A30 1054. ' �+ • •
Aodl�tlon D�x' / � `�
. _ d• � p �
� � a�,�.
a� q !
. . � � b'
,(� �/I � �v '2�-.
I �-
� I O�-,_.,�,Q,,
�� .
Person Cau�v Health Deoartment
E�viranmer�tai H�itlt Sedion
• ��i: �� •. �_
ia�c Mao #: .f�3d "Il� �
Perasl #: � --
1) p� � i
>�
oYM�iO �
Z� Na�ns and addrrss a� c�t awnar:
S� � � /G �{- � nsme��� ��'`�e
� Pr�Q�.Y �01'!. Loc �zx Ta�t�tt�pc .
Dtrec�ons fio u�e pr�ty I�n� r�d -- _. nwnbe�s�: �
�
�-'y5 �l
��r
3�1�" � . n7�S�}l
5�ri�'�x'( ��`t�-
4) Pro�ed Up and Struc�urs Dascrlptlat: answer � of the followln9 �
. � 6a�g �
b) Stk�C 8uit Moduiar 0. SNgb Wide Q Daubie Wtde �
c) Numbar B� • � � Number of � cr peo�ie to he senrec� ,, .�
e) Ba�t Yas Q�ye� � of baseme�rt �re�
n C� D� Yes 4 N�] •
� Dbnenaians of Propoaed SU�x�ure: Wlditr�6 p�th; �:. �C1�-c_�� .
���h► TYPa Prlvatta'� (naw � ar eods�n9 �. P� 4�dY 4 Sarfig ❑
• � Are ariy vreBs cn adJo�ng p�opeity� Yes 0 No� !f yas. loc�tlon
�� lndtca�s D�d Sy�m Typs: (sys�ns can bs ralloeat in ore�er otyoia' pret�ierux)
�C�rnr�o� ---�o�d Com�al — Ai�tv° �enovatlw
� (�!I)� � ` . ., ,�,,.� .L�v�"z. .u� ���
,%�� �� C;�'.-�� � �i..b��� �"����` t��` �,
� .� ��„� ��,.�.�'
�' .
' ' Ci.PARLY STAICE ALL CORrtERS AND f.J1�lE3 OF THE PI�OPERTf. -
STAKE THE CORNEii9 OF ALL PROP03ED STRUCT!lRES.
. • P�EA�SE ATTApi SURVEY PU►T OR SRE Pl.�W TO TH19 APPUCATION
l h�eby malos �on� to the Person� County N�ith Department ior a s�e �vak�atlon for ths on-a� sewage �ai syat�n ior
ihe abo�e-deacri6ad propaijr. f agree tt� the � of th� app�tion aus true and represent thn ma�uan i� to be
p�ced on Uta ptopetiy. 1 und�tand if the s�e is a�eted orthe ir�ded u� dtangas� the pe�mit st�il become in�d. i ut�nd�
that as ap�rt, 1 am r�ie for i�Wtying and meriafn9 P�Y �. comers and maldng U1e sibe ac�bin iar ihe
personnei af tne Pe�son courrty He�tn oepartment to c�nduct their e+raiva�ona ��d that � am re�po� for noiifyina the
Hesith D�tfitetrt ii my/ P��li �!Y � � ��d bY � �Y � � �. .
/ . /���/%
t � �G' Gi' . � � ' //�� ? C d f •
• �1AH1eC 01' �8� '.�f+�w81�V@ . �� -
�...... _. ,nn9lStii
��L
�^��
r�. �
O�
�
,
.,�
r-
PEi�SON COUNTY E�1ViRONME�YTAL MEALTH � �
�. - PLF�SE SE� ATTAC�lE� PLAN FOR SOIL AREA AND S'YSTE�IfI LAYOUT
T�,� � � 3c� � co s �, z- .
Zoning
APPikanC
locaUa
Township CJ�S f� .{�r k
Subdtvialon: SK!!on• L.at
tmprovement Permit � ;
A buildin4 permit cannot be issued with anlv an Imarovement Permit
New �/ Repair Addition Type of Strudures�p Water Supply � .
# of Occupants #•af Bedrooms 3 Other
8asement? �,_ BasemeM Fuctunes? �
Projeded Daity Flow: �O g.p.d. Pennit Valtd �cr:� Five Years 0 No Expiratlon
Proposed Wastewater System Type: � Con u�c�#; o.�, I
Pump Requi�d?' Yes X� No
Proposed Repai� • COn V@/1 � ov�• � .. r �� , .� n . -
Pertnit
� s-fc��� �a�'
�
�
h ! O r.a-Y .
ro�
V v v �-1 �-0 3
Owner o� Legal Representative S'� �re: • Date:
Authorized State Agertt: � Date: �- t� Od
The issuance cf this permit by the He�atth De in no way guarantees the issuance of cther p�rmits. The permit
holder is responsi6le tor diedcir►g with appropriate goveming bodies in mee��g thear requirements. This site is
subject to revocation if the site plan, plat, or the inte�ded use ctwnges. The Improvement Permit shall not be
affected by a change in ownersl�ip cf the site. This pertnit 1s subject to compllance with the provisions of the
Laws and Ruies for Sewage Treatmeot and Disposal Systems of the North Carolina Adminlstrative Code.
