A30 4JUL-13-2010 01:03P� FRO�- %- jt{ --J O �, a7 '�� � Wz�� T-221 P.001/003 F-350
Amount Paid: a00 .O o ���� 3�� �.�.�� �arcel #:
Receipt#: 1 U �-F I -1
�`��.s�- I�I�II�.���
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IE�.m.v-a.sr.msr��rs..�.�a�.�ml1 1��I�•�.A �JL-r.
Application for Services (Septic Sys�ems and Wells)
Services
0 Ymprovement Permit (Site Evi
�zpa,00l�300.0a (if> 600
61Sd.00 {if site visit require�
Permit (New/Replacement/Repair)
$300.00/$Z00.00/$75.00
1) Scrvices Reqaested by:
Name: �j�, L,� 1.,...�.� �
;
Addr�ess: � 7't . a
L�.��.�a J.. �tr� z�z2�2
fl Copstivction
lFee is deDenc
0 Repalr of Eristing Septic System
o Ch e
P6one # (home): 33L �a� Zs'7.3
(work/cell):
2)Name aad address of current owner ('if differeut thau applicaDt):
Name• P .r�C.�.
Address: s �
� �� 1
3) Property Description: Lot Size: 2G.fs�c�.Subdivision: Lot #:
Address and/or directions to Property: 2 � .� �- � �-� K
. .
4� Proposed Use and pe of Structure:
Residential BusinasslType: Other
Number of bedrooms / Numbar of peopie served (seatslemployees):
Basement: Yes No (w[th�bing: Yes No �'��
Garbage disposal: Yes Na
� Water Supply: -
Private Well �posed Existing �
Community WeEI: Public Water System: .
Are �ere wells on the adjoining propeRies? No _
Yes "(please show location on site plan)
Nnte: A COlftpleted 4DD�lClllhOlt litlest RIsD t/ICIRde:
D A plai/site plan of the proper[y that shaws property dimensions and the size and location of all
praposed structures.
D A signed copy of the `�ot ,Prepa�ativn' form ver�ing that the property is ready to be evaluated
x am submitting this appfication to request services �rom the Persoa Coanty Health Departmeut. � understand that
if tbe information provided is incorrect or if the site is subsequently altered, nr if the intended use cha�a�es, all
permits and approvals s6a11 become invalid.
Signature (Owner/Le�al R�presentadve): ��' .��� i?ate : /�
� oros
Person County Environmental Health, 325 S. Morgan St., 5uite C, Roxboro, NC 27573 (336-597-1790)
2010-07-13 12:21 Page 1
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A}�plicant ( ' � �x� CTW'� n � :
Location: '
49 '. � �'SQ ►-�� � � c9� '�e 22fa
_ �Tnapravemeat �'ermit
�'�rmi# V�Iad �or � �`ive � � _ Pto �ii�atlon �
. Type �of Facility: New l� Addition �ate� ���ppiy r/1/`e ���
# of Occupants Q # of drooms � ojecte3 Daily Flow � C� O g.p.d.
Proposed Waste System: • Type: �=�
Proposed Re}�air. � � Type: �
Permit �Conditions: . :���2 S t�'�P � ���C' �
Owner or Legal Represeatativ S� • n- .•� Date: _
Authorized State �Agen� ,� � �✓�.� Date:
'o�� P—�— . .
The issuance of t3�is peffiit by. the Health Departinent in does not guaianfes tfie issvancs of other pezmits. It is the iespansiibi7ity of the �
applicant/properry owner to in suze ti�at all Person Couniy Pla�mg and Zqnmg and Bn�ding Inspections reqwa�ements are meL This .
Improvement Permit is sub jecf to revoca�on if the site pIan, plat or the intended use changes. The �mprovemeut Permit is not
aifected bp a c3�.wge in ownersiaip of the property. This. permit was issned in cflmpliance.wit6 the provisions of the North Carolina
`Zaws a�d Rules for Sewage Treatment and Disnosal Svstems' '(15A NCAC 1�A .1900). Neither' Person �ounty nor the .
