A31 52Application Date: g�� �— b% U U �_� .. J(7
Amount Paid: � 00 .0 d �' �Q .
Receipt#: 3 I 0 6� 7 �21 S 3�'7
� ���� ���� ��
� —�/f'w/■ r- -_ � � �t����
� 1 / / �Lw._....'3C�.`<S�]L.i[�a[:D.TtT.SYlYT_4�..9 RT.'Q'�.f3L.i1 7E—JI.�.�..�...11.�a:Ih,.
, J Application for Services �
(Seotic Svstems and Wellsl
�mprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
C Mobile Home Replacement or Building Addition
$150.00 (if site visit required) �
C Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: ��2
Parcel #:
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of sy:
❑ Permit Revision
$75.00
� ❑ Repair of Existing Septic System
No Charge
Important: If the info�mation in tlie application for an Improvement Permit is incorrect, falsified, or the site is altered, tl:en t/:e
Imnrovenient Permit a�:d t/:e Authorization to Construct shal! become invalid
1) Services Requested by:
Name: �'A m�s 1� . ,�p Jc-�.a�.l —.2
Address: �"j/ P�ut�S A�;�,.t L?c�
i(o n ,2,0 �j/. C . �S_7 �(
Phone # (home): 3 3!�- �19- �S�Gz-
(work/cell): � 3G -s�i5- �7�/3
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: � Subdivision: Lot #:
Address `and/or directions. to Property:
�1��-cl �� /�( ��� (�.n� AC t`aSS �Qcn-� Ff8 %i � C h wrtl,
4) Proposed Use and Type of Structure:
Residential I/ Business/Type: Other
Number of bedrooms �_ / Number of people served (seats/employees):
Basement: Yes No _� (with plumbing: Yes No _�
Garbage disposal: Yes No �
5) Water Supply: -
Private Well ✓(Proposed Existing �
Community Well: Public Water System:
Are there on the adjoinina properties? No %< Yes
(please show location on site plan)
Note: A completed apnlication must also include:
➢ A pladsite plan of the property that shows property dimensions and tlze size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the 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):
Date : 0
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
��� � . ��� � ��� �� T�x M�p � P�rce�l #
� • �� � - � - � - � - Su�bdivi�sion
� � , , � � � , � � � � Ph�se Sect�ion Lot #
,
Permit Valid for V
Type of Facility: �
# of Occupants �ax
Proposed Wastewater
Proposed Repair: �
Pernut Conditions:
/ Improvement Permit
Five Ye rs No Expiration
; New Addition Water Supply �•�
�# of Bgdrooms, Projected Daily Flow �_ g.p.d.
Owner or Legal Represe
Authorized State Agent:
•- .
� - Ll�
Date: � �' � C
Date: g-/ -d�
The issuance of this pernut by the Health Depariment in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit 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 and Rules for Sewa�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site pla�T and additional attachments (_�.
Proposed astewaterSystem:���p,� Type� WastewaterFlow ���,p g.p.d.
New Repair Expansion Soil LT � Z.s g.p.d./ ft 2
Type of Facility: �ri ��_�ZSi�r,r� Basement _ Yes No
Wastewater System Requirements
Tank Size: Septic Tank: DOb gal Pump Tank:`--�--gal Grease Trap: ----gal
Drainfield: Total Area: /OSb sq ft Total Length "(ob ft Maximum Trench Depth �� in
Trench Width J„� f Minimum Soil Cover: � in Minimum Trench Separation: � ft �
Distribution: V llistribution Box 1/ Serial Distribution Pressure Manifold
. � ,
Specifications: ��
Authorized State Agent� �- Date: g=��-G1�
Permit Expiration ate: -/V-
The type of system permitted is Conventional Accepted Alternative. I accept the specifications of the
permit. � ' /
Owner/Legal Representative: Date: (� "� - � %�
PCHD rev. 11/10/OS
���.s:� ���.���
`----- � ������-
I� ��a � � � � � �. ¢.ffi.Il 1I-3T � .�.. ]l �1�.
WELL PERMIT ew ✓ Re air
� _ P �
Tax Map: Parcel: ��
Subdivision: /� Lot:
Applicant's Name: J e m
Mailing Address:
Q rnc o r o. 1�( C. 2757�
Phone Numbers: ��„-�Q562 ��-1 3�G-��-s�y� �w)
Location of Property: A-cr-o�s �om ��09 Z 6 n �.r�� 6�� l�S �
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 � years from the date of issue.
Other Conditions/Comments:
Permit issued by:
�
Date: 8 - l� -b8
CERTIFICATE OF COMPLETION
New Well Inspection:
E. S/Date
Location:
Grouting: " " �'12Q/�D
Well Log:
Well Tag: J 5 �
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Well Approved by;
-Z�I��D
Date Sample Collected: �-/d J��
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
�
License #:
te: //�Z9-/0
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
RESIDENTIAL wEr.L coNsrx�crtoN �coRn
North Carol'ma Deparunent of Environment and Natural Raourca- Divicion of Watcr Qualiry
WELL CONTRACTOR CERTIFICATION # c� ����
1. YVELL NTRACTOR• •
O
W (k�dividual) Name • �
i-i uc�Sc� fi V�1 e. l l Co. �,�1 C„ '
. Weq Contractot Company Name � -
' STREET ADDRESS �,���__1�r2�I �f,�
1��2[�AC��� �71�—�7v rl �
�.Ity or Tcwn S e� Zip Code
c.�(�,.'�77- 37� �-
Area code-�hane number
2. WELL ItJ�ORMATION: 2
StTE W ��LL ID *(M applieabla>,�cJ � � ��
STATE WEIL PERMITN(f►appliubb)
DWQ a OTHER PERMIT t�{if appGcable)
WELL USE {Check Applicable Baoc): ResidenGal W at� Suppiy ❑
DATE ORlLLED���+�I� � � d
TIME COMPLETEO AM O PM p
3. WELL LOCATIO :
CITY: �li1%O�'G �y �S COUNTY
��,rr.� ( g �h; II � �c.�„
(��Ir i't Narrls. Numbws�ommunlly. $ubdivision. Lot No.. Parcal. ZJp Code)
TOPOGRAPHIC 1 LAND SETTING:
O Slope ❑ Valle�y p F{at O Ridge p Other
(chaek eppropriab box)
May be in degrce;
LATITUDE � _ minuta, sceonds or
LONGITUDE in a dximal formet
LatitudeAongitude source: ❑GPS OTopographic map
(locaHon of we! must be shown on a USGS topo map and
etlached to fh�is /am inol ushg GPS) �
4. WELL.OWNER
OWNER'S NAME
STREET ADORESS r
--,�o}c1_�,��� �C. 2,2_ �Z9
city or�own state zip code ._
��
Area code - Phane number
s. weLL oEra�.s:
a. TOTAL DEPTH• �f �_ -�i
b. OOES WELL REPLACE EXISTING WELL? YES p
a WATER LEVEI. Below Tap d Casing: FT.
