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A31 86Application Date: �? �3 - �Q p(� Tax Map: 3 � Amount Paid: 306 . 0 O � � Qj I J� Parcel #: �� Receipt#: � aa� �y _��q .,Mc � � � . �--� `--��`�. � �I��$� �� 7�� %�" I�� 1L�i aca-a -n u�ca ga.�r-ua�c� �ra 4:.,en. Il IE�I x�, �n Il tG�a Application for Services (Septic Systems and Wells) Services Re uested � Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 if> 600 d) (Fee is de endent on the e of s stem ermitted) 0 Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 O Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e ��" ,-�1) Services Requested 6y: r Name: � � y (,✓ �/�l� Address: �y0� e,%Ulli.2��v /.�/� �9 ��f �v /�'C- 2 �5 r1 � Phone # (home): (work/cell): _3�� .�� - �`/�' �/ 2) Name and address of current owner (if different than applicant): Name: p`i ��%i � Cti. �t i��'�� Address: ''—r � g�9- �l - S�s� 3) Property Description: Lot Size: .S � Subdivision: Address and/or directions � Property: ��y �u1�1 y �c 4) Proposed Use and Type of Structure: Residential _� Business/Type: Other Number of bedrooms _,� / Number of people served (seats/employees): Basement: Yes ✓ No (with plumbing: Yes C/No � Garbage disposal: Yes No _� �_ ; �5) Water Supply: � Private Well Proposed �Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes Lot #: (please show location on site plan) Note: A comnleted application must also include: ➢ A plat/site plan of the properry that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that 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): Date : � .3 � 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ' �13:.r�7 � � �.�� i ��J��I � �� -�.��1 �� -�o� � ��.�..Il I�3C��.11� Anplicant: ��t � ( I � W �l � � � �� S. ��rmii �alad �o� � �`ive ��s Type of Facility: .51� %'� # of Oc�upants ��(O # o Be� Proposed Wastewa System: � Proposed Repair. �ea T�x , ap � a.rc�el : • � Su;bd'ivi.s�ian � h�:s�e Secbian:Lot � � • , impravemeat �ermit - � _ �o �i�ation � New � Addition �ater �up�pip � %`� �. . ooms *,_� Proje�ted Daily Flow �ooc� g,p.d. �Cr Permit�Conditions: . �,P �1` �'P �� 1� Owner br Legal Represeatative Authorized State •Agent � Type: Type: � b�g___ 'J . Date: �_� Date: ? 2 ( U —� r_ . � The issuance of this peffiit by. the Health Deparnnent in does not guarantes the issuanca of othei peimits. It is the responszbiliiy of the � applicantfpzoperry owner to in sure that aIl Person Coimty Plaiming and Zonmg and Bu�ding Inspeciions requirements are met This . �mprovement Permit is subject tu ievoca4ion if tlie site pIan, plat or the intended use changes. The Ymprovemeat Rermit is aot a�fecte� by a c3�ange in ownership oi the p�operty. This. permit was issned in comglianca.vvith the provisio�s of the North Carolina `Zasvs r�d itules {or Sewa2s Treutment and �rsnosal Svstems' __(15A NCAC 1�A .1900}. Neither Psrson �onnty nor t�e : Enviranaieatal �ealth Specialisi� warrants tb�at the septic tank system wz71 cantinue ta funcfion satisfac#orily in the futnre or'tiiat the water supply w�'ll remain:potable. ` . --- ... . � - . - - � ------- Autiiorization io CoBstract Wastewater Sys#em (Iteqniretl for Bwiding Pex^mit) � * See site plan and additional attachments� (_�• �Z jE�� w � . �. ,�p cTv- Propos 3 Wastewater System:�/� �`C�'IJ�`^ � C�ic�.+�.i �� Type � G Wastewater Flow %� U_g:p.d. . New � R.epair_ Expansion � � Soil I.TAR. ►`�'r � g.p.d1 ft Z . Type of Fa�ility: . �� 1� I R� S.: Basement � Yes ,_ No � . r �� astedvater SgTstean �equiremen$s � ian� Siz�: Se�tic '�and�: I a��g� �p Tank: '— gad Grease 7['rap: — gal �rain�eici• Tatal Area: S�a� sq ��Total Y�eng#h S�� ft ' 11�aaiffinm Trench �ept� ZO in ��enc� '9Vidt9� �� ft 1Yg'sn'a�uua Soi1 Cover. _� in lYlinimnm Trencii Separation: ,� ft : �istributson: . � �is-tribn#ion �oa Serial �istribntion Pressure 11�I�nifoid . t , �upe�cat$ons: S45�w� lCi�l (9c.c`� Gl/ 1�''�' `'� j� jc.l,�2 �{-- l.J � r''� W� t"'� ��'" � Aut�aorize� State A.g�t: - Permit Exp� The type of system permitted is Conventional �Acc�ted Alternative. I acc�pt the spe�ifications of the permit. �j � �w�er/�Esal �.8apresa�ative: 4�^� Date: a 6 �D ' PCHD rev. l l/10/OS . ,, Q W � � a �� I430.15 � ;`�.��'' �� , > � > > � �'��3 � S-02-34-�0-W 2422.20 ; tJ.00• 21-00 -W N- 08- 2 9. OO. g . A 98.20� t68•OQ�Ir � . - 498.00' p'.p2.21-00-W �- � 3•'Z.Of N. 12 . � x 29•r �o paG A9 .� � S. R, � �� 2 � �N• Q Q�i �.��.ss ��.� �� I��.�a-��-�•-n-T ��.Il IF1I��.IL�II� Applicant Location: Tax Map 3/ Parcel # �(� Subdivision /✓/,y' _ Phase/Section/Lot # # of Bedrooms System Type (From Table Va): Operation Permit Product (IIIg): � 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. (Au oriz d t) �� (L�sed Contracto 7'?�� / O /?�.� !''�'i � sre �� ? �+' ,i I � 75' `�„ � � � �,� ti �.. 3'i � 3: � , � u � �� 3 3 /z � 6" Scale: i�T� 0 (Date) 9 �r (Date) �y/',�: �„�s,r�i/�e ,f„/b ��a�,e. �,�,,�,,,�� ,,� �,� �-�� ¢� �e2� !�/�T2�8v�� i.�/�, l.�� Co.d�/f�ef� �✓ r�.�/'s �iy��l�y �<�/tif� �� ,-,., � N . � c%o.✓s �� r-o.✓ �j� o�' /�� da�.f3 Tax Map: 3/ Parcel #: �_ Septic Tank System Checklist (Type II-I� System Type: � Notes• Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: Copy of OP (Revised 12/09 BH) e-mail Date: ��. s.� ��.� �� _= � � � �� .�.��.� .��.�� WELL PERMIT (New�,Repair� Tax Map: 3 � Parcel: �� Subdivision: Applicant's Name: � � � �i {� � �� '�"-F-�'� �� Mailing Address: ' Phone Numbers: Location of Property: �a S--� C�'�r� �� n Lot: 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 S years from the date of issue. Other Conditions/Comments: � Permit issued by: � Date: �/�t{�((7 CERTIFICATE OF COMPLETION New Well Inspection: EHS/Dat Location: S Grouting: � o�� V �° Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installe� Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Well Approved by: �r��..t¢�� Date: S' Date Sample Collected: ,� L�-�� Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 i : �� 8/1/08 y . . /' , . . / � • .. ' . ' ! - ''� ;t . . . . . . , � - . ` .