A31 130�,�-1 `i �j.. 30d',0° t�e( i Per,vc�,F- � tg2o4 2,
3 I 4 0� �� ) �11d11�1� `V`� Tax MaP �
Application Date: Parcel#• �_
Amount Paid: O .00 I �D • ��,:`►'� '
s 4�sa �C��J�T°IC�"
Receipt #: 1 i��U µU ,��.�'so��ao�d�4.fl lH[��lL¢�_
�,►�ea. f-� r _ _ _ -----
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�� 7ao�
Anplication for Services
Services
Improvement Permit (Site Evaluation)
$200 00/$300 00 (if> 600 gpd)
Mobile Home Replacement or Bu�ldmg Addit�on
$150 00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In,,formation: / � m� �-�- �� ��
Name: � � ���SPhone (home): �"��17�S�Zl'�i
Address: (work/cell):
2) Name and address of current owner (if different than applicant): Phone:
Name: �'N 1.���'� -j-��'
Address:
3) PropeMy Description: Lot Size: 1' � Subdivision: i
, ��� �--_
Address and/or directions to Property:
0 yes ��n "Does the site contain any �unsdictional wetlands7
� yes k�7no . Does the site contain any existmg wastewater systems? _ ,
� yes' C�l no Is any wastewater going to be generated on the site other than domestic sewage?
D yes n���/o Is the site subject to approval by any otfier public agency?
❑ yes �io Are there any easements or right, of ways on this property2
(if `yes' is checked, please provide supporting ciocumentation)
s�54g-I���)
4) Proposed Use and Type of Structure:
�Re dential
ew Single Family Residence Maximum number of bedrooms�_
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes C�t� With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Ma�cimum number of employees:
Total Square footage of Building:
Ma�cimum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well � Community Well ❑ Public pate�r �� Spri eg �
Are there any existing wells, springs, or existing waterlines on this ro e ❑ y
6) If applying for `Authorization to Construct ; please indicate`�preferred system type(s): ,
. . O any
� Conventional 0 Accepted .D;Innovative ,�❑ Alternative ;..0 Other, ...__
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurateL or if the site is subsequently altered, or the intended t�se changes, all permits and approvals shall be invalid.
�
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
� �/
Date
• 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)
1
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P. c. e, P. �ai
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IO PROPOSED
� WELL
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PHASE I
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LOT !0
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�
�! Tax Map: � Parcel• � D
���) ���� �� Subdivision ►•��S
` � 1 � � .�a1 � I� ,�i�iti-a�,d rrJ
— � � � � � � Phase/Section/Lot # Q
7I�s��a���„-„-„ ����.Il IL���.Il�I�
Permit Valid for: Five Y
Type of Facility: ��i �a,
Number of: Bedrooms �
Proposed Wastewater Sys
Proposed Repair: ��l
Permit Conditions:
Improvement Permit
rs Non-expiring
New �Addition _
/ Occupants / �Fmployees / Seats:
� - - - ,._,., � t—r � _._.
Water Supply: �%
Projected Daily Flow: gallons/day
Type:
Type: -
(X) Owner or Legal
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
a�:rl Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed%�astewater System: � ro �?�al� Q���c�-ion �1�em� ('�)Type�g_ Design Flow 3�0 gal./day
New V Repair Expansio Soil LTAR:�� � 3 gal./day/ft2
Type of Facility: ��'� �c��2. �25�ci�y�C2 Basement: _ Yes � No
(*) System Types Illb, Illbg, IV, and V, require periodic sys[em inspeclions by tke Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank !`� gal.
Drainfield: Total Area � 1}D sq. ft.
Pump Tank-'�1 gal
Total Length . 0� ft.
Trench Width 3 ft. Min.Soil Cover �_ in.
Distribution: Distribution Box�/ Serial Distribution �/ Pressure Manifola
Specifications: {� -bo
�
7—b
Grease Trap ---� gal.
Max. Trench Depth 1� in.
D���
Min.Trench Separation � ft.
Authorized State Agent: Issue Date: �- Z�j -/�
Permit Expiration Date: � - 29 - / �
Tl�e system permitted is: Conventional /Accepted ✓/ Alternative / Innovative . I accept the conditions
and specifications of this permit. J'
(X) Owner or Legal Representative: Date: �[ 6�j /
Person Counry Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
���, sf ���.� ��
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SITE PLAN
Name Tax Map #� Parcel # � 30
Subdivision 41' �je(�5 Section/Lot#
' la'q—/
Authorized State Agent Date
System components represent approximate contours only. The contractor must,/lag the system prior to beginning the
installation to insure that propergrade is maintainerL
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— 300 ` /-� cc �ec�
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S ��43'34" E
� 225.00'
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7F��n.�a��s��n�nn��,Il IF-'���.11�I�n.
