A30 145� '� �'r�� ��� f �
A iication Date- �'� ` /�' �/ �� Tax Map #:
Amount Paid: • � � ���I�. 1
Receipt #: . � �/� ParcEl #:
�1��_.�`� ���� �.� �I
- - _ --- ������
7�aa�aa-oaa��• maa�mll IE�Ls�m71�7�a
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUiHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownedagent/prospective owner): es (e � ��0..�0
Home Phone: ��- �"9R- Oo9 X Address: �y -- •• �.
Business Phone: j 3%- .i 9 4- b09 �' ,F� �,rtYi� M,II� N� �'i i"41
2) Name and address of current owner: k
� r,�l'f1. l\S IL1� `,� '7 52.1 I
3) Property Description: Lot size: � o.�x'3Township: Pxr.s� �-kSubdivision: _ Lot#
Directions to the property (Including road names and numbers): 4� S� k,lo-s ��.l or'b� ��V v..�n 1.
prop��-!., Of1 (ti� �-Slc�o Ai �4 t l�..nde,r�r-�:-�,-9 Co�t
,—�-
4) F�roposed Use an tructure Description: answer each f th� fp �ilowing questions: � '
a) Proposed Existing Type of Structure: �OG'i=et lQ✓ Width: �� Depth: ��
b) Number of Bedrooms: � Number of occupants or people to be served: ,
c) Basement: Yes , No � Will there be plumbing in the basement?
d) 6arbage Disposal: Yes , No �
5) Water Supply Type: Private �(new or existing , PublicJ Community_, Spring _
Are any wells on adjoining properiy? Yes�o _ If yes, please indicate approximate location on the
'site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED;� ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposai
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.
Owner or Legal Representative
���'j--4
Date
PCHD, rev. 06/27/02
���y ),.)� ���� ��
� � � ����
I� ��a a- � �.� � � ¢ �.11 IE-3L � �.Il �1�.
Location: �IaS
Ta�x M�a � �
S�ui h ci�'i v i.s�i o n
P�rcel #
Fh���se Sect�ioi�i Lot �
Improvement Permit
Permit Valid for ✓ Five Years No Ezpiration
Type of Facility: �,„�T 'i� ��QQ,,, New 1� Addition _ Water Supply n��.
# of Occupants �_ # of Bedrooms � Projected Daily Flow 3c�� g.p.d.
Proposed Wastewater System: �'_I.�����.v� ( z5`�. r� A� w � . Type: �i
Proposed Repair: �,,r�,�� Ca5`/ r��,.�.: r� C'' `�- ��o� Type: �/
Permit Conditions: j� rn:�. �� �- �,,�:r. 1��� 5i1-e, A aln� rn� ►-�a� 5,�� ���- �
rY'QS,e/ve ��eG�re C1� �o.. 1� r.,.��er. � --
Owner or Lega1 Represent�ative�S�i
Authorized State Agent: �g�,_�r �
x Q�ti,,,:w,� Date: � ` � ���
� � D ate: �/- � $-o�-/
, --
The issuance of this permit by the Health Department in does not guarantee the issuance of other permib. It is the responsibility of the
applicandproperty 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 Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply w�l remain
potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
� w'ao-aS
Proposed Wastewater System: ����� ��G�. Type � Wastewater Flow 3�� g.p.d.
New ✓ Repair Expansion L25� �-�� Soil LT � a� g.p.d./ ft 2
Type of Facility: ��.� ��.:.1 .��: Basement _ Yes x No -
,
�
Wastewater System Requirements C��� a� -}-„ .�,��,,G.r��-
�is/.
Size: Septic Tank: 1t�u� gal Pump Tank: --- gal Gre e Trap: -^- gal re��)
ii-L. q �`�'�cS 4-z�--os
field: Total Area: 6 s ft Total Len ft Mazimum Trench Depth � in
zh Width �_ ft Minimum Soil Cover: � in Minimum Trench Sepazation: �_ ft
�,_ Distnbution Box X Serial Distribution
Specifications• rV1.d,h1�.�
Authorized State Agent:
Permit Expiration Date: -
7
Pressure Manifold
��
Date: �( -/3 -oS
The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of
the permit. .�
Owner/Legal Representative: Date:
6- I 7--� �
PCHD7/30/2002
.������ �I��.���
�� � .������
��.���� � ���.g �e.��.
� � SITE. ��.'�CH: .
Name �`�a Sc.�.t� TagMap# A3� Pazcel# /�!5
��b�xon wesl 31 � � �ection/Lot# �
jZS . � � �./ - /3 - oS
Autho�cized State t ' Date .
�� Syste� con�ionents �p�esent a�iproximate�coninurs only. The contr�tctor must, flag tlie system priar ia
lregiris�ing the installaiia� to insurie tha�t�imiiergmde ra srrasntained:
• � �_ 07.0 .
r, . . � . IC3�a� G�Q �1- �-05 CS
.. W'2�\ '�ia.�. r,.,cr-\c�.�..
c,;.�•• b1,c� ��•
0
N
1
t
h
• �we11
�'
30'
�Z• 3w�{
62
IS'
,,,� �s' ,
sts
. � r�� �
j Y
110�1 �
I
� a ttpar
,'�!', �Y
� '�. __ — —
�
�,�Q a�
, 3 bec� 3L�p � �._.r•na.aciv�.