Environmental �eaith Specialist' warrants ti�at. the sepiic tank system wi11 continue ta function satisfacton7p in the future or�tiiat
the water snpply w�'II remain�potable..: = --.... � . .
-�uthorizataon ta Constract Wastewater Sys�em (Reqnired far Bwlding Peraznit) �
.* See site plan and additional atiachments (�. '�.`z ���<,,� �
- . � . . �� .
Proposed Wastewater System:� �PA'��C , CLlarto %+r`Type �� Wastewater Flow �� O.�:p.d. .
New � Re�air_ ExPaasion , . • Soil I�TAit: • Z� g.p.d.! ft Z .
Type of Facility: . . -- �J � ,� � �� Basement ` Yes �, No �
. � � - — .
: �aste�vater S�stean��ea�laiirements � � .
�an� Size: Se�4ic �ank: 1�9�a gai Pnmp Tank: �c�c)gai Grease Taap: � gal
��rai�eicl: 'Tot�l Area: O$� sq f� � Total Y,,ength 3�2 d it ' lYlazi�anffi Trenci� �eptii f� in ..
��emci�'�idtHi �#� 1Y�i�naa Soil Cover: �_ in 1d1'in'imnm Trench Separation: � ft
�isiributaon: �3i�trib�.ion �oa Serial �istni�ntaon �, Pressure Manifold
�A,,� 4 � ���� /%
5pe�cationsi � �� �G�LYf�+`e►�'i, � Sor` � : C9�i v���'crlr�c3f . �� �u�'�,,P '�' _NtGr7 � �
% . .f%G Fc. , .o .,a c
A /1 _ `r ..
Autiaorized State A.gs�t: _��
- Permit Expiration Date:
Date: �
. , . . . , . ... Y . , . � - .
The type of system permitted is Conventional �Acc�te3 Alternative. I accrpt the specifications of the
P�� � � .
i�wn�/�,Ebal ��pres��ta�ve: � � _ Date:
' PCHD rev. 11/1Q/OS
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STT'F PLAN
Name
� tr � ✓► Tas M�p #� Parcel #�
g� Section/Lot#
2
Authorized State Ageat D e �
S,ystem campaaeats trp�seat appm�a� avamurs on1y. T3e aoatracmrmust9ag the aystem paar m hegmnmg �e ias�arion m
iaslrs �atPmPetgiade is mamm�ed �
��W _i _ � �r�� r�� ze S1� �Y.� S�� a C . ' +�,-��� �� �a�n e�
�,�nm� � �����-���� S�, � �� w�
� � a � �.
�� ��,ts�- i n5��� S�S�n�►_ G�l,�,r�F►� �� co�i �'�� S.
�
�~y � �c s�iGl s�s�'w� n,� Cd.�.�-c�r, v�
ii� � � ��i �'��E M
��1R r �Yi�.��� �i�i. �/ j' `
t
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CiU1R1ENE D. HORTON
D.B. 2�5. P. 81
L�M�LOi��R
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= � � �J�T'II'�Y ��jtr�vr-e lp�,��v�
lEsa.-ra��m �aa��eaa�mll. 1HI�.m.It�EIl9. Ownei:
Tax Map: 3� Parcel #: Date:
I.ime �'ap
# i?ia�
1 �.
B '
3 `i
4 ,�
7
8
9
10
Tap (Scl�)
Line Length
�o
70
30
�dovv / ��ot
. �,
. 04�
•co
.o u
. �o
(� O ft of line x 65 gal. per 100 ft= 2 3`ic� '--� ; 100 = 2 3`� gal
75% x� ga1= �S gal per dose �� gal per minute (gpm) _�'!ow I�ate
�+'riction �ead
Loss: � � ft per 100 ft of supply line x~ 2'�� ft of supply. line =100 =� S ft
�ft x 1.2 =� ft of friction head �.
_ __-- ---- -------_ _-- -----_ _...---. ______ ___ __ __ __ .
_ _.
