A30 63�, �i
Aaplication Date: Z��O�
Amount Paid: 0�00
Receipt #: �. `1 U�
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APPLICATION FOR SERVICES
Tax Map #: �3 O
ParcEl #: � 3
IF THE INFORMATION IN THE APPLlCAT10N FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFlE�,
CHAiVGED OR THE SITE IS ALTERED THE911 THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
COMSTRUCT SHALL BECOME INVALID. - ,�
1) Permit requested by: (Owner ge prospective owner): �.?�'r� �—
Home Phone: Address: 2n ' �
Business Phone: f � � ��
2) Name and address of current owner. �2.� !n ,�� t�
3) PropertyDescription: Lotsize: ��3�' Township: '�i�Subdivision: Lot# �
Directions to the prop�ty (IncJuding roadpar�es and nurr�be ): , „_, , � �
4) proposed Use and Structure Description: answer each f th Ilowing questions:
a) Proposed �, Existing , Type of Structure: � 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) �arbage Disposal: Yes , No �
5) lNater Supply Type: Private �(new � or existin�, Public� Community� Spring _
Are any wells on adjoining property? Yes No �,If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ iVo,�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEi2TY OR SlTE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AfVD CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PR�POSED �OCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPs4RTMEIVT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
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 inv lid. f
��. ��� -o r �
Owner or Legal Representative
Date
� PCHD, rev. 06127102
\
'�
,
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AppliCan� �"�� cCC�
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T��x CJi:.;i G� '� r c:>.I :'
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P i�Yc:i_�•L' Sl'�� Gl;O:hl! L.a t�
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. �ffi�B�IID��'ffi�$ �C�fl� ; .
Pezm�it �aiid for ✓ g'+ive 'Ye�r�. I�Tq� �ira#s�n '•
Type of Fac�ifi,�: l,� '�'aY•.l � �� New ✓�ddition i��tt� �upply � t�,�i c�+�
# of Occupamb �c� # af B om� ,�_ Pxojected Dat�y Flow 3c�o g-P•�- •
Proposed Wastewater S�stem: i�'rr� �, �•� C a5%, re ��.a �.� � . Type:
Praposed Repair. f-{['(,O(.7a� � C a5% �xa.r.w.�►�.� ' ' 'TYPe: .
—�'�T
Pe�it Conditions: �l 1�� 8��sk�,�tck.. ��c.t- .�nu. --�� l�� � c✓rt/ Guc,s+�►o�,- -
's�.
Qwner or Legal ]
Authorized State
r1�¢/'' Q/1 hi'�¢' s20 hi '
;�."l +U • • �ct—�'� �
�s . - �
Date: �-I,5'- I ]
Date: � -a -os
J
"rho issuaace of ifiis pe�it hy the Health ep� in does not guarantea die issu�nca of other pcmute. it is the respons��lity of the
aPP�P�P�h' awnter to m stue that all Pcson Cotmiy P'la�ing and• ZoninS and Bu�7dmg InsQections reqnirements are met �9ais
I�proven►ent Per�lt is su�jeet ta rev�cation if t�e �ite plan, plat or the in#euded ease e3aanges. Tlae Improve�ent Permit is no# affecte�
b� a'c�nge m ovamership oi th� P�lP�- �� P�¢ was isaueai m compliance wiih the provisions of t�e 1V�rih Carolimma `Lrrws m:d
,t� for S e Treabme�ei amed Disnagal S`e»ste�ars' {15A NCAC.IBA 1900). Neitf�er Person ���nty nor the En�vironmentai Healtia
Special�st �rmrrants that �Ipe sep�8c t� systea► wn7i con�►ue to f�c.d6on s�tisfactoral� ffi the futnre mr that tlaa �a#er snppl� will remain
potahle. � " � ,
�An�o�taon t� ��nsta�c�'�a�v�a#er� Sy�stea�i (� �or �uiya� �esmit) .
* See site plan and addi#anal c�#achrnents (� � �
Proposed. V�astewate,r SYstem: Acca�lc.Z. C a5l ��,.�.w, � Type� Wastewater Flow 3Gc� . g.p.d
New ,% Repair Fa�in�ion ��� So1 �'� . a�5 g.p.d.! $ 2
Type of Facility:. s� �� r}-t..,,,.� .�w�.w ���Basemeut �Yes x No
�F�e�vater Sy�� Reqnireme�t�
Size: Septic'T�: � ovo g�ll . Faa�P �aa�: -- � gal' Gr�ase Tra�: �' S�al
fie1d: 'I'otal Area: �a�9 sq f� '�ot� Le�gtla �3O ft 1dlaaimum'�renc�a IDepi�a. a8 ffi
r.h ��� s� f�t Soa� Cover: �_ � 11�nimum Trench �epazation: 9 $
Dist�a#ion: �- l�istn"butian Box Serial Distabution
.
3peri�cations: �ollow s��c ak� Ca . "' �
.� .