Applicant: ( �,ameran �
Location: �lq S --�
Operation Permit
Tax Map � Parcel # l�
Subdivision l�ii�d Shzc4l�erN �e�5
Phase/Section/Lot # 9 �
# of Bedrooms 3
System Type (From Table Va): � Product (IIIg): �Z—
Type V& VI Expiration Date: Type V& VI Renewal Date: �1
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
Anthnri�atinn.
Scale �Q,
PCHD, rev. 12/14/12
.7-�-/�%
(Date)
7-7-l�
(Date)
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Tax Map: 3 � Parcel #• ��
Septic Tank System Checklist (Type II-I� System Type: �Z,
Notes:
Pump System Checklist
Pum Tank InitiaVDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back lug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Com onents InitiaVDate
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Alarm float (6" separation)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
A roved and secured riser
Su 1 Line
Size and material: in. sch.
Length: ft.
���.s� ���.���
- � �c�����
�° �ra�vn�r��a�rxa��rn�.�.Il ����.Il�lia
WELL�ERMIT
(New 1� Repair_)
Tax Map: � Parcel: , 30
Subdivision: '►�; [� S�Yn i,� �err�.�5 Lot: �
(`
Applicant's Name: mP.ra r .J o n P�
Mailing Address:
Phone Numbers: q � q- �Z — DORB _
Permit G'onditions:
1.) See attached site plan for proposed well location.
2.) AZI applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not uarantee a potable water sup ly
Other Conditions/Comments: �A,l., i-�a �/� Gl li ��1� aG�S
Permit issued by � Date: GL' Z� �
�Tew Well:
EHS/Date
Location: �S/ - - �
Grouting: -( �
Well Log: g 1
Well Tag: - ZS-1
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab: " �i i+� iM$
Well Driller:
Pump Installer:
Approved by:
Certificate of Completion
�.iner:
EHS/Date
i:n�wucl� ' V r�Fr�, �r� Ca .
,� « ��
pE�c►� �. st-�
Additional Comments: � �8`13 Gk�'lu,l� 4�r�b Qp
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #: ZlaSa: �
License #:
Date: 8 a9 I�}
Date Sample Collected: - ZO -L Date Results Mailed: ��
EHS: ;
Person County Environmental Health
325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 11/26/13
Aug 2714 01:24p
..i�ES�,AEIirT�A� 1�lELY,�ONSTIt11CTi0IY RECO�tD
North Csratina Uepariment of�,:vira�� �N� R��� �h��n of Watet Qu&iity
w��.�. corn'nacroR cE�YxFrcArivrr ;a
f. iNPtL Cp►i'rRACtOR: _ �`�,.'—". •".—
h �
Well Contractpr (In�i " Nama
weil Con�acrnr Comnany rtame '""�""` •—
S i R EET �1DpRESS p� �!� 1. �
'S� �u�. �
Sfate ipCada
i�?�..�-__..�� ��i � f f
Area cade- Weane numper _
2.1A'ELL INFOt21�t7Tp�y:
"S{TE W�LL t0 ppr aypicaour
W��l CQNSiRUGTIOtY P�RM1T�
��ER'4SS�CWT�O PERMIT�t(if app�ita�e)
3- �1. i18E (CAetk APR��aOle Hazj: ResiQertGal 1Mater SeipPN
DATEORIti�� -
TlMECOfUPE.EFED�` :4 ^ AM�Y Pl��
a. � t car►a�:
rii� w ciourii7
. •
(S�Ret ksrna, Canntuniqt. SuOGMcian. Lot Np„ P��, ���
TOPOGfiAPFile !l.q� SE7T(NG:
c Srope s Yat�ey Y�tat D Ridga e pphat
trtracic aepropriue eo�c)
U�liiT{!DE �ay De � dtgee; '
""� �--�----- Itti►tutn, sccaods or
LOlVGfTCiiDE � in ade�;mal forteryt
LatiNdeliongitude sourc+�•� $ p �apo�hic map
f�CCa�ion or wsd mustbe slrown an a V5G5 tayoo map �nd
af�achad �p this lomi d�ot ttskfg GPS)
� y11ELt OWNER
OWNER'S NA1U;� ��� r S
STR�'T ADOR�5S —�"-
Ciry o� Tvwn SCdle .�iD Code
A�ea cOCE - Pi�png nuin� �
6. tAt�1.L Q�TA�tLs: �
� TOT/lL pEpTy;
b- ��S 4kELt iiEPLACE LXfBTNUG YV�L.C? YE59 fVO V
=. �YATEEi iEVfL 8ciow Top at Casing: �..