�an,o�ofn��-�'1Ze' �— " �'-0FC��`silIIv�'1��. Z '� �Tf+
- ---� -- - _ _
--
— — — — — -- -- -- --- ----
---- -- -- -- �otaI Dynamic �$ead = � l ft of Eleva�on head + ft of Presc��re head +- of
nchon ea =
�c S,�Pt� �i�e �.Q,.��l.. �- � �-� � . �Ea
Pump Requireanent: � 8 GPM @ 2�• ft of Head "'��� ��n'�°�` �"�.
Drawdown: ����al per dose � 21 gal per inch = g� � inch drawdown per dose
a�� :r�,a:� :� � ,� ,,��
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--
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1�) �I �I �� i�iiiiiiii°i%iiiiii:iiiiiiiiiiiii�
� .... :... .. ... ���+���������N������.�.�����l��.�
1 I 1 I i.. : � ., _ : a ::: v:
' ' , ' �._, -. -
9mmra � ' S
� l�ianifoid Siz� / � Ta �
�i%ld M�x Na Tags off one side
;iz� (I2educe b �s Tor ta ' �oth si�
�i4" ta s 3/." ta s 1" ta
2" 4 �.
g» g 5 3
.� �� 9 �
� ��e � 4a+
- �iow er Tap
Size iLlcu¢rial Flow Gr''yt
�� " ScJied 80 �•j
f� " Sciled 10 i.l
,�
;, " :iched 80 I�1 !
'!, " Sclied ?0 1? ?
`-•---�.���.�� ���� ��
�.` �-,� � � ����
I� ���-���-���.-�,� ���.�.71 IF-3L�.�IL�Il�
T�x M.� � i + F�rcel #
� � hclivision
Ph�s .'S c �ian'Lot #
1dEMA 4X Simplex Control Panel � .
x � Ihut SealBoth
h" X 4" Pressuse Treated Post j j ��s Of The Con�iik Concrete Riser
� Sloped To Shed Water 12" Sep�ration 24" MinuYnun
\ Electrical Con�it -- : . ., . - • ' • ' ' ` b" Sepuation
�1 TluYaded Gate Valve •
. . � . ' t � _ U11L7I1 � .( � r
' , . . , . ' . . i.ff.�%• .
� ACC2J3 COYEI• • ' � • � � �
6" Cover • ' • . � � '4r�PortLand Concrete Grout •
� ' ` .." � Mutu . _ .
• � � �` _ ; .` •• � . . ' � _ , .
�•, • : ,... _ - •- . . . - - ' ' Zip Coxd a . � Openuig Filled With
�., Opening Filled With Anti Siphon Hole •'I'�S Supply �: portlaiud Certtent Crraut
Inlet i4nm Septic Tank Portland Cement Gmut (DovmHill) � I L� `' � '
4" SCH 40 PVC Pipe � ' • Outlet To Dutnbution
Check .�,Ny�n 2" SCH40PS1C Pipe
, Valve Rnpe , Float Wires .' �
High Water Alarm Level ' '
� (6" Separation� �
_ High Level- Pump On 7�, �
.. �� �f rVaporLock � � Floats •: ' ��j �'� �
• � Drsvdawn Hole • • \�
'� I (Up Hill) �,Removable " •
� ' �4 F7oat Tree �
. Lavr Level -Purnp Ofi � ,
';. ' puznp : 2 � �✓"1
� �
. Pzecui Concrete Tank 4" Conczete -�- .
� • ,.; (Material Strength >3500 PSIj Block � I ' � �
• ..��. ' ,' , • . ' • " ` ' . ^ . ' ' � :` . . � , � ' .' , i.
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Oc�v �az.Lorr � T� � p� � �
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`�~ � � c� � ����
I��n�n�� n�a�n. ��rn�.am.11 .IL�I � �.II.�I�n
WELL PERMIT (New�JC Repair�
Taz Map: � o Parcel•
Subdivision: Lot:
Applicant's Name: (',�C�,--�-� ���-'4-d.-�
Mailing Address:
Phone Numbers:
Location of Property: �� �- --'?
zZ
Permit Conditions:
1) See attached site plan for proposed well location.