.��5
� �a�. 33o Fi
D '�ir�ou d-v
�.
1$ " -I�arc.f• . c'� r�'�
�.r-,'eQ i�l�.'e�+.--�' .
~ . �O �1.a a.. G�.�S �,�,-.� Sw \4 L.L�.� •
. �.e.¢e� ..� 1 ul .
^ 1 �� o,�-\ SC2,p �,•c 1:Y.¢s �a..�
c��, �-+ c�un�,�xr .
-- N`n.v.�kc,a�., � s.¢�aae9�s .
._----.�...! _ _-- ._
-- - - ---
� " _ _.
- - - ------- - �
. .__ ._ __
� � � , �� �
-- ��,
---_ .__ ------ -,
. � - - ��� _._ _
�
� � 3zo
a
�
e �, r '
� c, usv '
. // �� / � �
Sca1e: r = 6�P
PCHD, rev. 09/12/01
.���'��:�'-...:.':`�� ��. ����.': .= . ..
...
..�
.....:: .: .: ..:
:...��. .��
..
:
���;<: ...�:. :. ::����.'��
...; .... � .: .... . . .. ..
�:�;::�°� :. � � ..; :
::.,.,� .
� �:�:�.��.�'� .
•.::.:.'�Y..A�:':...,.i...:::i.rni:i'�j::��iti��..: ; ..�r; 4 • : . ::., ::• .
... ....... .. . �
• ... .,�}..... i; � .. .
.,-
. . . .:.:.'., �.
JG�n:,;�.s��a�:�a��� �:.ara���u;7L';��3C.�,xo.�;�31'�; :
WELL PERNIIT � �
P]LEASE SEE AT�ACHED PLAN FOR WELL SI'1'� LAYOUT
Tax Map �a0
Applicant: R��
Subdivision: �,�
r __,.+:,..... ..,� �-
Parcel # ! �-%S
;�� "5���.,
'�ype of Water Supply:
ltequirements:
T�ovvnslup:
Lot #
a
�Individual _ Community Public
Site Approved By: �,�, S � 12�05'
Grouting Approved By: �t� R t� 2L��
Well Log: (�5 �-a3'��S
Pump Tag: �
Well Tag: ✓ -
Air Vent: ✓ � �
Hose Bib: ✓ �
Casing Height: - -aS
Concrete Slab: `
W ell Driller:
Well Approv
Liner.
�Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
... % .�.1�
****See Attached Site Sketch****
- c.�et� s�k. r.�..Z
Wells must be 10 feet from properly line9. �e �^''�`' �`"`' {t°�'
� Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any buiiding foundation
� -
Other conditions: �%(� � 1�t 6�ch
PCHD rev O1/27/04
����1 �� �.GS..L.i �� V ia. V
, _ �> �
v � `�/ � ��� .11
��v��-��.�����.� ����.�.��.a
Applican
Location
.
e
�x M�p Parcel ##
Su�bciivision
Ph�se Sect,ion ot #
# of Bedirooms
.�t -l:::
. � ; � �� ,.:.
System Type (ln Accordance With Tabie Va): .�
THIS SYSTEiV1 I-!AS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROL:INA GEiVER�►L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITiCDiVS OF ' THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUT ORfZATION. �
� . 'j�$ 9� � a3 -:os � .
Authorize State errt Date
Installed By: �� � Date: �S � �3^c75 � �
CZ ��ow taai N
P_
I o' 7S l� ��L'� i
�
�I- �7-u�
Pr� - � oo�
s�rs-� yz
�n
8�0 .
70
(o c�
W
�
�3 yo.'
PCHD, rev. 07/29/Q4
�
� 2 ��,.,� � a� �
:�E��iG T��� �R��������.� ��9E��L9�T {T�e 91 �!
Tax Map #_� Parce! # i c.�5 Sys�em Type (iable Va) �
Owner/Applicant ��, �.c�., Subdivision
AddresslLocation SeclPhase Lot # I �
Seotic Tank Init�aU�ate �ditrt tca�ave� nes Ini�a a��
State �I
�a�a���,,._r » -��
Tee and Fiiter
Baffle
Sealant
Riser (if applicabie)
Tank Out(et Seai
Permanent Marker
Pump Tank
Capacity gai.
Wate roof /Sealant
Riser
Water Ti ht
� � Pump
Checl� Valve/Gate Valve
An�h-s�p on o e
�Alarm (visable and audibie)
Electrical Camponents
Rate (gpm)
A�proved Pump Model
B(ocl� Under Pump
Pump Removal Rope/Chain
. �Distribution. System
Serial Distribution
ressure an o
Low Pressure Pipe
Ap�r. Pipe Ik�taterial and Grade
✓
Trenct� �dth � ft. - ✓ s �-os
� Trench De th � � in. ✓
T,rencl� Lenqth 3 �/c� ft. ✓
Trench Grade �
Tr.ench S acin ✓
Roc�C De th and Quai'
Dams/Ste downs etc.
