A30 72t
1
The Dist� �ct f�ealth Departmer�t
Orange, Person, Caswell, Chatham, Lee Counlies
..,
`� Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Date �
x Owner: � . �'.,
u
0
pq Location: ( �
• e� ',.�.";-�� .f�13 '+5.�-=.� � � . .
J' +!
,j�:�� Contractor: ---
� Water Supplyd Private � Public
�7
Sewage Dispos acililies: No. bedrooms -� Dishwasher, Disposal,
1 washi�m�Chine.t other automatic appliances
•Size �of tank: ' '��� � �' -'�'2�= Nitrification line: �� ' � ��
• v, • j} �Jl ✓ � �
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
5eptic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner-as-not-to-�r ate a public health hazard.
Septic tank and nitrification line ,�IUBT B� INSE'ECTED AND AP'-
PROVEB BY A MEMBER OF THE DIS�RICT �LTH DEPARTMENT
STAFF BEFORE ANY POftTION� bF THE INS AL TION IS COV- -
ERED AND PUT INTO USE. ;, ;' � 1� „ '
�-_. � j��� � f �,t ;�`!_ nf �"
t, fr
� ��
Date approved: " t t Signe `.�.�� r' �"s' ''��;,jj.�t'�''� ~
• 'j �, Sanitarian �
Well: � "
�
Sewage Disposal: � �
i
By: �
Certificafe of Co letio� �
Date Approved / �
Counter- i
signed
(Owner or his representative)
. �
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/ / '
Fi / �,�
: ` j �, ,f
By: i �'
Sani�arian
(OVER7� • •
Location of well and sewage disposal facilities sketched on back.
.
�
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
(1j (2)
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- �� CG34
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # ,� =�l% Parcel # `?'7 �
Zoning /�Townshi _��fa�.. ��
ClwnPr/C'nntrartnr %�� s�:�. /�C.� %�.� �� Date - �
oti �-f
S.R.# //���
Location/
Subdivision Name Lot#.
�
5EWAGE SYSTEM SPECIFICATIONS
r Lot Area -j "� ��+'� S Size of Tank � �
Mobile Home t�' Size of Pump Tank "IA
ess # of Bedrooms�_ Nitrification Line �CL�,1C .7 �
Max Depth Trenches „2 [, ��
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere m nd use anged.
Well and Septic Layout by
Comments: __ _
�� Date � i/-` _�`1�Installed by rn � Approved by
�
� Well Permit Paid WELL SYSTEM SPECIFICATION5
�
H Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved ✓ Required Well Log _
Well Head Approved Well Tag _�
�ro� uting H
Comments:
Installed by
This report is based in part on information provided the homeowner or his/her representative in the application submitfed for this permit. The
environmental health specialist is no[ responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wa�rants that the septic
[ank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
`� �.Sv��
. . �� . PEP,SON COUNTY ENVIRONMENTAL IiEALTH '
_�
: WELL LOG
� Date:�,1�— � � � � .
Owner: G' ,, � /� � = � �
Location/Directi ns: � � �� jz.�� //A ��
SR# ,1�,6� . � �
��b'�vision Namc: Lot #
Drilling Contractor: � ��.�r Gr/� l� �
WELL CONSTRUCT'ION
Distance from Nearest Property Linc �s Distance from Source of
Pollution /D � /��'�S
Total.Dep.th: � Ft. Yield: GPM Static Water Level t� Ft.
Water Bearing Zones: Depth ��Ft. ,��F� - Ft. �t.
Casing: Depth: From_�to�Ft. Diameter: 6= Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight: ,�.3 Thickness: ,Height Above Ground: i � Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �
T � � `.
Ir 'yes" give reason:
Grout: Type: Neat Sand/Cement Concrete �
Annular Space Width Inches
Water in Annular Space: Yes � No =—
Method: Pumped Pressure Poured
Depth: From (� to � d r t.
Materials Used: No. Bags Portland Cement�_ Weight of .1 bag�_lbs.
