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A31 179. � � � � � Od p� . Aaalieatlon Da�: 7'�"� 6 ��.� ,�O� Tax Mau #: Amount Pald: a20�a � � Reast � 7 D 3�i- �� Paresl #: � :�� . : �� t U �� '�—' _ � � � �JN'�'� _ ��.�..�-.m--- ,---� �m..�.� �r.�.�.�.� . - ;� � . . : �:�� 2) Pe� �,� bv: co�,,,��. �: J neU a- Sh�� 1��r Hame Pfione:3�6-36�y-�9 73 • Address� 'l056 Jo n�aXa�_ _ ___ Business Phone: 5�`1 � 7ab a • �-i�;l pJCv ,11�C a7�"?3 3. �e51P �t 19—.�— vc,7t Nartle and�ddt8s8 Of nt aWR6r: ' r' i�n 5 � '�rl GY 3� -Property Description: Lcrt size: ,%C�U� Township: � Subdivisian: Lat� DirectIo�s to the Property (induding road names and numbers}: _ ^ . 4) proposed Use d Structure Description: answer each of the following questions: _. a) � Proposed � Ex�stinn9 _, TYPe af � Struc�ure: ��-t ?� f3 u� 1-�– Width: Depth: ••' b) Number �f Bedroo � Number af occupar�ts or people to be 3� - •' c) Basemer� Yas�Wo _ WUI th�e. be plumbing in the basemenYl'_�� ! . . d) 6a.cbage t}isposai:lfQs , No ✓ _ . �} Watgr Su}�Phl �IPe: Private ✓(new ✓ or ex3sting�, Pubiic . CammwuiY •�9 . � Are any wells on adjoining propeKy? Yes No _ ti yes, please indicate appro�amate loc�tiori on the .sibe pian. • . � poes ycur praperty catrtaln previousiy identiiied jurisdlGtlo�i wetlands? Yes_ No ✓ PLEASE NOTE THE FOl.LOWING: ' ➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MUST BE SUBA�7'fED WRH THIS APPLICATION. ➢ PROPERTY UNE3 AND CORNERS MUST BE CI.FARLY MAR14�. •, ➢ THE.PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAi�D OR Fl.AGGED. � ➢ THE SITE MUS'fi �E REF�DILY ACCESSiBLE FaR AN EVALUATiON BY THE HEALTH DEPARTNAEiVT STAFf. ' .' i hereby make aQpllcatl�n..to #he Person County Heaith Oepartrnent far a site evaluation for the on-sits sewage disposa! system for the above-desc�ibed proQerty. 1 agree�that the cantents of this application are true and represerit the ma�rimum faciliiies to be piac8d on the property. i understand ii the siis is aitered or the irrtended use ct�anges, the permii shaU 6e�me irnalid. Owner or Legai �-J�'U% Date or�.�n � t161271�2. � �� i ��.J' �� : \..�� v > J d � � � �� 1�° an.�9-n��m„-n �,r,i-n <�]��.�.�. �'1LaL.SI,�.tE� T�x �V1a�� rc�e-f � ° Su�bd�ivision Ph��se,Sect,i�an.'Lot � P�rmit Valid for Type of Facility: . # of Occupants �r Proposed Wastew Proposed Repair: Conditions: Owner or Legal l Authorized State � # of B System: _ Iffipravement �'ermit 1�To Ezpiration 1T New Addition �ater Snpp�y �_ s Projected Daily Flow �$D g.p.d. °� � Type: � — . � Type: �l o � , �'( �` .- - 0 Date: .S�•.30 • �g Date: $-7-070 The issuance of this permit liy�the Health Department in does not guaiantes the issuance of other permits. If is the responsibility of the applicant/property owner to in sure that aIl Person County Planning and Zoning and Building Inspections requirements are met This Impcovement Permit is subject to revocation if the site plan;'pl'at''oi the intended use changes. 