rior ta resurnij�� �aor��ull use_ The �;-e11 ma}• be disinfected using the enclosed disinfection procedure. A
«�zll contractor or plumber can assist }�ou if ne�ded. Once the chlorinated water has been thoroughly
flwhed out of the system, please contact the Health Department (597-1790) to request a re-sample.
For additional infornlation, please feel free to contact Environmental Health at 336-597-1790. Our office
hours are 8:30 to �:QO, Monday through Friday.
Sinczrelz�.
�..�....� a- �.:�
Derrick A. Smith, LSS, REHSI
Environmental Health Specialist
Person County Health Department
Yerson Caunry Environmental Heaith, 3Z5 S. �lorgan S[., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808
(revised 07�29i 13)
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �:4��t�S 51��'Sol��
Address 1310 1�C,SZ(LS SiOR� � County PERSON
Collected By i� . SM��
Date Collected 3 aS l Time Collected ��•4� P�
Source: '�Well 0 Spring ❑ Other
Location: ❑ House Tap ❑ Well Tap `� Other (,O�cis�4E S(� 1b�'�
❑ No Charge �. Charge
........................................................................�
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Total Coliform
FecaVE. Coli
Present
❑
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Results
Reported By� .. � � M c��
Date Reported r� ' � � � � �
Report Called ❑ YES �O
Called To:
Absent
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Da�e: _ '
Owner: �
Location/Directions:
,;;�.;'�:V1S1UI1 �T�ll17C;:
Drilling Contractor:
I'LRSON COUN'CY LNV]:I:ONMLN'L'AL I1�AL7'll
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w�,i.i, i.oc
WEt.L CON.STRUCTI01� -
Distancc from Ncarust Pro�x;rty Li,�c_ /.S o. u s llis��uicu from Source of
Pollucion_ /o �? �lus
Total Dcp.th:��_ Ft. Yicld: _�IS GPM Static Water L,evel_ ..��� Ft.
Water Bearing Lones: Depth /T Ft. � Ft. Ft. �t,
Casing: Dcpth: From n to�_� Diameter: 6•' Inches
TYPE: Stcel Galv�inizccl Stecl '� �
If S[eel, does owner approve: Ycs No
Wcig}it: �� T'liickness: /8'� , Height Above Ground: ) �. Inches
Drive Shoc: Ycs �—'"� No -
Were �'roblems Encountercd in Sctting the Casing? Ycs No !
��
ii "yc;s' give rcason:
Grout: Typc: Ncat S:u1dJCcmcnt '� Concre[e �� �
Anr►ular Space Widt�� � Tnchcs
Water in Aiinular Spacc: Ycs No ��
Method: Pumpcd Prc;ssure Paurc.ci �— '
Dcpth: Fr�rr� l� _ �o ,�. b rt. W
Materials Uscd: No. �ags Portland Cemcnt�i. _ Weight of .1 ba�y lbs.
� If mixturc (sand, gravcl, cuttin�s) - Ratio:__�_ c�
ID Platcs: Ycs ✓ No � �
4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ,A�3UVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTEll lN ACCORDANCE WITH REGULATIONS �SET
FORTH �3Y�THE PERSON Cnt1NTX E-IEALTH DEPARTMENT.
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Si�nalurc ol Contractor � Datc