If mixture (sand, gravel, cuttings) - Ratio: � to r
ID Plates: Yes � No � � �
� 4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
___��c�-n, — ��l'���- �o .- L�%s.i
Signature of Contractor Date
�
Application Date: o�— � —Q _
Amount Paid: 1 0. UD
Receipt#: ► D 3 �1 �
�� �#- �.�,� S s� I�'I�I�.� ��7
.% J _ � � � u����-
a� V� / IE�..:ca.wn�a: .c:av-n.ira-x�_.t•+.�cnd:,tn..Il. TL-`�Ia�.cn.�.d:..�-n
Application for Services
(Sentic Svstems and Welis)
� Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: � 3 4
Parcel #: �_
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If tlte information in tlie application for an Improve�nent Permit is incorrect, faJsified, or tlie site is altered, then t/:e
Improvement Permit and the Authorization to Construct slial[ becnme invalid.
1) Services Requested b :
Name: s �' �G�
Address• � ��"�� l�5"
�ol�h o�v � � ,zT��3
Phone # (home):
(workL�: 3� lo -5��%7—�`Z z 3
2) Name and address of current owner (if different than applicant):
Name: T ` R� -v�-r .��� `'
Address: o/.� ��i'
x ` 7� �3
��
3) Property Description: Lot Size: 3�`'� � Subdivision:
Address and/or directions to Property: ,��� J�,
Lot #:
4) Proposed Use and Type of Structure:
Residential _ � Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes �No _(with plumbing: Yes� No __) Garbage disposal: Yes _ No X
Approximate size of building foundation: Length 2�T � Width �G �
5) Water Supply:
Private Well � (Proposed Existing _) �� ��'�"'f%
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and locatiort of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that tlie property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid. /� �. .. /%
Signature (Owner/Legal Representative):
�D
Date: � v
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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���� �a���ti��! i�il�b�� ���a� ��iac����i�
T� �� #: � 30
� �. . � -. - -. .
Parc�i##: � �
�l�to�Ce Hc�e Re}�l.aceme�t
Buildimg �,ddition � .
A�plic�n# N'asne:
� Adt�'e,S9: ' ' Z.S gar
� . � � l�l �' � �-a�, �1 c 2_130 3
' P'h�e �'�:
, V �Y�s . �Io �. .
Peanrt Lmcated:
. insrallat�� Date: I n- 2� - R� D�sign �ow:. �( Q_ {gPd)
Cu�nt Cantraet �vith Cert�ed Opeerator an file (if res�uire�: �
'� Water Su�piY: �, �Ie�l � Fublic o� Camm�aity
�
�
�
�7'aste�vatex syst�em sho� nm vssuai evidence of failua� on: �' 7� 0� (date)
� � . (A�Plica�t's sign�sre if �ite �rt is not �e�
' � ������������a� :�pr����
1 •
Z-��'og'
` n�ental� Heaith �pe�iali.st � Date
111i�105
� . .���,�� ������ ..
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7 � � ��� i
' IE�.��-�� � ��.�.�.H. 7HL�.m.a�
SITE S�TCH � .
Name � Ta$ Map #�Pa:tcel #�
Subdivis' _ � Section/Lot#
" 2-�� -� � .
. A thori2ed State Agent . - Date .
System cam�ionents ne�resent a�proximate�cont+ours only: The contractor must, fTag the system prior to ,
beginning the installrxtion to insure thatpmpergmde rs nraintuined
0
Y�
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Application Date: � � � (��1
Amount Paid: ' 06 , O 0
Receipt#: 0 3 _
Tax Map: /'�"3�
Parcel #: ?�
�� �`-��. �� ���..� ��.��.