'She Improvemeat Permit is not a�ected liy a change in ownership of the property. This permit was issued in compliance with tt►e provisions of the North Carolina: : `Laws and Rules for Sewa�e Trermnent and Disnosal Svstenss' (15A NCAC 18A .1900). Neither Person �oun.ty� nor='.:'the.` �= Environmental �Health Specialist warrants that the septic t�ank �ystem will continue to function satisfactorily in the futnre or'thaf the water supply will remain potable. � � _ � Authorization to Construct Wastewater 5ystem (Required for Building Pernnat) * See site plan and additzonal attachments ( ). � Proposed astewater System: ZS% 'I�pe � Wastewater Flow ��'�g.p.d. �� SQil L'C Alr � 22GS g.p.dJ ft 2 New � Repau' Expa�s . TypeofFacility: ,�i�r��-e rsi�ic� Basement_ es_No . �Vastewaier System Res��rements 7f ank Size: Septic Tank: � 1 D DU gal Pnmp Tank:-g� Grease Trap: ^�'al Drainfield: Total Area: �o� sq ft TotaY Length �, ft � 1V�a�mum Trench Depth �an - o.e. Trencl� Width � ft Nlinimnm Soil Cover: �_ in Minimum Trench Separation: �_ ft Dist�ibution: _ V Distribution �oz Serial,Distribution Pressnre 1�Ianifold . �� r Authorized State A.gen . Date: 8'– 7. �� Permit Expira � Date: �1–J–/l l The type of system pernutted is Conventional v Accepted Alternative. I accept the specifications of the p�• � -�C.+l� � . � �' _" _ _"(/ �ei�/Lagal �tEp�esantative: Date: ,3 •3d •o�' PCHD r�v.11/10lQ5.. � . � � ,: � �� ,`` 36 so' �� NS _ ., � �` • O -,\' � .. S73. _ � z4O4126"E �O l - 6 NF . �', � 1�', R�� U� ' Ua� �.a�n�1 � _ 3 � `'� ��'�' � �asy� �� ` IF �� 6� ` `' \ � ��5�� 'p 1 � � �p a�a�V ' � � � � �faP��.�� ``� `��_. � �� \ - `��—, �� '�� I s-tiu� �Y�Wa� hl � 11 ALLISON M. DACUS CHARLES G. DACUS `�j�-1�-1 �S�"Z ' D . B . 580 > P . 837 �'I ••`.` ° � �� . . ►P � ,� . / ' �� 1 U. 0\ � . 466. 14 � '��' � _ _ _ . / IF ._.._ � . , ..o.. � _ _ . -� �a�zvau st aput�.ca _.... �:.�,�,..�.��._ _ �„�_,.�,<a.b,�..<a �,,, 9��,my� a.cnsua o.� uoz�r�jjrr�sut a�,Su:uua�aq . � � �°u��'�' �� 6 �so#�axctuoa ar�y •rt��uo scno�uoa: a�tviusxat�v. �rsas�9iac s�uaunQ�su�r uca�sti'S . � „'' . -� � •- ■ � n� � / • � � '� .A• �•■ � � � � � � � - � ' . • � i��its79lr1�Ci��..�.rn _ _ ■a . �J� , + � � I �1C'@'�'I_G3[ �'°��.s�..-�� n^\�( /(��7�',-��-� (� r r� ~•� � `/' 1►J' � �tl � �/ 7� ��1��- � �--��''�-' = ;� � � ��' i� �i T �Q.-��- � ---� -_-�--� �� .�. �,I � �.II. ��. anp(ican Loca�ion a �� .� �� : ; � � - �ra� � ...�,�� c�� ; �_ � � � ��Y ��o�� N r�o�r o-a� aa � � . SJst�m Type (In Ac�ordanc� Wizh Table Va): Z -rH�s s'rs-r�� "�s�s ��.:.1� ��s�r�� ii �� ci��c� 1n�tz$'3 ��iCa.�L.