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A30 153Application Date: `� a0 - � Q� � Tax Map: Amount Paid: �2 00 . O U �� `(�- 1� � 6 Pazcel #: _ Receipt#: ,i I 0� �I� � [6 �73 �� -� �-.��-.�s�.�- I�I�I�.� ��T - - � � ��- T�-' -�tn-a}-nu aaaa�*^�ac=-�rnd.:.�u.11. ��an..11d�n Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 if site visit re uired) $75.00 � Well Permit (New/ReplacementlRepair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Rgques d by: �, Name: �' �� ' ,� Phone # (home): S�% =� �D �% Address: (> S C/l� � (worWcell): �3 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Address and/or directions to Property: _ 4) Proposed Us nd Type of Structure: Residential �_ Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (w� plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: Private Well '� (Proposed Existing � Community Well: Eublic Water System: Are there wells on the adjoining properties? No �Yes (please show location on site plan) .� Note: A comnleted apn[ication 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 submitting 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): � C�I"`llJ�� Date : �Q—% 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) i �� ; �� ..�. � ~ �' '� � ��' � � � �l� �� -�.��m�� .�.11 IE-��.11�11�. . � T�x Ma� �rc�el � S��i�b d;i v i.s�i o �a Ph��s�e Section'Lot � A}�Plicant ,�,1-[�n � �d'� � C.DV � � l � � Location: < < ,. � w o 0 � � �; �.Y Improvement �'Ermit - P�rmi# Walid �or ��ive'�s s l�To Espiration Type of Facility: New � Addztion �Vater Snppiy �� . # of Occupants,^1�' # o Be ooms � Projected Daily Flow 3� g,p.d. Proposed Wastewater ystem: � Type: �o Proposed Repair: � Type: Permit�Conditions: �� c� 1��t Owner or Legal Representative Authorized State �Agen� .....,,. Date• S The issuance of this peffiit by the Health Departinent in does not guatantee the �c�„arce of othei permits. It is the responsib�ity of the � applicant/proPerty owner to in sure that all Person Count}► Planning and Zamng and Building Inspections requirements are meL This Improvement Permit is snbject to revocation if the site pIaa, plat or the intenderl use ci�anges. The Improvemeat Permit is not affecterl by a change in ownership flf the properiy. This permit was issued in compliance.wit6 the provisions of the North Carolina `Laws and ltules for Sewage Treadnent and l)rsnosal Svstems' (15A NCAC 18A .1900). Neither Person �onnty nor the Enviranmeatal I�ealth Specialist'warrants that.the septic tank system w�71 continue ta function satisfactorily in the future or'that the water supply will remain: potable. - -- . . � � � � Authorization to Constraet Wastewater System (Reqnired for Bu�ding Perm,it) * See site plan and additional at�tachments (_�• �Z ��pu� . � �,,,- - . Pzoposed Wastewater System:� ]�� CLta+-� �O`2� Type�� Wastewater Flow ��g:p.d. New � Repair Expansion Soii LT ► 2� g.p.d./ ft 2 � Type of Facility: �' ��_�'-1 I�S • Basement _ Yes No - � , �rVaste�vatea� Syste� Require�aen$s '�ank Siz�: � Septic Tank: �c9e�ga1 Pnmp Tank: gal Grease Trap: gai �rain�eld: Tot�l Area: �Q�O sq ft �Total Y�ength 3 rPO ft � 1V�azi�►nm Trencli Depth 2� in Ts�emci� "AVVidt�► �, , ft Ngini�aux� Soil Cover: � in Minimnm Trench Separation: � it �� ' • T �istributaon: Q� �istribu#ion �oa Sesial �istribntfion Pressure Speci�tcations• �S'� �( IfJ� i?c�� W ��1-� � gfl � r� �tE'S � Antho�izesl State A.gQnt Permit E:m' an Date: Date: �1�7'9D• The type of system permitted is Conventional i�' Acc�ted Alternative. I accept the specifications of the P�� . i�wn�rl.�Egal ��psese�tative: Date: ��3J�� ' PG� rev. 11110/OS � �i-hox W�`�-�, �t-� Rp � �i �e S 0 �. S88°08'�4"E 249. 23' ( TOTAL) � W PROPO H OU SE SI TE �6. 