-- �� <O ���'�
I� : �:i w-:i i .cn �z ��^+�-� �r-� :ia �i::zz� Il IL-3� <e-_,.�n.1 oy1�a
A�plication for �er�ic�s (Septic Systems and Wells)
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a��,�e'�
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Ses-evic�s Re uested
C Improvement Permit (Site Evaluation) � Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of svstem ermitted)
❑ Mobile �Iome Replacement or Building Arldition �J Permit Revision
$150.00 (if site visit re uired) $75.00
C 6i�e�1 Permit ( placement/Itepair) ❑ Repair of Existing Septic System
$300.00 $200.0 /$75.00 No Char�e
1) ices Requested by: L
Name: �M�►�c W• i✓jo�T�t v� .� r
Address: 4 0 )o n A-� c„
x, �� Nc Z�S�Y
So 7,�
Phone # (home): ,33(0 �Q9 �^
(�vork/cell): ;33� S// 2730
2)11oTTame and address of current owner (if differ�nt than applicant):
Name:
Address:
3) �rogerty �escriptnon: Lot Size: 3'f� A�r
Address and/or directions t Property: y9.S' P�!
� M� �-e n� f�ch�
4) �roposed Use an Type of Structure:
Residential Business/Type: Other
Number of bedroom� ,3 / Number of people served (seats/employees):
Basement: Yes � No (with plumbing: Yes No �
Garbage disposal: Yes No ✓
5) Water Suppl�
Private Well (Proposed Existing _�
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
vot #:
����� � � � ACI�.
(please show location on site plan}
1�Iote: A completed a�nlication mus� also include:
➢� platlsite plan of the �ropes�ty that sltow� pYo�erty dimensions and tlYe size and locntion nf all
proposed structures. � .
9 A signed capy of tlie `.�at Preparatiora' for�n verifyin; t/tat tlae property i� rsady �o fie evaluutec�
� am submitting this ap�lication to request �ervic�s from the ��rson CounB� �ie�ith �epartment. � unalerstand that
if the info��ation provided is incorreet or if the site is subseque�atly altere�d, or if the intended use changes, a�l
peranits and approvais shall become invalid. -
Sag���ar� ��wner/Legal Repr�sentative): % �-
���� : 3 - I I -o �
10/03 Person County Environmental Health, �25 S. Yior�an St.; Suite C, Roxboro, NC 27573 (336-597-1790)
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Pv��i�a�Ada���s5: IQao JoL,r A-(I� � �d.
�o�c��csro f�C� 275��
�'�n�ne i�aaa�i�e�: �{ 1 SRq -� o� S_ �G�- � ��4 - 2� 3�
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af qO. -
��s��nit �o�sda8aoaa�:
1) See attached site plan for proposed well Zocation.
2;� All cr�pdicable State and Counry Negulations goveYning construction and satbacks a�ply.
3) Permits expire S years from the date of issue.
d��3�er �'a�adati�ns/�o�eengs: � r- �� �� � �_
e� , � � 1
����aa� a�5�er� �Sy:
1��� `�✓`���� ���p���o�:
Location:
Grouting:
Well Log:
tiVell Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
— �����: �— f �— a�
���'�'���A�'�' ��' ��1���'�'��I�
,•
'�Y�� ���ero �'�rC �Pz-
�a�e� ��s�������n:
EHS/Date
Tnstaller:
Depth:
Grout:
3�Ie� A����o����a�:
EHS/Date
�ompleted:
IV�e�od/Material(s): _
�,a���a�� #: 32�
Pump Installer: License#: i •
-�
�i�IW�� �p�r�w�d ��• ��te: �' ( d �'