(Use'+' �( qbove Top d Casing)
d TOP OF CASING IS '� � FT. Abae Land Swiace'
'Top d casing ter�ed at/ar below land surface may require
a variance in aocordance wdh 15A NCAC 2C .0118.
e. YIELD (gpm): � METHOD OF TEST Q�II
T. DISINFECTION: Trpe f�1�1 y`7 Amamt
y. WATER ZONES (deptfi): ro p�{
From'� �� To�=C/ o F,�om To
Fram � .� To �� ��Fran To
Fram To From To
s. cnsiNc: (�..Yi 6� � P�.s�� � 3' ��i��►
�P� �� �M1(�9h1 Mat �
Fran��,To�Ft,� /dd'
F�om To FL G�
From To Ft. �
7. GR01lT: Depth M�erial n Method
From 6 To ^� Ft e_ `�'�_ I'
From To Ft
Fram To F4
8. SCREEN: Dapth Diarneter Sbt Size - M�erial
From To Fl ln, 1n.
From To Fl in. in.
From To Ft in. in.
9. SANWGRAVEL PACK: '
Depth Size Material
From To Ft.
From To Ft
From To Ft
10. DRIWNG LOG
From To
(� ' �o
.�.b �.i
G /�
Fortnafao Description
��
_S�. �./�C�
�N4T
11. REMARKS:
100 NEREBY CERIFY THAT THIS WELL WAS CONSTRUCiED N ACCOROANCE WIiH I�
1SA Nf'.AC 2C, WELL CONSTRUCTqN STANOARDS. AND THAT A COPY OF TFi15
� RECWIU HAS BEEH PROVDEO TO THE WELL OWNE0.
� C�n % �v,
SIGNATUR CEQTIFIEDWELLCpNTRACTOR OATE
PRINTED
r�
THE WELL
Submit the oriytnal to the Diviston of Water Quality within 30 days. Attn: information Mgt.. Fortn GW-ta
161T Mail Service Center— Raleigh, NC 27699-l617 Phone No. (919j 733-7015 ext 568. R� ��
���.sf ���.���
`� � � ����
I���a-��-,.-�-�. ����.Il IFIL��.IL�I�
Applicant:
Location:
Operation Permit
�
�
System Type (From Table Va): Product (IIIg): ��
Tax Map � Parcel # SZ
Subdivision
Phase/Section/Lot #
# of Bedrooms �
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.
1
(Authorized gent)
��onar� d �rr'e✓�"
(Licensed Contractor)
%�Z����
(Date)
' 7_ /'/d
(Date)
Taz Map: � Parcel #: �
Septic Tank System Checklist (Type II-I� System Type: �
Notes•
Pump System Checklist
Contracted Certified Operator (Type IV +Systems):
Notes•
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Copy of OP e-mail Date:
� •1J
North Carolina State Laboratory of Public Health 06 N. W?m�ngton St.
Environmental Sciences Raleigh, NC 27611-8047
htta://slph.ncaublichealth.com
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH JASON FOUSHEE
325 S MORGAN STREET HURDLE MILLS RD.
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES011311-0057001 Date Collected: 01/10/11
Date Received: 01/13/11
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt:
Sample Description:
Comment: Nitrate sample over 48 hrs old when received.
Time Collected: 3:00 PM
Collected By: J. Smith
Well Permit #: A31-52
GPS #:
New Well 1(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 23 mg/L
Chloride < 5.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 2.00 mg/L
Iron 0.81 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 7 mg/L
Manganese 0.21 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate Unsatisfactory 10.00 mg/L Ofe
Nitrite Unsatisfactory 1.00 mg/L Ofe
pH 7.0 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 5.50 mg/L
Sulfate 6.10 250 mg/L
Total Alkalinity 95 mg/L
Total Hardness 85 mg/L
Zinc 1.10 5.00 mg/L
Report Date: 01/31/2011
Page 1 of 2
Reported By: �e�de 7'%lokeal
❑PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL W,4TER SAMPLEANALYSIS
Name of Owner or Tenant �ASUY1 �ltSh�,
Address____�_.-�,,J���, M,��� �, County �rSei�
Collected By J S
Date Collected /' Z.S �
Tiine Collected /Z�'/D
Source: �riNell 0 Spring C�ell Tap 0 Other
� �e-sai �e Cs��
Q'No Charge � ❑ Charge
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Total Colifo►-m
Fecal/E. Coli.
Results
Pi-esent Absent
0 �
❑ LV
Reported By
Date- )�2'1 i�� l l
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