A30 20t�
The Disfrict f-lealth Depc�rtment
Orange, Person, Chatham, Lee Counties
SEPTIC T�►NK PERAAIT
Date 1• ` �;�:..� �
f t
! r,,l �
of owner '� � .,, � . ! "` „�— `� . .: � '.
r . � ;ra
and Directions s'��''
� �
Person or firm doing installation: _ �' ,�''y` �%
Address '' ;' �
. . f-.
No. of persons to be served '' '" } '� bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank �`�
f -4 �
Nitrification line: f +%f • ' � . ''�` ` "'
Septic tank and nitrification line must be inspecied and approved by
a member of the Health Depazfinent staff before any portion of the
installation is covered.
Date Approved:
�•� -��
$y;—�-�� /�
i ,�
i_
Countersigned
(Over)
. <.r
P't� ��� ..r�r :.w�.
�A 4
S`anitarian �' �
O. David Garvin, M.D., M.P.H.
District iiealth Officer
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurerrfents in order that installations may be located at later
� date. � . _ ,
,;� �
� _.,,�
�
1
� .
.
� -
,� `
-,
— - .. F �;a ...!. -�� __ .
Application Date: ���` � � Tax Map: � 30
Amount Paid: 0200 . D O Parcel #: �2U
Receipt#: � 0 � t{ 7.
� � s1' �`--��`>.s..�" I�'I��..���T
- ������
��.�-aa ���.-�.-�.���..�.� ���..�.��
Application for Services (Septic Systems and Wells)
� Services Re uested by:
\`Name: � o� P e # (home):
� Address: �.iiJ (wor ell): _�'�1 �j - D 16 Z� Gai � 1
�c i I �- �a N - � � �oUsl-��-)
� �
2)Name and address of current owner (if different than applicant):
Name: ,�
Address: OD /e ."
r�/ C
3) Property Description: Lot Size: � Subd' 'sion: �� Lot #:
ddress and/or directions to Property,: ,�, �'% r� �l�u� �—
/A � •
( �suh-�-/i�
4) Proposed Use d Type Structure:
Residential � Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes No �/ (with lumbing: Yes ✓ No _�
Garbage disposal: Yes No �
�5), Water Supply: � �
Private Well �(Proposed Existing _�
Community Well: P.ublic Water System:
Are there wells on the adjoining properties? No � Yes (please show location on site plan)
Note: A comnleted annlication must also include:
➢ A platlsite plan of the property that shows properly 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): / Date : � U
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro; NC 27573 (336-597-1790)
���y ; � �� ���� ��
�-.'� � � ����
1� �n� n- a� �-ncn � � � �.11 I� � �n.11 -�.l�n.
W��� PERMIT (New Repair�
Taz Map: Parcel• �%
Subdivision:
ApQlicant's Name: (re �
Mailing Address: , , l3
2 7S
Phone Numbers:
Lot:
Location of Property: �{q S--? Le-E- a h �—�� 7� 57 �T-
1'ermit Conditions:
1) Se� attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.�
3) Permits expire S years from the date of issue.
Other Conditions/Comments: . � se�. S��e_ SK���,,�
.r
P�rmit issued
I)ate• 8 -24-/0
C�RT'�FICATE OIF COld�LE'I'ION
New Well Inspection: Liner Inspection:
S/Date EHS/Date
Location: Installer:
Grouting: ��l(d Depth:
Well Log: Grout:
Well Tag:
Pump Tag: 2y� � Well Albandonment:
Air Vent: I 0•' � EHS/Date
Hose Bib: Completed:
Casing Height: Method/Material(s}: _
Concrete Slab:
Well Driller: �'��c� ✓�
Pump Installer:
�
tiVell Approved
License #:
License#:
I)ate• I 0� I?-1 U
Date Sample Collected: ��� �- ! Z- ! D Date Results Mailed: "' "��
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
�"� � )� J�' 1�.1�� �l�l
`_ ' �--� � � ��7-°IC°�
�]Ca 9a]['�irn �emm �Sb��ID.� �L �I.�D�.��
�I'I'E S�TCi�
Name 1,7 o�r i G l��eez � Tax Ma.p #�_.Pa:tcel #��
Subdivisi Section/Lot#
�' - y�-(a
� Autho�ized Sta.te Agent Date
System cnmponents re�resent approximate�contours only. The coniructor »aust, flag the systesn prior to
beginning the installat�ion to insure that pmpergnade as maintained
0��'1��'1 �-.` �; tll ✓lC�LJ W�LI� Qhci prD�h'.rl�/ Gl���hc�d✓1 ojc� W�� , ,
� � I� �-�J�I � r�✓► us� �r r�'r� a-�tv►�t�was�r �- c.� r�
� �on Z., � D�'l� /l� ��C� and ��e�o .