Date �amp?e Coilected: S'� �1-U�
P�:son County Environmental �ealth
3�:; S. l�torgan St.; Suite C
Ro�:boro, NC 27573
Date Results Vlailed: � I q- 0
Phone: 33b-�97-1^90 r�.ti: =30-�97-7808
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Mar 31 09 03:51p Keith L. Barnette 336-598-9275 p.1
WELL ABANDOIVMENT RECORD
North Carolina Dcparrmccit ofEnvironment and Natural Resources- Division of Water Qualit��
WELL CON1'RACTOR CERTIFICATION # 3 Z 6�
1. WELLCOLVTRAGTOR:
��-� v i S 4 r� e�fe
ell Contiactor [individua3) Namc
t� r�� �� e.- i„% �P,�i( I��f ��� r n U
Wetl Con�ractor CompanyNunc �—
Sf'RF.ETADDR.ESS I G� �i7�C �, Pn r` �
�oxbo�o /V �L 2 �? .�'7
C�iy or Town State Zip Codc
c'-�3C � - __S"�i4-0ol�
Area code - Ph pco n�umber
2.WELLINFORl1tAT[Of�I: ,yI/n
SfTE WELL ID #(if appiicable) Jr� i�
STATE WELL PEitMIT �/ (if npplicabieL,' �` ,� �
COUNTY WELL PERMIT H("dapplicable)_/ r/�
DWQ ar QTi(ER PEEZI�IIT q(if appliqblc) �
4VELL USE (C��le epplicahle usej: Monitoring Residen '
hlanitipaUPablic IadastrinUCommercial Agriculturst
Recavery lojeet[on Irrigatioa
Other (list uu)
3. WELL LOCATiON:
Cd[JNFY (S O n QUAARANGLE NAME
NEAR�S'T TOWN: � � 11 �0
� q0 ��h� ! P�
(Socc�llt.00d NamG Num6er. co��uy. s�na��oa, t.�tr�.. r�i. z;P caa�)
T�f2P�GRAPHIC / LAND SETfING:
to Valley Flst Ridgt Other
(Circic appropriare sctlin�
I.ATTTUDE --1�y be in degea.
-- miautes, s¢auds, or m a
LONG7�{JDE . �dccimal focccwt
LatitudeJlongit�de source: GPS Topc�grap6zc map
(Laca�ion of we!! musl be shown on a USCS (opo map and
otloched to Ihisfarm �rrot usi�rg GPS.J
4s. �'ACIIdTY-'[hc namaof the busmeuwhcre the wdl is lorated CompWc 4a aad4l�
crh msiewui�� wel l, sk�P a,; eeropiete 4b. wr3l�er inrazwetion ody.�
FAC[LiTY IA �(if applicable� � �
NAME OF FACIL,ITY
S'i'REET ADDRESS
�iry or Town Sfate • Zip Code
46. CON'i'ACT PERSONNVELL OWNER:
rIA3� � r'� l�1 i- `Q (� �
srxr�r a►Do�ss 6`� 0 a� �} Il en �.' �
l�ox6ol�� � Z� �'��/
c�cy a ro�, s�c� z�p c�
3�-�y�-��"�S
Area cade - Phoac number
5. WELLDETAlCS:
a. Toial Depth: � G � tl.. Diametcr.��i��,
b. Water Level (Bclow Mcasuring Point}: L/ D ft.
Mcasuring point is � ti. abovc land surface.
6. CASINC:
a. Casiug Dcpth (ifknown)�
b. Casiag Removed:
Length ❑iametcr
0 3 ft. � i n.
ft, in.
7. DTS[IVFEC'fION: I G � �
(Amount of 65•�.-75°!o calciam Irypochtoritc used)
8. SEALING MATEWAi:
Neat Cement
Cement Ib.
Wata gsj,
Bcntonite
Bcntonite ►�.
Type: Slurry_Pellets
Watcr g�,
4thcr
Type maicrial
Amotmt _
Sand Cement
Gement � � Ib.
Water � D G 8a],
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20. WELL DIACRAM: Dmw a detazlcd sketch of che weif on the back of this
form shawing tota3 depdy depth aod diamUer of sauns (if auy) mmaining
in tfie wd�, gravd interval, intervals of casing puforations, and depths a[�d
types of fi13 materials vscd.
i � nwz� w�i.[, a.sAxnoxEn 3� � i" � y •
I DO I�REBY CBR7'[FY TiiAT THIS WPLL WAS �.HANDONED 1N AG�CORDANCE
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7�IIS RECORD HAS BEEN PROYIDID 1'O 17� WELL OWNER.
