A31 133Application Date: �� I 3 .��� �� ��q ���� Tax Map: � 3 I
Amount Paid: �� .�,.: �' �- Parcel#i �
Receipt #: I 7 � � � � � ����
TE:"�aavnn-cDan4�raeem4":�.A 7HI�m.H.9��a.
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❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd) _ _
❑ Mobile FJome Replacement or Building Addition
$ I SO.OU (if site visit required)
� �'Vell Permit (New piac ent/Repair)
$3 00.00/$20 .�00/b75.00
ilication for Services
Services Re uested
❑ Construction Authorization
(Fee is de endent on the type of
� ❑ Perinit Revisiu;�
I $75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: � j�l Vi 5 � f3� rn�F�
Address:1n6� V���a`► ��"'�+ Z�_
�n�( {x�r o,/Y L? 7 5� �l
2) Name and address of current o�vner (if different than applicant):
Name: �nn�� r�urk� Pr-
Address: ��� r� 1 e ? !�r
���f� ,�,►Ils �� 2�5�1(
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Properly:
Phone (home): � 3 6-��3 -p �Iz y
(work/cell):
Phone:33� - 3� y-�/� 6 9
Lot �#:
❑ yes 0 no Does the site contain any jurisdictional wetlands?
O yes ❑ no Does the site contain any exist'vig wastewater systems?
❑ yes ❑ no Is any v�aste�vater going to be generated on the site other than doriestic sewage?
❑ yes ❑ t�o Is the site subject to approval by any other pubiic agency?
❑ yes ❑ no Are there any easements or right of �vays on this property?
(if `yes' is checked, please provide supporting documentation)
4) Pruposed Use and Type of Structure:
l7�tesidential
❑ tiew Sin�le Family Residence Maximum numaer of bedrooms:
C� Expansion of Existing System If expansion: CwTent number of bedrooms:
❑ Repair to Malfianctioning Systzm Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Kesidential
Type of business: _
hiaximum num'ner of empluyees:
Tutal Square footage of Building:
Maximum number of seats:
�) `Vater Supply: ❑ l�Te�v well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring
t�re di�re any existing �vells, spri.ngs, or existing watcrlin�s on this property? ❑ yes � no
6) If applying fur `Authorization to Construct', please indicate preferred system type(s):
❑ Com�entional ❑ Accepted ❑ lnnuvative ❑ Alternative ❑ Other ❑ Any
I cert� that the inforniation provided adovz is complete an� cof•rect. I al.so under°stand that if the informatioti providec� is
innc�urate, or if the site :s subsequently altered, or the intended use cha�iges, all ps�mits and approvals shall be inculi�l
� 0�
Signature (Owner/ Legal Representative*)
�` Supporting documentation required.
���-13
Date
Permits are valid for eitl�er 60 months or are uon-expiring when accumpanied by an approved plat.
A completed `Lol 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)
�
. _ B 1038
..:,
� PERSON COU�TTY �iEALTH DE�'ARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT
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Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.'
Tax Map # �� � Parcel # � 3 3
Owner/Contractor
Location/Address
Subdivision ?Game
Township
r Fau.l Kne�
N�'i � � 1 L o►.
s
or'K
,� I�� Lor� Kd Su.b -D! u,
S.R.# � / I �
Lot# � a
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area a.-�f y l��rP Size of Tank DOd
SFD Mobile Home � Size of Pump Tank
Business ,# of Bedrooms J Nitrification Line y0 X3 �
Max Depth Trenches a''�;,� ,
Permits may be voided if site is
Well and Septic Layout by_�
Comments:
�
�
Date �/Z3�/�� Installed by ►,��Ytii< 1�:x�J��.so�proved by.
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual �✓ Semi-Public Required Slab
Public Replacement Air Vent
Site Approved_ Required Well Log �
Well Head Approved Well Tag —�
Grouting Approved ;a�c�
Comments:
Date
Installed by,�
� Approved b}�
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contain�d in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for staternents 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 warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
,
LEGEND
Peggy Y. Pocterfield
D. 8. 147-695
REFERENCES
'�— Exist. iron pin D.E. 179 -424
�'— Iron p�n set
F.E. p-231
--�— Math. or trov. pt. only
�— Exist, stone or conc. mon.
--�— Conc, mon. set
�— NCGS mon. (horiz.control)
�ECORDING DATA TAX MAP
�
,
I �1e) hereby certify th
owner(e) of the property
hereon Wt�ich vas conveye
recorded in the Person C
Office in Book � Pa
hereby edopt thie plan o
my (our) free conaent, e
: building linea, and dedi
easements, parks, end ot
or private use ae noted.
certify chat the land ae
the subdlvision regulati
Pereon County� North Car
, 19�
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`"_��, ; �.1 � ���� ��
�` � � ����
]�.��. �- � �� �.� � �.11 IC-3I � .�ll -�.I�
. VV��L PERMI�' {New Repair �
Taz Map: 3 � Parcel• �
Subdivision: �Lot:
�
�ermit Conditions:
1) Seg attached site pdan for proposed well location. -
2) All applicable State and County regulations governing construction and setbacks apply.'