� .liio�-rH �'Ai�OUNA G��ERAL ST�Td.!'t�5, �3U�E� FaR Sc��ilA�� TR�AT11��T �.�dD DlSPOSAL, �ND - eaLi CO[�f31�'IC3NS O� � Tl-�E 1NiPF�01l�:�tE�T P�s'�.�fll�' �I�D GQi�STR�ICTIO�i ,�IiTH��s TlC3N. �-. � . � � ��'I . . � - � �-�� . � uthorizetf State Agertt Daie . ln5tallerl.By: i-Ar�a�d�� 'C', Date:• �-Z��/ . ti �� r�,s�� :'u°"��a�iL�� a � 3�i�1�' �8 a � � ; ax IVi�p � a31 Parcz! � 1�q Sysi�e� Type (Table Va) CL O��vne:-1App{iccr�t � � S�bd�,ision A1 A- AddressJL�c��ion Se�lPhas� Lnt � � d��. �'�n� �ni�a�� 9oi�ar�c��a a�� In�� d� . State�ID/date - 7-//- Trenci� �df9� � 3 fi ,TS. -2y-c� Ca aci — o al. i � � Trenc� De�t� y in: ,,� Tee and Fil�e� - • � Tre�ct� Le� 0 ft. Baf�e � Trenct� G�ade � � Sealant Tre�cf� S aczn � Riser (ifi apc�iicable � Roc� De tii and Qual' � �'an� Ou�ef Se�l Daens/S� do�nm� etc. � Pem-tanent iUla�er Pressure Laterals � ' � Pusn� ��#� • Hoie Spacing � . � ISe�i�nt Riser Water�Tight � . ' � P�sm� Ct�ec4c VaIvelGaie V«ive nti-s�o an o e ,Afarm (visable and audi�ie) ��ectrical Comporten�is Rate (gpm) . . Approve�9 Pump iViode� Bioc� Unde� Pump � Pump Removal �Ro�elCt�ain . � D'as��aa�oet: S�r�a Serial ❑isiribution �- � Pressure IU��nnod Lnw Pressure Pipe A�pr. �'ip� 11At�te�iai and Grad� iJaiv�s � 0 Sleave �qui�' Set�� Fram� vVelts � From Prapecty (ines StruciuresBasetnenis � � iic es 1 ra�naae a�s S�r#ac� Wa#ers Public Wa#er Suppiies Ve�tical Ct�is (�2 �t.) U�ater unes Ve�iicle �Tr�ffic � � � - , �EasernerrtslRi trt � . O�ee' 9- i�/ Easem�r�ts R�PdE ��ammen� a �chd r�r. 3ta �IG'l ,i,r• � 0 .- • c � �� . �� . ,� , �. �+,, � � '�� ` � - H y. �` � • , � ��.�� . , ��. � �" , . . . g' � �' � . . , � �go �. ,� r .. � � :� � � �. �' �� . � �� ,0 . ��' ,,, . � I � J � �J • �� •� � � . , � • . � ; �� I : �. ..� _ �-� �� . .� . � .� . : � _ . . . .. � . . . , �� . .. � �. .,r . . _ � I y I•1 �`��a �.� �� ~ � � � �T�� . I�.a�.rn�-oaa,��.aa�Il ��ea.Il��. a�a�r a� �,.�- / � f�aao�► . � � D�I� O�lep �6'— 3— o� �wner: �e � � � � e Well Log 3 I vr' Tax MaP � Parcel #.� e Lr�cat�on: � � ,� ��,,L�� r• i:�7�1 Vi830r1. �"�-..-•� IAL� '�..�.. W'e.�1 �onttructioa Dist�nce Fn�r� neanst Pruperty Lime (Mini�mum 10 fe�t) _t D� Dist�ce frvm �aptic System (Muumum 60 feec) o �'" TotaI Depth: �c �� ft Yicld: 2� ____ GPM Stutic Watcr I.�vcl: �Q� g Water Bearing Zor�es: Depth f} �} � ft 1� � �.` c�.��$: �� Dep�b: From �_ to 6 ft. Diamctd :� in Typa; Ga�lvanixet3 Stecl �`p8ht: �'I�ickaeas: - Height �bav� Cmnund• i � Usive Shoe: Yes .ihu Any problems �c:ountercd while setting r.asing? �Yes No i� "y�s" give re�9au• Grout: .Ur�t: SaucUCemeni Canc�ete GraveUCenaer�t Annular S�Sacc Width ,� inches Water in Aanular Space r Ycs No '.1�cih� oi Groui: Pwnps�i .