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ATURE F CERTIFIF.D WELI, CON['[2ACJ'OR DA?E
SICIVA'IiJ[tE OF PRIVAT$ WhT,L pWl�ABAh[DpNiNG 77r[E WELL DATE
(I7�e private a�ell awner mnst 6� aA indiridml vho nal abandons bislha resid�tial well
utacwcdartcc lvilh 15A NCAC 2C .DI13.)
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P Ni'6D NAME OF PERS IY ABANpONING THE WFZL .
Submrt a copy tp tie owoer and the origioal to the Div'sion of Water Qnality Nithm 30 days. �'orcn GW-30
Aun: Infor�atioa 74ianagement,1617 Mail Scrviee Ceoter– It�leig6, NC Z7699-1617, Phoac No. (919) 733-70I5 ext 568. Rcv. 5/06
Mar 31 09 08:43a Keith L. Barnette
336-598-9275 p.1
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P[.'k� reQU1�27144
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28047 -- 306 N. Wiimington St. -- Raleigh, N. C. 27611-8047
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM
Name of System: Montague, Tommy
Address: 690 John Allen Rd
Zip:
County: PERSON
Report To: Person Co. Health Dept. ATTN:
325 South Morgan Street Ste C (336) 597-2371
Roxboro, NC 27573
Courier: 02-33-15
Collected By: J SMITH Date: 5/4/2009
Location of sampling point: Outside spigot
Source of Water:
Source of Sample:
Type of Sample:
Type of Treatment:
Type of Analysis Private
Time: 1:50:00 PM
Remarks: Permit # A30-72 - �
Parameters Results Units �� Date Analyzed: '
Silver <0.05 mg/I ' '= 5/5/2009 '�
Alkaliniry as CaCO3 42 mg/I 5/5/2009 .
Arsenic <0.005 mg/I 5/5/2009 '
Barium <0.1 mg/I 5/5/2009
Calcium 7.3 mg/I 5/5/2009
Cadmium <0.001 mg/I 5/5/2009`
Chloride IC <5.0 mg/I 5/5/2009
Chromium <0.01 mg/I 5/5/2009
Copper <0.05 mg/I 5/5/2009
Fluoride <0.20 mg/I ' 5/5/2009
Iron <0.10 , mg/I ` 5/5/2009
Hardness as CaCO3 (Ca,Mg) 30 � m�/I 5/5/2009
Mercury ' <0.0005 . mg/I 5/5/2009
Magnesium ' 2.9 mg/I 5/5/2009
Manganese <0.03 mg/I 5/5/2009
Sodium 8 mg/I 5/5/2009
Nitrite as N <0.10 mg/I 5/5/2009
Nitrate as N <1.0 mg/I 5/5/2009
Lead <0.005 mg/I 5/5/2009
pH 6.0 Std. units 5/5/2009
Selenium <0.005 mg/I 5/5/2009
Sulfate <5.0 mg/I 5/5/2009
Zinc 0.86 mg/I 5/5/2009
Date Received: 5/5/2009
Today's Date: 5/15/2009
Report Date: 5/15/2009
Ref: 6220 Login Batch:
Reported By: ���Q 1 _��
Sample Number: A688949
Explanations
Coliform Analysis:
If coliform bacteria aze Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
u
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH Tommy Montague
325 S MORGAN STREET 690 John Allen Rd
ROXBORO, NC 27573
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://slph.state. nc.us
Phone: 919-733-7834
Fax: 919-733-8695
StarLiMS Sample ID: ES050509-0051001 Collected: 05/04/2009 13:50 J Smith
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ` Received: 05/05/2009 09:16 Angela Heybroek
ES Microbiology ID: 4494 Sample Source: ; New WeIL 5 Well Permit Number:
GPS Number. Sampling Point: : Outside spigot , A30-72
, ;,
Sample Description:
Comment:
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert a
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Joy Hayes 05/06/2009
E. coli, Colilert Absent ' � . Joy Hayes 05i06/2009
Report Date: 05/06/2009 . Reported By: -Joy Hayes
Page 1 of 1
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1