77' �•��--. D-box �� q� r � � � P �. TRACT C 1.59 ACRE �,� . ��q� Y 4 �� A/ f � aOV'� YY �� ' r� 248.86' cn �o� �� et�,` �TOTAL ,�-- . o �� . �,r-�- , WILLIAM C. HORNER � D.B. 179/186 S C�� ; l `�= � �` ��. � I�'I�� T . . � � � � � �� IE�.�s�� .]1 � IE3I�.�.]l�I1a SITE PI.AN �3Q � � � Name �� v� � 1'� Taa Map # Parcel # Subdivi 'o Section/Lot# uthosized�State Agent Da e � System companeais nepxsenr appmaumate rnnmrrrs aa1y. T3e ooarractarmust9ag the systrm prior m bP �e nni z�b the iasrJ!ladon m insrue tGat amaerende is msiarafaed — ��' )�.1� �� ,�, � � � � �� .na�na-am n�na�xn. c�1rn.��.Il. .�I �.�.� ��n. WELL PERNIIT (New �Repair� Taz Map: � 3 6 Parcel• �� Subdivision• Lot: Applicant's Name: �,a ��p.�►��, v, � Co V�� i e. Mailing Address: Phone Numbers: Location of Property: �� S� � � �� Permit Conditions: � 1) See attached site plan for proposed well location. 2) All applicable State and County regulataons governing construction and setbacks apply. � 3) Permits expire S years from the date of issue. Other Cotzditions/Comments: Permit issued by: � Date• `7 S` l � CERTIFICATE OF COMPLETION New Well Inspection: � EHS/Date Location: S Grouting: -/G� �/ Well Log: Well Tag: _�_ Pump Tag: Air Vent: I/� Hose Bib: �— Casing Height: Concrete Slab: Well Driller: � Pump Installer: Well Approved by: Date Sample Collected: P-'Z5 I 2 Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspections EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): License #: License#: Date: rZ l Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 8/1/a8 ��.sf� ��.� �� ,� �� IE�.�.� � �� m�.��.Il I�ZL � �.Il�I� Applicant: _� Location: � Operation Permit � � Scfl v� (1�-e Tax Map � Parcel # j� Subdivision Phase/Sectoin/Lot # # of Bedrooms 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 Authoriza.tion. System T e: (In Accordance with Table Va): s�� Product: Y� �( Initial: � Repair: Expansion: .___._... ...--� . .... .. . ........�--- -... __ - - � � ; Y�� -- REHS/REHSI �..t � � � Licensed Conh ctor � ��Q� � '�— I� a?� Scale C�� . . _. . . . . _.. ---_.'-_.. .. . �l2 t�... _. Date 1 �`%iz%ii � Tax Map: �� Parcel #• �� Septic Tank System Checklist (Type II-VI) Notes• System Type: �� Pump System Ci�ecklist Pum Tank InitiaUDate State ID & Date: Capacity: Riser (6" min.) NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioniizg 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 Pump model: Block (4") Nylon retrieval rope Float tree and attachments On/Off float swing: in. Ala�Yn float (6" separation) Anti-siphon hole Check valve Tlireaded union Gate valve Conduit sealed Outlet sealed Approved and secured riser Su ly Line Size and material: in. sch. Length: ft. RESIDENTIAL wELL coNsrRucriorr �coRn Nwth Carolaia Deputiment of Envuonment md Natural Resourca- Division of Wata Qualiry WELL CONTRACTOR CERTIFICATION M.� I 7C 7. WELL C91�fiRACT 7 — • ..,�r,,� � ' � N _ W eN Can (Individt� Natn� . Nu�gdri We,ll Co. ��lC„ ' . W aM Cantraetor Canpany Nams t� ' STREET ADDRESS � ��___��!'2/� � /.�C2[Z?(� �/'2� S ats �� itY � �g1�,. ��7- 3-� � �� 2. WELL IPI�ORNIATION: // � O J /� � SfTE W�iLL (D *(uapplicabN)�" STATE W ELL PERMITA(it appucabM) DWQ or OTHER PERMIT �(if eppOcable) WEIL USE (Check Applicabb 8arr Residential W atat Supply � DATE DRIILED 7� � I��,2[� [ C TINIECOMPLETEO ��'O� AM❑ PM� 3. WELL IOCATION; CITY: ��OrC� COUNTY f ��Orl �� 7 y ��U� c��.�, ��, �� (strwe Nam•. Nume..s. c subaMs l.a ra.. rarcN. z�a cad.) TOPOGRAPHIC / LAND SETTINO: QSlops ❑Valky pFlat pRidys OOther cu,.a� warov�+�e. ��q May be in degroe; LATITUDE � _ mirwta, saands or LONGITUDE in a decirtal Gormat Latitude/longitude source: ❑GPS pTopographic map pbcatbn of w�M must be shown on a USGS topo mep and ettached Ao fha /am inof usirp GPS) . 4. WELLOMVWER �,� ��,, l, `� OWNER'S W1ME � ) � � � � b/y'(�N '�.PV � f STREET ADDRESS - Criy or Town Stata Tip Cods ,•. ( 1- Area code - Phons numbet 5. WELL DET/1il.s: ?/ a. TOTAL DEpTFk J�o S b. �OES WELL REPIACE EXISTINfi WELL? YES p• NO p� c WATER LEVEL Below Top d Casin� 3 S FT. (Use'+• q q� Tap d C�4g) d TOP OF C/►SIN�i IS � i FT. Abaa l.and SuAacs• 'Top d casinp terrr�ated at/a belaw land surfacs may require a varlanca (n axo� wtlh 15A NCAC 2C .011 Q. �. YIELD (9Pmi I METFIOD OF TE$T Q�K. � �� p. WATER ZONEB (depth}; Fram �� To� —�r— �� From To From To From To From To From To 6. CASINO: /l�J� ThicIQ►ess! Deptfi � � Mat From'�� To ��y Ft From To FL � Fr«n To F�� ,� �l� T. QROUT: Deptl► Material ,,, Matlwd From 0 To "� Ft �`�S � T _j�_� From To FL From To Fl !. SCREEN: Depth Diametar Sbl Slze + Material From To FR in. in. � From To F4 in. in. From To Ft in, in. 9. SANOIGRAVEL PACK: Dept� Size NAatertal From To Ft. From To Ft From To Ft 10. DRiWN(3 LOG From To �'�� S O t� /c�� 3G5 11. REMARKS: F�aUon Descriptbn a � � G� � � l'J'�o-n, 1 DO NEREdY CERTFY iHAT 7FMS WELI WAS CONSTRUCiED N ACCOROAMCE WtiH 1SA NCJ1C ELL CONSTRUCiION STANOAROS. AND 1}4AT A COPY OF 7}NS aE e� �ovoeo ow►�a �.o , .^ � >G � �l SIGNA RE OF�ERTIFIED WELL COJ�l�RI�CTOR DATE PRINTED Submit the orlgl�al to the Diviston of Water Quality within 30 days. Attn: Intormatlon Mgt, F� �.�� 1617 Ma(1 Servic� Cenbr— Raleigh. NC 27699-1617 Phon� No. (919) T�3-7015 ext 56D. Rev. ll05 North Carolina State Laboratory of Public Health 06 N. W?m�ngton St. Environmental Sciences Raleigh, NC 27611-8047 htta�//slah ncaublichealth com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH JEAN SCOVILLE 325 S MORGAN STREET YOUNGS CHAPEL CHURCH RD. ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES012612-0096001 Date Collected: 01/25/12 Time Collected: 11:30 AM Date Received: 01/26/12 Collected By: J. Smith Sample Type: Sample Source: New Well Sample Description: Comment: Sampling Point: Well head Temp. at Receipt: 6.0 Well Permit #: A30-153 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 28 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 < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 3 mg/L Manganese < 0.03 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 7.7 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 5.10 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 81 mg/L Total Hardness 82 mg/L Zinc < 0.05 5.00 mg/L --.�,.-1 T-y �F_� ...-�� ,..~�' I _. r. � `/' �✓ _ \_iJ L/ � x Report Date: 02/16/2012 FEB �, � ZOi2 Reported By: ��llkc x��rq �°�.' : Page 1 of 1 ' North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH JEAN SCOVILLE 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES012612-0133001 � �� (�� ES Microbiology ID: 33723 GPS Number: Sample Description: Comment: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta�//slqh.ncaublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 YOUNGS CHAPEL CHURCH RD. Collected: 01 /25/2012 11:30 Received: 01/26/2012 09:22 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A30-153 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Total Coliform, Colilert E. coli, Colilert Report Date: 02/01/2012 Test Result Absent Absent Explanations of Coliform Analysis: Analyst Darneice Lyons Darneice Lyons �'��/� V �J� FEB � � 2012 Reported By BY: Date 01 /27/2012 01/27/2012 Joy Hayes a�,, � `��`° `�.;-: �,. ,�� 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. ' � � �b1 � �� ius��C� ��ale'�, �� ?e��,�Q ,� ) � � � pti=,t- �: �1-� ir Q u,/aS Q. C�Q_ �. ;�y _.(�..� ��:� � �� , �t. v-Pn ��.c..o,, ( i�,r-�� R� s S'�r�. r . �� ' �-�� s . :; :