N� "+'i! Abos+e 70� ottas'rng)
t1. �OP O� CqSlNG t5 _ i w�f. �bove Land 5uriaca•
'T�G oJ casi �y �rrnlnated aiiGr he�aw iano sursace may ceqai�e
a raciance In �CCordat�ce wflA t 5A NCAC �C .Ot t 6.
9. YlEID (gp�n): � ��T►fOD dFTEST_C3�,�, ne• _
f�
4. �ssr�cc�oa:
g. WATER Zp� (IIgplh)-
�ram�_ �o�_
F:cm ro
� �_ To
7. CJLRIkfa� �
p.1
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From�,.,.,4_ ; d
Fr4n� 70
From 7a -
Thickasg�I
F�,_���'�� 0` 4m��r W�0 �1 aGal
�rom To Ft. .
Frorn To� Ft
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8. GROUF: Deprh fNalBt�ai MeNod
Frorn�_ To�_ FL ��r�'p,�
Fran:_,__�-�- To_-r..__ FL�� -T�"-i--^,
From To �t, �'�
9. �����N: �P� , Diarr�ier Slpt Siye I�Aater'raf
fi� io F� 3n, '
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From � To—�.�_ � tn, in_ ----..�.
FfO�T - �o FI..` at M ,
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1�. 3J1Np1GAAVEL. Pl1CK:
UBAUt �ze M2teti8l
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From____ 'Fp Ft,��"
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rcm ,To
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12. R�MARiCS:
• �Formation Description
r
t DO N6AEBv CERnerTw�r :ras v.� yy� CO►�,TraVCtEo araGco�t
�+s� x�c �C, wEu oorusrauCr� sr�upaRps. AruD tw�r � Copr of T�� `�n,H
NtC R>t�S EN PR4VIDED T01'/e YYCLLBWkER.
SiGNATiiRE 4F GF�iiF1EF! WELt CONTHACTOR pA7�
nQ�atr�r, .f�....- �_ i
.• u..w�naa vr pERSDPi �ONSTf2UCTf1+IG TH� YitELI
Submit t�a original !o the pirislan of Wafer Quaiity within 3Q d�ys_ Attr�: tnfarm�tio� A�pt.,
1 Ri17 Mali Srrvlr,a f �►nMr _ p�ta:..l. ►tn e-r�M ��� � ..�
�- r...... r..0 i � �
North Carolina State Laboratory Public Health
Environmental Sciences
i�icrobiology
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES102114-0078001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
CAMERON JONES
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://sloh.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
1843 CHARLIE LONG RD
HURDLE MILLS, NC 27541
Col lected: 10/20/2014 13:45
Received: 10/21 /2014 08:15
Sample Source: New Well
Sampling Point: Well head
J Smith
Angela Heybroek
Well Permit Number:
A31-130
Environmental Microbiology - Colisure Profile Method: SM 9223B
Test Name: Water - Colisure
Analyte Test Result Analyst Date
Total Coliform, Colisure Present Susan Beasley 10/22/2014
E. coli, Colisure Absent Susan Beasley 10/22/2014
Report Date: 10/22/2014
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
/ � ,
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.
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
CAMERONJONES
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slah. ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
1843 CHARLIE LONG RD
ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541
EIN: 566000331 EH
StarLiMS ID: ES102114-0104001 Date Collected: 10/20/14
Date Received: 10/21/14
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 2.5
Sample Description:
Comment:
Time Collected: 1:45 PM
Collected By: J Smith
Well Permit #: A31-130
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 80 mg/L
Chloride 15.00 250 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 18 mg/L
Manganese 0.39 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 8.1 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 15.00 mg/L
Sulfate 9.00 250 mg/L
Total Alkalinity 258 mg/L
Total Hardness 270 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 10/29/2014
Page 1 of 1
Reported By: Arnold Hall
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �Qi�e-i- yQ�S
Address �g4� ehc��1�� L.� o�c�
Collected By��
County PERSON
Date Collected � � a � l� Time Collected �j : 9-( o,r.
Source: �Well ❑ Spring ❑ Other
Location: ❑ House Tap
❑ No Charge �Charge
-�Well Tap ❑ Other
........................................................................�
************************************************************************
Total Coliform
FecaVE. Coli
Results
Present Absent
❑ �
❑ �
Reported By �
Date Reported �� � — %Y
Report Called 0 YES ❑ NO
Called To: