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A31 191�.�-� o� �� Application Date: < < -6 � � . C► C � .� � � � f'J � '� � a � 0 Tax Map: Amount Paid: app , OQ ��6 ' a, 3 y L` �� \ Parcel #: Receipt#: �,� �2 �I o2 �l j O a� `� �---��_�� a�v0.;r`e.sL �_.__ _ • -� � � �tLT � � ]� L, a� � � N ek�.,� Zr_'�aa�iLu-aca:LLa�Tca<c��rv�d..cnlL �r 3rx_,.�¢.k�.li.a , )� (na e e�� .. Y � � Application for Services (Septic Systems and Wells) �� Jer � > � P�Y s+; M�� 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/Repair) $ 3 OD.00/$200.0 0/$? 5 .00 Services Re uested ❑ Construction Authorization Fee is de endent on the e of s: ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Charge 1) Services �equested by: Name: � �"�i Address: � F� C i 1 nl � a�sg3 �/, Phone # (home): ��i�0 ' �j0 � — a �) � (work/cell): ��Q - a �q ' D'� �P �I 2) Name and address of current owner (if different than applicant): Name: �/�j Q�J Yl e W YGYIYI Address: �?� s Qp�h � P1f�Y �. N L � Property Description: Lot Size: �C • Subdivision: _ Address and/or directions to Property: pn ti� d�. ��, C 33(, ��.¢-3� �� Lot #: 4) Proposed Use and Type of Structure: Residential ✓ Business/Type: Other Number of bedrooms t-( / Number of people served (seats/employees): Basement: Yes No �/ (with plumbing: Yes No � Garbage disposal: Yes No �/ �ater Supply: Private Well � (Proposed� Existing _� 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 pla�: of the property that slzows property dimensions and tlie size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' for»t verifying tlzat the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. /� � Signature (Owner/Legal Representative): �U�l'� , v� Date : f/- 6' 6i 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) Application Date: -7 o�g Amount Paid: Receipt #: ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 lif> 600 eodl ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 1) Applicant L Name: Address: 2) Name and ad Name: � Address: '��.5� ��q �� Tax Map: T'13 � � � ��.� Parcel#s � �L�r]['D0�9.II�QDTM� n�T C'J3T.�dA.LL ll 1LC'lw9L.0.�'�. tion for Services Services 0 Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 0 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone (home): �� ( �/ (work/cell): c�'� nt): y� Phone: Lot #: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ 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? O yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: �Residential O New 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 ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage ofBuilding:d'�!l�� a� Maximum number of seats: 5) Water Supply.: ❑ New well ❑ Existing Well � 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 inaccur e, or if the site is subsequently altered, or the intended use changes, all pet�mits and approvals shall be invalid. , ��- � Gr� gnature (Owner/ Legal Representative*) Supporting documentation required. 3�� Dat 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) ') , �� . � C) J \ � • � < <�) � \ " I � � �,�,.�,�-�,�.:�� -��-.:,��, Building Additions/ Mobile Y�ome Replacements Tax Map #:�_ Parcel#: 1�,_. Address: Approval Requested for: Mobile Home Replacement �/ Building Addition . Applicant Name: �; ; �n`�.^ W�enn Address: �3y5 (��►��.e��r �1 l�,�v� �P IV��\\s , r.l a75�11 Phone #'s: F,�i�l - ly�l -�.nds. iv.a�YP Permit Located: ✓ Yes No Installarion Date: io a6 o Design flow: 3l00 (gpd) Current Contract with Certified Operator on file (if required): N� Water Supply: �_ Well Public or Cammunity Wastewater system shows no visual evidence of failure on: � 3� 8 I (date) (Applicant's signature if site visit is not required) � Comments: -�c� _e m�- 1� 0.� ��sa �- �5�'+ "Fr��n^ ��e I I Addition/Replacement Approv�d �� r,. n �, ��5 Environmental Health Specialist ��/a�3/�y Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount .y net ' �–�� -� �� ) � � �\� i � � � , . �� 1 ,/'�'y� ' � �' � �./ � � .� ��.��o-�-n ,�,;-, ��.�.�.II I�-��.11�. T�x Map R �.rc�el : � Su�bd:ivis�ioia h�:s�e Sect+ian:Lot :' ��rmi# ��3ad �or %� Type �of Facility: # of Oc�upants �`� Proposed Wastewater' Proposed Repair. � i�ipravemeat �'armit . . _ �1'0 �i�ation � PP � � � �` , ' New � Adciition �ate� �� i �oom� � Projected Daily Flow (� D g.p.d. � Type: Type: Permit�Conditions: CP � �'`� �� Owner or Legal Representativ S' e• ' ` c Date: Authorized State•Agent � Date: o lo � The issuance of this pe�it by the Health Department in does not guaiantes the issuanca of other pelmits. It is the responsibility of the � applicant/pzopezty owner to in suze tha# all Person County Planning and Z�nmg and Bnilding Inspections reqturements are met B'his . Improvement Permit is subject to revocation if the site plan, plat or the mtended use ci�anges. The improvement lPsrmit is not ai%sted by a cliange in ownership of the property. �'his_ permit was issned in cnmglianc�.with the provisians of the North Carolina `Laws and Rules for Sewag� Treutment and �isnosal Svstems' (15A NCAC 1�A .1900). Neither Parson �County nor the Environmental �ealth Specialist�warranis t1�at.tlie septic tank system ws71 cantinue ta function saiisfac#orily in the future or'iiiat the water supp(y w�ill remain: potable. - � .-- . _ . . - . Aut9�oriz�tion �� Constract �astewater System (�teqnirerl for Biuiding Per�it) � * See site plan and additional attachments� (_ j• �z �� , - . ��. � . Proposezl Wastewater Sysfem: . � 'C�ai-v� %� Type�.� Wastewater Flow ��-:p.d. New � Repair_ Expansion _ p�, � Soil LTA�t: � 3� � g.p.dl fi Z� . . Type of Facility: �� I� s• Basement Yes 2`No - • , — , . ; �astew�ater Syst�ffi �.ea��ai�rements � � ia� Siz�: Se�#ic �ani�: dC� �ga1 �p Tank: , gai Ggease'izap: gal �rai.n�seic�: 'Tot�l Area: �� 0 sq ��Totai Length► �EO ��t � l�asi�n� Trench �eptia �g Z0 in ��emc3�'Gi�idt9� ��t �niffiu�a SoiA Co�er. _� in 10�1iniffinffi Trench Separatiom: ��t . .�:. . . 33istribuf�on: � _ �istribntion �oa Serial �istrii�ntion Pressure 11�Iainifoid Spe�cations: k �.�4 (l l�—%��?C v✓� �� '> lnc�' ll��t�e �SI1t�flOY']Z� .Stdf@ L��Ilt: - permit Expi The type of system permitted is permit. , i3wne`f/�� ;al �8�p�es��tive, Conventional � Acc�ted 7 i , _� �. t�lternative. I accrpt the specifications of the � �;� Date: �O ' d �" � a PC"� rev. l l/10105 A� �Op� �,� T SE� i �qS� � �� ► � ��'iiT FSS i � � c.,� 1 F t ► w � 16 .- . � I,� N59 ° 59 ' S9'` E �- 1 NF �' p. 00 ` T�iAt �i� 2�s . 35 --� , � 3 � __,_`_ - - _-- � o o � _ _ ---=-- - O �n 4 1 �` �j �ss � � � I � j EARL WRE1� • s �% WA�NEP �16 � � , ' � � �, , fl.g. 72 � \ W � � 1 - `_ �� "�.-� � . � , ` _ _._._ -- — -�- --- --- � `- � �,�. � �a ---; �, �; � � � � �, � I ' � � � s \ �- ;�__ -� � , � -b Q, � � � 'S � �' � s � S � 7 � � � � � � n � � , � � , � � S � r . ^ � � �n � � � � � -�j' �'- .� r` I � � �:' ; ' �, „ �- Q � � � � � � � � >> � C ' S � b� Q Q � � � � 1 �` � V� �,c �` n � � � ,.