Pressure Laterals �
Hole Spacing �
o e �ze
Piqe. Sieeve
� um-u s�t�rotectors
Requi�ed� Setl�acics
From Welis �
From Pro erty lines
StructureslBasements
itc �es raina e a s
� SurFace Waters
Public 1Nater Su lies
Vertical Cuts >2 ft.
Water Lines
Vehicle Traffic �
Other
���3os Easements Recorde�
e ie erator ontc
. Tri-Partate Aqreement
Coerarnen$s
E�
�resti.�
i
�
�
pchd rev. 3J13/01
Barnette Well Drilling Inc 336 598 9275 08/23/05 04:41P P.001
:� `~���� S.� :I�'��$.����T a�� oo � �, �
���' - �� � � � � ��
. � . :.� � �TI�T'�C � �
�i�ra.vn���ra»n�irn+L,n►:A � ���•mIl�:Ila. Q� ��
Grout Log
p��; /ct �t . Tax 1VYap �_ Farcel #�
Location. S [.. �
subdivision: Y.ot #
Wcll Consttuction
Distance From nearest Property Line (Minimum 10 feet �' C7
pistance from S_e�tic System (Minimum 60 fcct) �
Total Depth: �,�D ft Yield: GPM Static Water I.eve�: �� £t
W'ater Bearing 7rones: Depth � ft�t_ ft�� ft..-- -- ft
L.S^
,-�f j-�'�i�'
� Q- S G
.y
C�sing:
Depclt: Froxn �S to �� ft. Diameter: ��in
Type: C�ralvanized Steel �,�
Weight: Thickness: 1�� I�e�ght above Ground: �� in
Y?rive Shoe: �es No Any problems encountered while set�ng easuig? Yes r,,, No
If "yes" give reason:
Crout: �
Nea�: Snnd/Cement '���oncrcte CrraveUCement
�. Axuaular Space Width � inches �/ater in Annular Space Yes No
Mcthod.of Cxrout: Pumped Press�ue Poared Depth to
Materials Uscd:
N'o. Bags Portiand ccmcnt � Wexgkit oi 1 Bag �ounds
� mixture (sand, gravel, cuttings) — Raho to
ID plat�es: „_ Xes _ No 4 x 4 slab _ Yes _ No
Liuer:
laepth:
Ft.
nate In�tall�d: Grout: Taastalled by:
Drxl�ng Log
Location Dr�wing
�p� To Formation
� S � �t. ��c��� t� f � (�y �
?� 21 � . � ,
I hcceby certify that the above infotmation is correct aud that this well was const�vcted in accordaz�ce vvith regulations set forth
by thc Pcrson County HeAlth D��ent. ���- - ,
.
S�gnature of Contructor
ID� zy�s Datc �
Pump Inst�lment
pu�»p Tz�stallation CQritractor: �� �� �� �( State Registration NumbCr: ����
pump Depth: QD ft S sc Water Level: ft
Pump Makc & Madel� i��',���c D'� Pump Size and �tating: ��_hp ,�� gpm
I hereby certify that this pump was installed and the well hcad completed accordmg to the Pcrson County Wc1I Rules in e�'ect
on this date and that a copy of this reeord has been ravided to the well owner.
�ump Installer Si�nataze ��"�' � Date: Y� $ PC13D rev 41/27/04
Report To:
North Carolina State Laboratorv of Public Health 06 N. W?m�ngton St.
Environmental Sciences Raleigh, Nc 2�s„-so4�
htta://slph. state. nc. us
lnorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
Courier # 02-33-15
StarLiMS ID: ES031610-0011001 Date Collected: 03/15/10
Inorganic ID: Date P.eceived: 03/16/10
Sample Type: Raw Sampling Point: Well head
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Name of System:
ANTHONYJACKSON
179 HASSEL HORTON RD
HURDLE MILLS, NC 27541
Time Collected: 1:53 PM
CollectE� Sy: B Hofi
Well Permit #:
GPS #:
Inorganic Chemical (Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Total Alkalinity
Fluoride
Chloride
Sulfate
Arsenic
Copper
Lead
Manganese
Zinc
Barium
Cadmium
Chromium
Silver
Selenium
I ron
pH
Calcium
Magnesium
Total Hardness
Report Date: 03/29/2010
51
< 0.20
< 5.00
< 5.00
< 0.005
< 0.05
0.007
< 0.03
4.20
< 0.1
< G.0�1
< 0.01
< 0.05
< 0.005
< 0.10
7.3
9
3
33
Page 1 of 1
4.00
500
250
0.010
1.3
0.015
0.05
5.00
2.00
0.005
0.10
0.10
0.05
0.30
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
N/A
mgi��—� ,
-.� jL;t� :.
1m9�L . . n 9.
�__
_ ---�
� 2p10
�.-_
��i//
Reported y: �%t� �d�
�,e�l �
�������
t 7at �ss�..� �, `�"�''
�.a,.,,ra,9�,�, t��v, �C
a�sy�
c,a - sd3 - �c.3�'s
�P_nk 'b �� o�
� -a�-�s c$