3) Permits expire S years from the d te of issue �
,
Other Conditions/Comments: e�mi �-i��. �r ��Pr ��5����On =
,r
P�ranit �ssued by:
I)ate: % -(� -�
C3ER'TIFiCATE OF' C011�'LE�ON �
NevcT Well� Insp�ction:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
L'nner Inspection:
EHS/Date
Installer: '-ta s
Depth: . 35 °
Grout: �S (� - 2�-13
Well Abandonment:
EHS/Date
Completed:
Method/Material(sj:
Wel! Driller: _�a��( W l Zc �c! 5���'� V t S �c r� e�}`�� J License #:
Pump Installez: License�:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed: ' .
� � c�'f CQ`� i �flQ
wa�� �-� �(o'`�
�z� a-f ��' )
Phone: 336-597-1790 Fax: 33b-597-7808
8/1/08
. , . �
• ` �� L�- �� S+ r0.,..y b e�►-c� i
PERS{}N COUtiTY ENVIRONME�ITA% BEAT.TIi (,� � �� �� e i d s
WELL �.OG
Date: g 2 Y� G �
Ownex: /�' �a�� e � SR#
X.oC�tiO�IT�irFrtinnc• 7ckc � 9 � c C�r�. '�' '1,�.,se r�., �.� F� �
abo�-�" +�.s .�.•�c�s- - .
Subdivision I�F�me: Lot �#
Drilling �ontxaetor: ��-7+, k'�.nPn`e
� �trELI.. COIVSTR[JC7�4N
I}istance from N'eaz�st Prt�gerty Line Distance from Source af
Pallu�ion
Total Dep.th: J�� FL Yield: 3 GPM Static Water Level � fit,
Water T3earing Zones: Depth Ft_ � FZ FL �t.
�asing: Depth: Frorn C� to �Ft� Diazneter. G�`� Inches
TYPE: Steel - �alvanized Stee1 �
If Steel, does owner approve: Y�s I�o
.
�eight: Thickn�ss: � 1 Hcight`Abovc Ground: �`5 j Znches
Drive Shae: 'Yes X No -
Were Probl�ms En�ountered i�t S�tting the �asing? Yes No�_
X[� "yes" givG r�ason:
�Grout: Type: Neat SandJCement � �oncrete
A�nular Sgace Width �iches
Water in Annular Space: �es I�o
.. .. Methad: Pumped � Pressure - Poured �C � - - -
Depth: Fr�m d to 2 a �t.
Materials Useci: No. Bags Poztland �Cement Weight of .1 ba� lbs.
If mixtule (sand, Pra�ve�, cuttings} - Ratio: to
II? �'lates: �es X No � -
� x 4 slab Xes��No
�
Fram Tt� Foxxna�i�n Descri tian
c r.6 4 r�
c S' t�a i�.: �%t�'- frrc r-ocl
t tf � I�" a r� ,rQ.� res�-
I HEREB'Y CER'TZFY Ti-�ATTHE ABgVE��1FORM�TIOI� IS �ORRECT ATiD THAT
T�S WELL W,�S CQI�STRUCTED IN AC��RI�AI�ICE WFTH REGULA'�'IQNS SET
FURTH BY �'HE PERSO�t C�Ui�IT'Y HEALTH DEPA�ZTMENF.
���-- ---�
�
Signature of Contractor Dace
b0'd dLS=�trO 96-Oi-daS
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
�3 � -13 3
Name of System:
DONNA FAULKNER
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://sloh.ncpublichealth.com
Phone: 919-733-3937
Fax: 919-715-8610
55 MYRTLE J DR.
ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541
EIN: 566000331 EH
StarLiMS ID: ES053013-0106001 Date Collected: 05/29/13
Date Received: 05/30/13
Sample Type: Raw Sampling Point: Inside spigot
Sample Source: Ground Temp` at Receipt:
Time Collected: 1:00 PM
Collected By: J. Smith
Well Permit #:
GPS #:
, ��. ,,-� .� ..
Sample Description:
Comment: " :
Inorganic Chemical 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 57 _ mg/L
Chloride 25.00 250 � . mg/L
Chromium < 0.01 0.10 mg/L
Copper _ __ _ < 0.05 1.3 . mg/L
Fluoride < 0.20 4.00 mg/L
Iron 13.00 0.30 mg/L
Lead < 0.005 , 0.015 _ mg/L
Magnesium 18 mg/L
Manganese _ , .. _ : 0.47 __ _ � , 0.05 . mg/L
pH �`7.7 � ��; N/A
Selenium < 0.005 ' ., ,,0.05 ', mg/L
Silver < 0.05 0.10 mg/L
Sodium � _ � 11.00 mg/L
Sulfate 8.90 250 mg/L
Total Alkalinity 204 mg/L
Total Hardness 220 mg/L
Zinc 0.28 5.00 mg/L
Report Date: 06/06/2013
Page 1 of 1
Reported By:
Hu//
JUN 11 2013
0
0
PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant Q� v� n A �Lt u�Kh��(
Address� 1�tU f�'� � � f. County �irS�y�
Collected By ��
Date Collected y' Z,q � �J Time Collected �•' 0�
Source: �Well ❑ Spring ❑ Well Tap ❑ Other
❑ No Charge Charge
���*�����*�*���**�****������**��*��*�**�*���*�������*�*�������*��*�����*
�������**���**���*����*��***��������*��*�***��**�*�*�����*��**�*�����**�
Total Coliform
FecaUE. Coli.
Reported By�
Date �1�� 1 l3'
Results
Present Absent
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