Z) All applicable State and County regulations governing construction and setbacks apply. �
3) Permits expire S years from the date of issue.
Other Conditions/Comments: �
Permit issued by: `.. �-c
Date• 2c� lv
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
.,
� ,o/�/��
����
G,�ovt
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
30'o�o�r✓ Well Abandonment:
���� '�'`f'� EHS/Date
y��� �'�'�Completed:
C� �'�� Method/Material(s): _
w�f�jf.t�`t'
'/ M�•-�1�►�
Well Driller: Yi4171L) � "�0��•1 License #:
Pump Installer: T- License#:
Well Approved by• Date: �, - ZB`-l�
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
nI � P�w��
�{�Ilv� 1
Date Results Mailed: �� � i
�'`
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
.
RESIDENTIAL w�r,L cor�TsTRucrioN R�cortn
North Carolina Department of Environment and Natura] Resources- Division of Water Quality
�V�LL CONTRACTOR CERTIFICATION # -5 v���
1. WELL CONTRACTOR:
/1%n f�%�i �w ..l7. �/'��wi► —
Well Contractor (Individuat) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020
City or Town State Zip Code
c 336 � 468-4440
Area code Phone number
2. WELL INFORPIIATION:
WELL CONSTRUCTION PERMIT# �3 O �
OTHER ASSOCIATED P.ERAl11T#(if applicable)
SITE WELL ID #(if applicable) -� ��
3. WELL USE (Check Appiicable Box): Residential Water Supply �'
DATE DRILLED �lJ ' �� � �U
TIME COMPLETED '���_ AM ❑ PM�
4. WELL LOCATION:
CITY: �� �V'�Q `2 %'l . C � s COUNTY�Q(,c�._
��� ��" �/ .,� �7��, i�.
Street ame, Num ers, mmu�i , Subdivisio , ot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
�Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE °_' " DMS OR � d DD
LONGITUDE � _' " DMS OR � � DD
Latitude/longitude source: �PS �i'opographic map
(location of �vell must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
,' f f�i �/o �^ 7Go h
Owner Nam�
1 Z ��- ��t ss��// � �7`a� �
Street Address
�Gt (/` � �`�'/r j/f l�/� � ����
City or Town State Zip Code
��3 6, �'97- 3 9 ��` c°. so f sy'31
Area code Phone number
6. WELL DETAILS: ��C� /
a. TOTAL DEPTH: � / �
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
6 U
g. WATER ZONES (depth):
� Top 7 U � Bottom �77�—
Top -� � q � Bottom Z Z Z. �
. ' Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thicknessl �
7. CASING: Depth Diameter Weight Mat al 3
Top��, Bottom� Ft. ./�I'� S��P- Z/ pV �l�s ! 1'!
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top� Bottom 3 FtNt� f' (��,,,� ��„j P,v�cc
Top�_ Bottom .+� 3 Ft. Qti�r,.�c. S/,,.�J, PU ^+
� Top Bottom Ft.
9. SCREEN: Depth Diameter
Top ottom t. in.
Top Bottom Ft. in.
T Botto Ft. in.
Slot Size Material
in.
in.
in.
, 10. SAND/GRAVEL PACK:
Depth Size Material
Top ttom
� Top Bottom Ft.
, Top Botto Ft.
11. DRILLING LOG
Top Bottom
�_i 3s '
�.i, /�a� �
tit7' l _ ��
�l 111�5� �
/
/
/
�
i
/
/
�
12. REMARKS:
Formation Description
Soi�f � /L1u � --
/�c,.�0 l ��.,,�.t,.
..S -
�,[ � ,
�, t � ��,�2 s 6
��/v � 973''
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: �'. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use "+" if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
� PROVIDED TO THE WELL OWNER.
d. TO? OF CASING IS � FT. Above Land Surface' (�
"Top of casing terminated aUor below land surface may require ,�, ����� /Q —/—/U
a variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD (gpm): OC. METHOD OF TEST �!� c,, A,�7 .f fl �I?