___.V Pressus� _ Pow�ed I3epth to � Ft. '_�v1xi��i�►�a iJ�ed: - No. B�g,� Portland cemeat Weig�t oi l Bag ._.._, Pouads� if mixture (sand, grav�l, cutting�) — Ratio to II3 plaus: � Ye9 � No 4 x 4 sl�mb ____ Yr� _,_,_ No Drillio� Lug Locatioa Drawirig I hereby certify th�t e3z� above informaric�n is correct �nd that this well was canstructeci in accorcf�t�,ce w�ith reguiations sat farth by -.he Pe'rson County H th I�eg �nt. Si�nstture nf l~OIIi�"XG�AP _ �O IL ��,�� Date�� D �� lt rc^ PCHD rev 1 5. F North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM M� Name of System: gishop, Ruth Source of Water: �� . �' 2 Address: Union Grove Ch 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 WILEY Date: 12/10/2008 Location of sampling point: Outside spigot Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 1:00:00 PM Remarks: Permit # ABi - 179 Parameters Results Units Date Analyzed: Silver <0.05 mg/I `` 12/11/2008 Alkalinity as CaCO3 54 mg/I , 12/11/2008 Arsenic <0.001 mg/I 12/11/2008 Barium <0.1 mg/I 12/11 /2008 Calcium 11.6 mg/I 12/11/2008 Cadmium <0.001 mg/I 12/11/2008 Ch rom ium <0.01 mg/I 12/11 /2008 Copper <0.05 mg/I 12/11/2008 Fluoride 0.32 , mg/l , . 12/11/2008 � Iron ` 2.76 � . . , ,� /mg/I 12/11/2008 Hardness as CaCO3 (Ca,Mg) . 43 _ mg/I 12/11/2008 Mercury <0.0005 mg/I 12/11/2008 � Magnesium 3.4 ' , . . �-ng/I 12/11/2008 �Manganese 0.69 mg/I 12/11/2008 Sod i u m 11 m g/I 12/11 /2008 Nitrite as N <0.10 mg/I 12/11/2008 Nitrate as N <1.0 mg/I 12/11/2008 Lead 0.013 mg/I 12/11 /2008 pH 6.7 Std. units 12/11/2008 Selenium <0.005 mg/I 12/11 /2008 Zinc 0.84 mg/I 12/11 /2008 Date Received: 12/11/2008 Report Date: 1/5/2009 Reported By: S Today's Date: 1/8/2009 Ref: 17512 Login Batch rpg�20033 s Sample Number: A68 620 m 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 . • r North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28407 - 306 N. Wilmington St. - Raleigh, N. C. 27611-8047 COLIFORM ANALYSIS - PRIVATE WATER SUPPLY Name of Owner or Tenant: Bishop, Ruth Address: Union Grove Ch Rd County: Person ZIP: Source: Well Type of Sampling Point: Outside spigot Collected By: JW Date: 12/10/2008 Time: 1:00 PM Signed By: Wiley, Jonathan Analysis Type: Private Report To: Person Co. Health Dept. ` 325 South Morgan Street Roxboro, NC 27573 (336) 597-2371 BACTERIOLOGIC ANALYSIS � � CONTAMINANTS RESULT Total Coliform (ColilertRoutine) Present Fecal/E. coli Absent Sample No: AB15380 Date Received: 12/11/2008 Time Received: 8:40:00 AM Date Reported:12/12/2008 Today's Dates. 12/1�/2008 `y`�- / Comments: New well permit # AB1 - 179 ` _�;�- � Person Co. Health Dept. ATTN: Wiley, Jonathan 325 South Morgan Street Roxboro, NC 27573 Courier 02-33-15 OF `� V�;� �,�,,; Ct�� —� `�\ �8 / 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 .t 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