Type of Wastevvater System _L'%h P�T � o nq � Wastewater Flow: � d d.
_9•A•
Faciliiy Type: 3� �• S� ��' • • New �
Repair �ansion ❑
8asement? 0 Yes ¢j No Basement Fnchu�ea? 0 Yes �No
Wastewater Svstem Reaulrements '
Septic Ta�c Size• �D �C) gapons Pump Tank S'lze: `-- gaqans
Tctal Trench Length: � feet Maximum Trench Depth � inches Aggregabe Oepth:� in.
y�1 i� rrn uin •
� Sal Cover. � inches Trench Separatton: � Feet on CEnter
Pertnii ExpiratIon Date:
Authorized State Agen�
Date: ��`' D
The type of sysbem pertnitted 0 dae� 0 does not. differ from the type specified on the application. 1 acr.apt
the specificaticns of this permit
. , �
OvmedLegal Representative Signahu�: . �
hu
oate: J'� 14 -0 3
PCHD, rev.11/18J99
� �I
. �
, �
Syitem c�
arlor M E
• � �,
. Applicatlon #: �
. . Tax MAp #: � � �,l�S
Parael #:
� Person County Neelth Dapartmer�t , �
Environmental Health 8ectlon
� SITE SKETCH,.
,
���t� re ��( � ,
�t's ame • � 8ubdivielon/6e�tlaniLot#
� .
1� � a
I Sta gent a e, � ��
npteaenf apprauclm�s conloura an�a ?9is conlrAclo� mriatJlag fbe systsm
- • -- �-- -�
�
�, .
__..__ . . . , r �� � 5� � .
soale:
Ar�uri rav_ �n[42�99 .
���.�� ���.���
�--�= � � � ��-��
IE�.�a�-���.��.��.11 IF3L � �.Il�1�.
WELL PERMIT
PLEASE SEE A'TTACI�ED PLAN FOR WELL SITE LAYOUT
Tax Map #: 3Zi Parcel #�_ Township
Applicant:
Subdivision:
Secdon: Lot: �
T�e of Water Sunulv: ✓ Individual Community Public
Re�.uirements:
Site Approved by - ' �
Grouting Approved bp 1 "I `�
Well Log - D -
Well T
Air Vent
Hose Bib �
Concrete Slab
�'� - � � - . � .. -.
,r, , :
.
�'�- �� ,•-. : �i►r... �� �. , ,
•- -
'�°See Attached Site Sketch�
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building founda.tion.
Od�er conditions: -
PC�-ID, rev. 09/07/Ol
���� �� ���� ��
�� . , � � ����
IEmm.�.a-�� � ���.71 I� 33L��,.71�.
Applica
Locatio
T��x Nl��� P�rc�el �
Suhei!ivi:s�ion
Ph:�se`Sec�t�ia�i Lot r
��' ! '. , • �� _.
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEIV INSTALLED IN COMPLIANCE WITH APPLIC�►BLE NORTi�i
� CAROLINA t;EiVERAL STATUTES, RULES .FOR SEWAGE��:TREATMENT ANQ DISPOSAL,
AND ALL CONDITIO(dS OF T¢1E IMPRO�/EMENT � PERMIT . AND CONSTRUCTION
AUTHORlZA'iION. � ' � .
. . ... .. .. . � ^�- 03 . . � .
Authorized State � enfi � � � � � � � � : � Date • - � �
PCHD, rev. 07I29102
S��i'I� TA1�UK iN�P�C'�iOM ��iE�B�.lST (Type 1� - I!!�
Tax Map #� Parcel # 1�'S System Type {Table Va) �
Owner/Appiicant �',�,�� a..4�.��e.tZ . Subdivision
Address/Location � Seclf'hase � Lot #
. St�te ID/date�-�ya
Capaciiy. `� - � .
Tee and Filter
Baffle
� Sealarrt
Riser if a licable
Tank Outlet: Seai
. Permanent Marker
Pump Tank
k
Wate roof /Sealant
� � Riser � �
Water Tighfi �
. Pump
� �heck Vatve/Gate Vafve .
- t�-si on o e
Floats/�witches � � � �
Alarm (visable and audiblel
Rate (gpm}
Ap�roved Pump Model
Bloc� Under Pump
Pump Removal RopelChain
Distribution System
Seriai Distribution '
ressure ani o
Low Pressure Pipe •
Appr. Pipe Material and Grade
Valves
nncatton Lines
Width �?� fk.
Depth � �-i� rn.
Length �{�� ft.
�. ,� Trench Grade ,��
� ���,.�,� Trenct� S acing
3��3�-�, Rocic Depth and Qua(iiy
b-�; Dams/Ste downs etc. �
�.3,��� Pressure Laterals
� Hole Spacing
o e ize �� � �
Pipe Sleeve . - - � �
� Tum-upsfProtectors • �
�Required Sett�acks
� From Wells �. � ,
Frnm Pmpertv lines � .. �;
_ . .�truciuresidasemenrs.:: . .y
� �tc es ramage ays . � : .