�,
�aat�ao�a� 3ta�e Age�: . l ��. `
Peanit Expiratinn �ate. � -�
.Pressure Manifold
Date: � -a--o5
The type of system pernzi-ttesi is Conventional �i.. Tnn.o�ative Al#ernative, I ac��pt tii� spacifications of
the peimit ' f - I I
��erll.�g�i �e�s�e�#'s�re• � ; � �� � � Date' � " f �
� . - �L'i�7/3012002
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' Authorized Srate Ageat D te � K,'el�l� �'` �l [��{
System compaaeais rrpiesmt spprvx�ate adatouav anlp. The coaaacmrmust9ag tfie sysuem pdor to begianiag �e iasnllation tv "" 7
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Taz Map:
Applicant's Name:
Mailing Address: _
Phone Numbers:
Location of Property:
W��L PEI2NIIT (New�C 12epair�
Parcel: V 3
�., �- �1��= �q
I'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 5 years from the date of issue.
Other Conditions/Comments: -
P�rmit issued by:
I)ate: �0 �Z /0 �
C�R'I"IFICATE OF C�1dI�'LE'I'IOI�T
New Well Inspection:
HS/Datef,ar3 p�9 ��P�i
Location:
ti' � `
Grouting: u �
Well Log:
Well Tag:
Pump Tag / _ �`�1•�
Air Vent: ,/
Hose Bib: ✓
Casing Height: ✓
Concrete Slab: ✓
Liner Inspection:
EHS/Date
Insta11er:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: /�P�v�d-`Z I.icense #:
Ptunp Installer: —� License#:
Well Approved by: ���,�Q ���,�- Date: �� �� �\ I
I�c-ic,-��- glal�►
Date Sample Collected: �(��%�� 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
: "r.STATF,�•-
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: +�P r3 , �1 ��,
/ � �, ..1, •
'ry/(� '•�' � 1>.:
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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # � �-C % � Iq
1. WELL CONTRACTO�f : (�
�/av/s t��t��1��
Well ConVactor (Individual) Name
Bamette Well Driilina Inc
Well Contractor Company Name
611 Barnette Tinaen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code
3r 36 � 599-0015
Area Code Phone number
2. WELL INFORMATION: �, �3b
WELL CONSTRUCTION PERMIT# I ��
OTHER ASSOCIATED PERMIT#(if appticable) / 6 3
SITE WELL ID#("rfapplicable)
g. WATER ZONES (depth):
Top� Bottom 1 s2-- Top Bottom
Top 2`S'o Bottom Z SS Top Bottom
Top�_ Bottom � • Top eottom
Thickness!
7. CASING: Depth Ulameter Weight Material
Top�_Bottom %3? Ft. 6�10 SD�_z/ PV�.
Top t 3% Bottom�_ Ft.� •«� a��✓•
Top Bottom Ft.
: 8. GROUT: Depth Material Method
� Top U Bottom�_ Ft. Sand/Cement Poured
Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
3. WELL USE (Check Applicable Box): Residential Water Suppiy f� : Top Bottom Ft. in.
DATE DRILLED ��3 �' �� Top Bottom Ft. in.
TIME COMP�ETED �� d AM ❑ PM Cy� � Top Bottom Ft. in.
4. WELL LOCATION: 10. SAND/GRAVEL PACK:
Depth Size
CITY: l /�l COUNN ��S+oH : Top Bottom Ft.
� L � ��,� � Top Bottom Ft.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOp BOttOm Ft.
TOPOGRAPHIC / LAN SETTING: (check appropriate box)
❑ Slope ❑ Valley lat ❑ Ridge ❑ Other
LATITUDE 36 °_' " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 ° ' " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: �GPS ❑Topographic map
(locafion of.well musf be shown on a USGS topo map andattached fo
this form if not using GPS)
5. WELL OWNER �1
, S•t+hh�/ rTaw%/Ns
Owner Name
Kasst I �o. �•'t � c�
Str et Address
,�,�� .r.a7
ity or Town State Zip Code
c �31 � �?y- Z( Z�i
Area code Phone number
6. WELL DETAILS: /�
a. TOTAL DEPTH: Z�' � r f
b. DOES WELL REPLACE EXISTING WELLT YES ❑ NO ❑
c. WATER LEVEI Below Top of Casing: Z. 5 FT.
(Use "+" 'rf Above Top of Casing)
d. TOP OF CASING IS �_ FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �_ METHOD OF TEST BIOWII 2O
f. DISINFECTION: T y p e HTF'I Amount �/ 2 C u p
11. DRILLiNG LOG
Top Bottom
�/ 3
/ O
�� �—��
,(, ZZ/ Z G v
/
/
/
/
/
/
�
/
. 12. REMARKS:
in.
in.
in.
Material
Formation D�scnption
�� ���
�� 4�S
�r�v i-a �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
; ACCORDANCE WITH 15A NCAC 2C, WEIL CONSTRUCTION
: STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
: PROVIDED TO THE WELL OWNER. �
_. �� �� 3-3�-r1
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
R' l T�Vi 5 1,�n Pf� �
: P INTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300
Fortn GW-1a
Rev. 2/09
���.s�� ���.� ��
`�_ _ �, C� � �l�'I�� �
I������,.�„ ���.�.I1 IE33L�.�.Il�I�
Operation Permit
Applicant: a"�'� 1 u� � � K� ✓�
Location: „ , __ n .. � r !
Tax Map�� Parcel # � 3
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 Authorization.
System T e: (In Accordance with Table Va): �_
Initial: � Repair: Expansion:
---.. . . __ ... _ . . . . . - � --- -- .. . .. —__.__._...__._. ._. .
_ .. � �. .. _ . .
HS/REHSI
�� �P,c.v�3 _
Licensed Cont�actor
Scale
Product: �2" ��L✓
33 -� �
� f�t4�P..ti �'
�s�( (
. _. 3- 2 3 �i1._ ._.: _....
Date
`3z3��
Date
�
Tax Map: �3� Parcel #• �3
Septic Tank System Checklist (Type II-VI) System Type: � � Z�(Uw
�
Se tic Tank InitiaUDate
State ID& Date: 7-13 ��o S 3 23
S`�r3 r �z
Capacity: vv
Tee and filter !/'
Baffle ✓�
Vent
Riser
Outlet boot
Perm. Marker l/
Distribution
=D=box (le�els _set)_. ,_
. ... _ ._._ _. ...._
Serial
Pressure Manifold
LPP
Notes:
Pump System Checklist
Pum Tank InitiaVDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
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
Pum model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Ala�-m float (6" separation)
Anti-siphon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Length: ft.
�
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ESO42611-0028001 Date Collected: 04/25/11
Date Received: 04/26/11
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 7.5
Sample Description:
Comment:
Name of System:
WANDA TUCK
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://slph.ncoublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
36 HASSEL HORTON RD
Time Collected: 3:00 PM
Collected By: B. Holt
Well Permit #: A30-63
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 9 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 1.10 10.00 mg/L
Nitrite < 0.10 " � 1.00 mg/L
pH 7.2 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 39 mg/L
Total Hardness 31 mg/L
Zinc 0.86 5.00 mg/L
Report Date: 05/05/2011
Page 1 of 1
Reported By: ?ie6�ie �%laKeol
Application Date:
� --3Q �1 �
Amount Paid: _
Receipt #: _
❑ Improvement Permit (Site Evaluation)
. $200.00/$300.00 (if> 600 eudl
J�Mobile Home Replacement or Building Addition
� $150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
=�� � (� ��q ���� Tax Map:
.r. ,,. � • � � Parcel#:
'"'� c���.TI�°II°�
I�+,:�rno-nu-¢nunmcnae�.2nd,m..11 ]C-3I�e,.m.�l.��r.
ication for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf rmatio :
Name: o � � V- ti
Address: !o �c � a�� �v► ,
r " c � C 5 �� �
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 33 � � 5'� `� • /� %' �rcc /�
(worWcell):
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address andlor directions to Property: �
❑ yes [ta-t�o Does the site contain any jurisdictional wetlands?
�es ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes �� Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
T �� �
4) Proposed Use and T e of Structure: �j `/ I��d ����� ����,
YP
L�tesidential / y' X% 7' �� 6ti ��`�� L�
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: l� New well ❑ Existing Well 0 Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� � ��� �
/�
ignature (Owner/ Legal Representative*) Date
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
I � ) ��
t ' �� !'� � � � � �
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:.1_:si:]L"L�9"1L7i"ct����{:Il'�.1��..i1 .ti�i �.tA.11 "�.11�
�a����1��3 r���n�m��/ l��a�ba�� ��a�a� ��������na��nt� �
Tax Nlap #: �� Parc�l#:� Address: �'�� � l��"`�'^ r�`� •
� . ,r �S C a /
Approval Requested for: Mobile Home Replacement
�_ Building Addition .
Applicant Name: t
Address: 4'' S �2
Phone �#'s: 7 � �-. (f� g�
Permit Located: � es No
Tnstallation Date: Design flow: � 3�0� (gpd)
Current Contract with Certified Operator on file (if requued): �..
Water Supply: �_ Well Public or Community
Wastewa#er system shows no visual evidence of failure on: ���� ���- (date)
(Applicant's signature if site visit is not required) Y
Comments: � � S�`���
.Q�'� 5-� � ( 4 .
� Qc�x 12 � �C2�!' 4��
�'�•. ' L � ' • •.. : • ��. • � % .
� �
A�3�������������a�aa� ��p�ov�edl
� �
Envirorunental �iealth Speciaiist
0 2
Date
PPrson Co�n�� Environm�ntal tiTealth; �?� S. yiorQan St., Suite C, RoYboro, NC 2 i � � 3
Fhan�: ��6-597-??9C/ ra:c: 3��5-�9 �-7503 � �v�:���i.�ersoncottnt��.i,e;
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