P � �J �� � n w e[ I s� r u,�e d ��ouvt- f� � �as�n ��a u f
� �i'1 on � � � rr � � ► ►� �0 �X 5%1 q
P �Q �/i �J Av�n��a� s- �c:e�(w;`11 Cu-� o� v�rns '�� na��
�nfir� n� P
� �� j;
�-�� t,�,�-
;,� ` '�' r.. ��.-------�--�-�--�f
��,.�,..:...__ ��'�� F ,
.�....��w.,.--���-
�-- �;
9 . r
�-:'
� �. . - � � � . . ��... . i , ..
� �, �f`€;�e,� �' t�q'°
� �y� � . r �� ;,
f q '�'�
� �'� ��" �
i �^ f
7
. . . i. f�Y.. . . . ' �i ..
� � N �� . .. a T . . f
$ f � �.,,s I
., , � �
�
. ,
i _ -__� �4y �`"�'°�-� � i
�,,,�s� : � `
^ ; � � .� � #
,��:�, f �� s
� �i V��f' �oA � f �fd.
f � � �' y�
� �� y � , S,�J=#,�
� J �°� � �.. ��� � � � j
�`.' w �._ ,�r �u��;; j ;.
3 t �.�,.--=--�
, ,�.w. '�... �........._--_ -__ .. ._..... . ._ _._.. ....-. _-~�`_"" .." __ -
���A r � /t ��p1�
r ,
�+L�" `'� � lJ� �V"V
, r �' : ��� :��; ;�e�
� �._-.--=
3`,r,�; �, G-�r�r;' ':�.T..—.—,—.::- "" _ " �, �t.,:
�....._.—,^
.:.......,,_r-�-,—...-.—•-_--.-- � � ,
� ���� _ . ,
' � ;,: : = �%��
I � S pv►"�Gt�T Dui OTTIc'e
� ueSi� a� � �
��
� 33� - sR�- ���o�
Sc�-� � � �` = s� ,
RESIDENTIAL WELL CONSTRUCI'ION RECORD
North Carol"ws Depattment of Enveontna�t and Nawral Raa�ses- Division of Wata Qwlity
WELL CONTRACTOR CERTIFICATION # � I ��
�. w�a. c w►cT .
W e1 (lndividuai) Name .
i-�u�14c�ri W � [ I Co. ��Jc„ '
. Weq Cantra�tor Campmry Name s-
' STREET ADDRESS r
f7A��� S� �p Code �•
tate
c.g,(�,-�77- 3?�$` � - .
Area code--�hona ntunber
2. WELi.1Id�ORidAT10N: �nn — ��
v
S(TE W'�.�LL ID i�(Uappuabk�
STATE WELL PERMR�t(itapp&�hls)
DWQ ar OTHER PERMR �('d app6cable)
WELL USE (ChedcAppGcable Baoc): Resida�tial Water Suppiy [}�
a►� nwu�n 9 -aZ-a�l °
TIME COMPLETW �. V� AM O��
3. WELL LOCATION:
CfTY: � C, COUNTY
�w� y�
(S Nucnb�. Can+munkx Subdiriaton. lot No.. Pare�l. ZJP Cade)
TOPOGRAPHIC / LAND SE7TING:
p Slope ❑ Vapey . p Flat O Ridge p Othe� .
(� ��h �4
May be itt degses,
LATRUDE _,'},_ _ minutes, sxads or
LONGITUDE � � �� ��
Iatitude/longitude source: pGPS ❑Topographic map
�rocerrnn orwe�m,urbe snowr, on a uscs ropo map �,a
ettached ta tf►is lbrm irat ush9 GPSI .