. � . Surface` Waters � - � - � � � ��
' � Public Watec Su plies
Vertical Cuts� (�2 ft. .
Water Lines, , �
Vehicle Traffic � � �
Adjacerrt�Systems �
Easements/Ri � ht of Ways / -
Other
(�T ,,�,.Y,Z Easements Recorded . ,
Comments�
. pchd rev. 3l13/01
.,� �rM�n�v�('��•..
WELL CONSTRUCTION itECORD � ��
�'or�h Carolin� • Dcpartment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
��'ELLCO�TR.�CI'OR(I\DIVIDUAL)NAME (pr(nt) WI -B .RT TON .� CERTIFICATlONY 2309
��'ELL CO:�'fR.�c•roR coaiPnr,v N�nne -..RANKIN WILLIAMSON, INC. pHONE M i 1
ST.�TE ��'ELL CO�S'(Rl'CTION P6RMITA ASSOCIATED WQ PERMITY
(if aaplicable) • (if applicable)
I. WtLL USE (Check Applicable Box): Residential L�7' Municipal/Public O Industrial O Agricultural O
Moni�orink O Recovery O Heat Pump Water Injection 0.. O�her O If Other, List Use
9
t0
II
13
Il
!a
IS
WEI.L LOCA N: C_ t
Ne�res� Town: ounty J��
'130 c�T
1 Sir;c� Naint. Numbtri. Communit'y, Subdivision, Lot No., Zip Codc)
OWNER: ' W TF
�ddress
� s �%Ro��� �.� � �,^��5�1
C�ty or Town Swte Zip Code
c_)-
nrc� codc• Phonc numbc I�` O�
DATE DRILLED
TOTAL DEPTH:
DOES WELL REPLACE EXISTING WELL? YES O NO O
ST.�TIC WATER LEVEL Below Top of Casing: �Q_F1'.
(Usc "+" if Above Top of Cuin�) ,
TOP OF CASING IS � FT, Above Land Surface'
•Top of c�sinr �arminattd sUor below Iand surface reQulres t
v�ri�nce ln uecord n wlth ISA NCAC 2C.0118. �
YIELD (gpm): �_ METHOD OF TEST � I R
WATER ZONES (depth):
3�
OISINFECTION: Type ��Amount
CASING: WaU Thickness
^ Deplr ia�7eter or� ei�ht/Ft. Yte 'al
From�„L To�_ Ft. �/ � �O
From To Ft. .
From To Ft.
GROUT: Depth�,� Matcrial Method
From� To_� Ft.�1�1�C 1 � �_
From To Ft.
SCREEN: Depth Dian:etu SletSize Msterial
From To Ft. in. ' in.
From To Ft. in. in.
SAtiD/GRAVEL PACK:
Otpih Size Matetial
From To Ft. �
From To Ft.
Topographic/Land setting
ORidge OSlope OValley OFlat
(check �ppropriu� box).
, , Latitude/longitude of well location
(deQrees/minutes/seconds)'
Latitude/longitude source:OGPSOTopographic map
(check box)
QEPTH DRII,LING I.OG
Fr�m ^'�q� � rmati�p4�c''�Z�ion��
C.> `� i�+i ��d�
\�1� � lG�
1,OCATION SKETCH
Show direction and distance in milcs f�om at least
two Statc Roads or County Roads. lncludc thc road
numbcrs and commo,�road�am�cs�,
�
yqs
� � �
' wc-w
16. RE�tARKS: s�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS7'RUC'fED IN ACCORDANCE W1TH ISA NCAC 2C, WELL
C0�'STItUCTION STANDARDS, AN THAT A Y 0 HI ECORD HAS BEEN PROVIDED TO THE WELL OWNER
`� ��-� �1-3 -- 03
SIGNATURE OF PERSON C01�}STRUCTING THE WELL DATE
Submit tlie orioin�l to the Division of Water Quality, Croundtirater Section, 1636 Mail Service Center- Raleigh, NC
?7699•IG)6 Pl�onc �o. (919) 733-3221, within 30 days. GW-1• REV. 07/2001
. •
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant •�,t�- �i �P�d
Address �p(�C�' ��Q i ��� � County
Collected By �
Date Collected c1a Time Collected ( ���.
Source: ��4'ell ❑ Spring O Other
I"
Location: �iouse Tap �Well Tap ❑ Other
��+�. s�;►g�-
�No Charge �harge
��**�*��***����*�**���***��*�*����*���**��*����****��**����*�***�*��**����**��
**����***��*���***�**����������*��****��������**������*������*���*�**��**��*��
Total Coliform �
FecaUE. Coli
Results
Presen j Absent
�� ❑
o �Y
�. �� M 1
Reported By � , __
3� �
bactreport
��
.
� , 1 .1• �
� � � + • i . a� l
� • • � �
. 1 �.� ►� �� •. ' � .. s
,.
, 1�1 .