/"'a � lL �v v. U�U w.�
f. DISINFECTION: Type HTH _. Amount � CU S : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
/%'JQ�j cr �/. C"o///lyy .
Sub'mit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-�a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev.2l09
Date Site Visited �--a3--(o By: (/13 Permit: Yles�TNo � G.�-c«�@ .Z�6e
��R�. <(� — � -- f T'� /c � <c�
What Is Height of 6aell Casing? Make Sure 12" Above Ground Level!!!!
i i ii i� , ,
/� a k�C�j s��, c.� �c�
BUII�DERS NAI�: ` �
/1-- �� ti'�� �� 1��.+ r2 c c� i G�
�Dx�ss:_ 3 ��1 �3 K cQ�/p /�� �� e�
���a � G� G � � � .Z
Pxo� ��x: �dG - �? s � 3
C, ��f�-- ?S9j"
.
�1� ?�.)�. ���� ��
` - ... � � � ����
I���.a- � �,.-,�,. ��.��.Il 1�33L � �.Il�I�
Operation Permit
Applicant: �►� � ���
Location: _
0
Tax Map
� ��� Parcel # �
Subdivision
Phase/Sectoin/Lot #
# of Bedrooms
This system has been installed in compliance with applicable , North Carolina General Statutes, Rules for Sewage
Treatrnent and Disposal, and all conditions of the Improvement Permit and Construction Authorization.
System T e: (In Accordance with Table Va): ��_ Product: C�Q� �
Initial: � Repair: Expansion:
�
ll
Tax Map: � � Parcel #• �
Septic Tank System Checklist (Type II-VI) System Type: �
Se tic Tank In'tiaUDate
State ID& Date: � �/ 2- S�/
�� _ a
Capacity: S ( 0�
Tee and filter f
Baffle �
Vent ✓'
Riser �/'
Outlet boot
Perm. Marker
Distribution
- --- — —
- - _ _ _ _
- -
___ tix_ e_v_e_s set _ _ _
.. __ __._ __ ... .
Serial
Pressure Manifold
LPP
Notes:
Pump System Checklist
Contracted Certified Operator (if applicable):
Notes:
Tank Com onents I itiaUD
Pump model: �Q � �r I �(a
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Alai-m float (6" separation)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: z–in. 5(Osch.
Length: � Z ,� ft.
�
'�
! '
r-olina 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
StarLiMS Sample ID: ES070611-0050001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ,
ES Microbiology ID: 28383
GPS Number:
Sample Description:
Comment:
�; �� �_ -
�.: �--.
•,� —, -, . � _
P.o. �o�aoaz�-=J
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://slph.ncoublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
Name of System:
CHARLENE HORTON
HASSER HORTON RD.
Collected: 07/05/2011 15:00 H. Kelly
Received: 07/06/2011 ' 09:00 , Angela Heybroek
Sample Source: New Well Well Permit Number:
Sampling Point: Outside tap ` A30-4
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Darneice Lyons 07/07/2011
E. coli, Colilert Absent . Darneice Lyons 07/07/2011
Report Date: 07/07/2011
Explanations of Coliform Analysis:
Reported By: Susan Beasley
�;
�,�� ������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.
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH CHARLENE HORTON
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
htto://sloh.ncaublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
325 S MORGAN STREET HASSER HORTON RD
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES070611-0024001 Date Collected: 07/05/11
Date Received: 07/06/11
Sample Type: Sampling Point: Outside tap
Sample Source: New Well Temp. at Receipt: 6.5
Sample Description:
Comment:
Time Collected: 3:00 PM
Collected By: H. Kelly
Well Permit #: A30-4
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 24 mg/L
Chloride < 5.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.27 2.00 mg/L
Iron 0.40 0.30 mg/L
Lead 0.017 0.015 mg/L
Magnesium 6 mg/L
Manganese 0.23 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 7,3 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 10.00 mg/L
Sulfate 11.00 250 mg/L
Total Alkalinity 107 mg/L
Total Hardness , 86 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 07/15/2011
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Reported By: �e�le �1lo�ceol