4. WELL �NYNER /
owN�t�s wv,� �c`i/, A�6� ez C'
sr�r Ress �o �os�l 1 �$ - -
�c,�.���e /lt, l s �11.G 2�<S�!
C'Ay ar Tam St�e Zq� Code ._
( } �
Area c�de - Phone nurtiber
5. Vi1ELL DETA�LS:
a. TOTAL OEPitt � �
b. OOES WELL REPLACE flUSTING 1NELL? YES�p
c. WATER LEVEL Below Top d Casin¢ �3 FT.
(Use'+• UAbo�ne Tap d Casing) �
d TOP OF C/1SING IS "f` � FT. llbae Lad Surface•
- `Top d casing terminated at/or below land surtaca maY require
a variance in accardance witti 15A NCAC 2C .0118.
e. YIEL.D 19Pm1: �� . AAETHOD OF TE$T Q�vl
� oisa�cr�oex Trpe �o�t
9. WATER ZONES (dapth� �✓/
From j'iD To�, ���� To
Fcnm d To�G� From To
From�To !90 �1 � To
6. C1ISING: �� � Tfrc�aiessl
Fran���� Et� � (2�
F�om To Ft G�
From To Fi '
7. GROtlT: Depth Material Method
Fram 0 To "� Fk e'!'S P
From To Ft
• From ' To Ft
8. SCREEi� Depth Diametar S{ct Size - Nl�eriai
From To FL in. in.
� Fram To Ft. in. in.
Fram To Ft in. h
9. SAt�iGRAVEL PACK:
Dap1h Size Mate�ial
From - To Ft
From � To Ft �
From To Ft
10. DRIILING LOG
From To
� " /�
L p
O �_
�y ���
f7o .'���
.�. ._
�
� � '
.
� .i � .
� u: � ,��
� ,
-� , j ,,�/ �r . / c� / /
i
100 NEREBY CEHTFY TFU1TliAS YYELL WAS CONSIRUCTED N ACCAROANCE VYIiH
IS�NCAC2C.W�LL CONSiRtJCi10l15TAFIOIIRDS,AND7HATACOPYOFiHS
RECORD i11�S�El1 PRWDEi],Il� iFjf YVEIl OWNFA
�-a �fa
DATE
WELL
SubmR the oriytoal to the Division oi Water Quality within 30 days. Atfi: lntom�afioo �Agt., F� C,yy_�a
161T Mai! Service Center— Raleigh. NC 27699-7617 Phona No. (919j 733-7015 ext 568. �„ 7/p,
�
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
EIN:566000331 EH
Name of System:
GOLVIA BREEZE
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
htta:/lsiph.ncaublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
5754 BURLINGTON RD
StarLiMS Sample ID: ES101310-0058001 Collected: 10/12/2010 11:45 J. Smith
������������������������������������������������������������������������������������������ Received: 10/13/2010 09:00 Angela Heybroek
ES Microbiology ID: 21494
GPS Number:
Sample Description:
Comment:
Sample Source: ' New Well Well Permit Number:
Sampling Point: Well head A30-20
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Darneice Lyons 1o/14/z010
E. coli, Colilert
Report Date: 10/14/2010
Absent
Explanations of Coliform Analysis:
Darneice Lyons 10/14/2010
Reported By: Susan Beasley
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 06 N. W?m�ngton St.
Environmentai Sciences Raleigh, NC 27611-8047
htt�://sl�h. ncpublichealth. com
inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH GOLVIA BREEZE
325 S MORGAN STREET 5754 BURLINGTON RD
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES101310-0026001 Date Collected: 10/12/10
Date Received: 10/13/10
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 4.0
Sample Description:
Comment:
Time Collected: 11:45 AM
Collected By: J. Smith
Well Permit #: A30-20
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 10 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 2.00 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 . ,. �.70 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 6.7 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.80 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 47 mg/L
Total Hardness 39 mg/L
Zinc 8.00 5.00 mg/L
Report Date: 10/28/2010
Page 1 of 1
Reported By: �e�iie �'%to�recl