-�-, � f 1 � C� � _ � �}'�� j �, \` � (�` � J� � � � / � � � �� ,� � �� l� � Qi' � P S � � � � "' ---- _ , ; �- �' _ _ �_ ? � s � Q � � ! -- , ; • � � `./ �r � , .�.,,� � 0 A� 'QOp� . � I �A rF �� 2 F,�s�� q �c o , F�T FS� N69°36'28��E --_�___ 290.5) ---__ _ _ �� _ _ - ,` 0 � �' � � o o � . _/ �,� �. � \ � � I j � � •--.- � , � C�/V � �� o � ` � , � � �' � cD,Q� R�� . � � � - . � F,� � ; � . � , � � � � . �-' �. � , .� � � � O�� I h� o � o - � � � � �, � . . n t � � , � f � /.� � l ,. � � . �' 1 ` � i i 4 i . i 1 - � � SC�te � l ��= �o� `-��. �� I�I��.� �� - � � �-�°�� IEaa.�Q-�mm,.,,... �aa�.Il ' g�Lm�.Il�]}�. � v -l� IS � STTE PLAN Name Ct� ' Tas Map #,��J % Parcel #�� s� � • n s�oa/z.ac# " o ro Authorized State Ageat Dat� System compoaeais xpnseat appm,�arr conmuzv anlp. The caatracmrmust9ag t6e sysmm prior m begiaarag the iasraUativa m '^",•' �arprapergradeisma�rrived ��.sf ��.� �� ga�na-�ga.,■-,.-,� ��n��.�. ��.��n Applicant: — i Location: N� �r �� s Operation Permit System Type (From Table Va): �"� Tax Map .�3�, Parcel # Iq 1 Subdivision Phase/Section/Lot # # of Bedrooms 3 � �Yl�ed 1-�0��1�.r1S Product (IIIg): �Z �w 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. �� (Authorized Agent) ��M1��u �-2w�S (Licensed Contractor) Cr^W�� a ro�� 1,� lo � '� II � �� ,,` Q �� , ��, �� ,, � ��P -�- ,�,�.�-- Scale: -5 �� J�la�l«, (Date) IO�a5�117 (Date) Line Length � 50�' k � �I �o�-� Total ,3co-('�4 � Taz Map: �3� Parcel #: 1q � Septic Tank System Checklist (Type II-I� System Type: -t-s.Q ��ZF��w� —�-- � ' n. . ■sic. .��. :' . . � � • � . Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP ✓e-mail Date: � ola��.o �,��.s� ��.�� —= � -� �� I�.��a�-�� .Il I�1I��.Il�1� WELL PERMIT (New_%�Repair� Taz Map: �31 Parcel: 1� I Subdivision: Applicant's Name: ! a � Mailing Address: Lot: Phone Numbers: �ff� �,r{- 2 �� 33(.'2�9 -� 7fQ T/ Location of Property: �Z(,r-Q( � /�l� �l f 5 � �' � �� 1��1�� /`�" ' Permit Conditions: � 1) See 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: Permit issued by: � Date: � d �� CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: � ✓`� �01�3\�n Grouting: `�>� �o1�31i� Well Log: � ��\�31�� Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: l�� Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: �rn.�'�Fe License #: Pump Installer: License#: Well Approved by:��n,�� 1-�-�- Date: ( olaS � t b Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 � North Carolina State Laboratory Public Health 06 N. W?mo gton St. Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncpublichealth.com M icrobiolo Phone: 919-733-7834 g y Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH ANDY TATE 325 S MORGAN STREET 2345 POINDEXTER RD. ROXBORO, NC 27573 EIN:566000331 EH StarLiMS Sample ID: ES011311-0095001 Collected: 01/12/2011 10:30 �� Received: 01/13/2011' 08:48 ES Microbiology ID: 23477 Sample Source: New Well' GPS Number: Sampling Point: Well head Sample Description: Comment: J: Smith ` Angela Heybroek '' Well Permit Number: A31-191 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Darneice Lyons 01/14/2011 E. coli, Colilert Absent •� • Darneice Lyons 01/14/2011 Report Date: 01/18/2011 Reported By: Susan Beasley _. _ _ __ ; JAN 1 J 20 �1 , ��f�.%' � Explanations of Coliform Analysis: � . � 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. North Carolina State Laboratory of Public Health 06 N. W�m� gton St. Environmental Sciences Raleigh. Nc z�s„-soa� htta://sl�h.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH ANDY TATRE 325 S MORGAN STREET 2345 POINDEXTER RD. ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES011311-0059001 Date Collected: 01/12/11 Date Received: 01/13/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 4.5 Sample Description: Comment: Time Collected: 10:30 AM Collected By: J. Smith Well Permit#: A31-191 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 36 mg/L Chloride 6.20 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron 0.40 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 10 mg/L Manganese 0.38 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 7.5 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.50 mg/L Sulfate 10.00 250 mg/L Total Alkalinity 136 mg/L Total Hardness 130 mg/L Zinc 0.59 5.00 mg/L Report Date: 01/31/2011 Page 1 of 1 Reported By: �e�ie �aKeol '�-SUif..'. .`�,P�a'"• J Z\�' _I � r ,�r ��r�:�� 3�. �� :�:�_:'..:��►�.��,..." '•;'� � ��/ RESIDENTIAL WELL CONSTRUC'TION RECORD North Carolina Department of Environcnent and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # J�t b�^� 1. WELL CONTRACTOR: k� � �� L^ 4b WeII Contractor (Individua ) Name Bamette Well Drillina inc Weil Contractor Company Name 611 Bamette Tinaen Rd SVeet Address Roxbo�o NC 27574 ^ City or Town State Z�p Code 3c 36 � 599-0015 Area code Phone number 2 WELI. INFORMATION: ��' �� ` ��/ WELL CONSTRUCTION PERMIT# �i OTHER ASSOCIATED PERMIT#(if applicable) g. ATER ZONES (d th): : Top� Bottom�� Top Bottom � Top� Bottom��_ Top Bottom ; Top��.,_ Bottom � �a Top Bottom ThicknessJ � 7. CASING: Depth r Diameter Wetght Materiat � Top � Bottom b� Ft 6�(r S� ��C Top Bottom Ft. . Top Bottom Ft. 8. GROUT: Depth Material Top O eottom � Ft. Sand/Cement Top Bottom Ft. Top Bottom Ft. Meihod Poured SITE WELL ID #(rf appticab�e) . 9. SCREEN: Depth Diameter Slot Size Material 3. WELL USE (Check Applicabte Box): Residential Water Supply�H Top Bottom Ft. in. in. DATE DRILLED �L) � 2'`"C C) _ Top Bottom Ft. in. in. TIME COMPLETED 3 a J AM p PM � Top Bottom Ft. in. in. 4. VYELL L CAT10N: ' 10. SAND/GRAVEL PACK: P Depth Size Material C�N: �/-„��C !�� COUNN ; Top Bottom Ft. �_ i L f � 3 7S � f^��.� �� Top Bottom Ft. ( � �o+ �Street Name, Numbers. Community, Subd�wsion, Lot No., Parcel, Zip Code) Tpp BOttOm Ft. TOPOGRAPHIC / LAND SE7TING: (check appropriate box) ❑Slope OValley lat ❑Ridge ❑Other LATITUDE � 36 ^_ " DMS OR 3X.XXXXXXXXX DD LONGITUDE �5 '_ " DMS OR 7X.XXXXXXXXX DD LaGtudeAongitude source: �GPS �fopographic map (location of.we!! must be shown on a USGS fopo map andattached to this iorm if not using GPS) 5. WELL OWNER�� r . �.� Owner Name ,Qin�c��e.. /?� sv tada' SS 17�,7 f!t A/► i or Town State Zip Code c 336� 26►-V7G�i Area code Phone number 6. WE OTAL DEP : / v V� b. OOES WELL REPIACE EXISTING WELL? YES ❑ NO � c, WpTER LEVEL Below Top of Casing: _�, �_FT. (Use '+` 'rf Above Top of Casing) d. TOP OF CASING IS � FT. Above Land Surface' `Top of casing tertninated aVor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): 2D METHOD OF TEST BIOWfI 2Of11 i. DISINFECTION: Ty� HTH Amount 1/2 Cu[> 11. DRILLING LOG Top Bottom / � �_/ 2v �_!� / / ; / / / / , , / . 12. REMARKS: Formation Description � D�C s � �!� � e i DO HEREBY CERTIFY THAT T111S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVID TO THE WEIL OWNER. ,� � '�� `l SIGN R OF CER IED WELL CONTRACTOR DATE I�C� v-►-- a� PRINTE 1 AME OF E SON CO STR CTING THE WELL Submit within 30 days of completion to: Division of Water Quality - information Processing, Form GW-1a 1617 Mait Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2�09