�ESIDENTIAL wcLL corrsTRuc•riori REcoRn Notth Carolina Departmcnt of Environmcnt and Natura! Rcsources- Division of Wntcr Quulity �VELL CONTRACTOR CERTIFICATION # 2S37A � 1. WELL CONTRACTOR: nQnn�s C�!mminas — �� , Well Contractor qndlvtdual} Name �C:iimminns DPVPinnmPnts_ I�G We0 Gontracto� Company Name M, 360 Troilinawood Road SVeet Address Haw River NC 27258 CityorTown State ZipCode 3c 36 i 567-0800 Area code Phone number ._-i 2. WELI. INFdRMATiON: WEII CONSTRUCTION PERMIT# �� 3 f �� OTHER ASSdCtATEO PERMIT#(if appiicaWe) SITE WEI.L ID #{�f appGcable� : 9. SGREEN: Depth Dtamete� Slot Stze Top Bottom F� in. in. ; ' Y Top Battom Ft in. in. , , Top Bottom Ft. in. in. , � g. WATERZONES(dep��t--h,,):�� Top� Bottom==� Top Bottom Top�� Botiom � Top Bottom Top Bottom Top 8ottom �'� Triicknessl Top �' LBottom_„�.FtD,�� ;� Wetght S��at � Top eottom FL '' Top Bottom Ft. � : 8. GROUT: Depth Material � Top � Bottom Z� Ft. Port Cement Top Bottom Ft. : Top Bottom Ft. 3. WELL USE (Check Apptiqbte Box): ResidenGal Wate� Suppty 6� DATE DRILLED � ' �� '" � D TIME COMPLETED �U '� AM PM Q 4. WELL LOCATION: ,/� CITY: VC�I Q V V 11 I� S COl1N7Y ��'V�)V1 l_. �(`�t � � O�c' I�G� (Sueet Name, Numbe�s. Communit Subdivislon. Lot No„ Parcd, �p Code) TOPOGRAPHIC t LA�`SETTING: (check appropriate box) pSlope ❑Valley p�tat ❑Ridge � OOther LATITUDE 36 •� �� SC� " DMS OR OD IONGITUDE q��' U�' 3�" �" " DM5 OR DO - LaGtude4ongitude source: [�GPS Qfopographic map (location of well must be shown on a USGS topo map andattached to this form i(not using GPS) 5. WELL QlAt�IER, ��,� II � � ��-�,..�i P Id Owner Name SUeet Address Ciry_orTown State 2ipCode U Area code Phone number " Method Pour 10. SAND/GRAVEL PACK: Oapth Sizo MaWriai Top Bottom Ft. Y ` Top Bottom Ft. Top Bottom Ft �. Material 11. ORILLING LOG Top Bottam Formation Oescrip6on / 1 �_/� �� I S / ' �j� i�o� i / / / / / ,,� / i 12. REMARKS: 6. WELL DETAILS: / � � a. TOTAL DEPTH: �� b. DOES WELL REPLACE EXISTING WELI�YES O NOja� : � HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Balow Top of Casing: '�` C� Fi. CC RDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION � �(Use'3+" if AbOY@ TOp Of CaSing) TAN,D RDS, AN THATA COPY OF THIS RECORD HAS BEEN '�� _` -� ;.. / � D TO T WE}'��. O�jVNER. ,_.. d, TOP OF CASING I3 �_ FT. Above Land Surface' t � ;,'-�� 'Top ofcas�ng terminated aYor below land surface may require `�j�� \ �___._ - a variance in accordance with 15A NCAC 2C .Ot 18. SIG TURE OF CERTIF ED WELL CONjf�ACTOR r e. YIELO (gpm): �� METHOD OF TEST All' ROta �� (/� F'� I 5 � u rn m��S s f. DISINF�CTION: Typa HTH Amount � 6 Z- � PRINTED NAME OF PERSON CONSTRUCTING .. • �, < < • - _ , ._ . ._:,.., . _ _._. _ . ___ ,. . ,.. ,. . __ ._.. _._ ; , _ ._.. . -,- __. ___.�.. .... Submit�within 30 days of completion to. Division of Water Quality - InformaUon Processing, � 1617 Mall Servtce Center, Raleigh, NC 27699-161, Phone :(919) 80T-6300 's __,. _. .. . -� _ r ��,��. r,..f. ��.-.. �.._.�.a_��.z_ ��;�;,__,.�_ � _____.__ .. .._- �.�.._ - � _ . �. _ : �;� �r , �� , - ��; . � �-.: . ,� � . � _f � L'_J � DATE Form GW-1a Rev. 2/09 � Application Date: �� Tax Map: � 3� Amount Paid: Parcel #: � Receipt#: ��_ ) � �� - - � � �� Ir=; ��-u u an �.�.,.,, �„ � d:�.11 TE-�i: ��,.�.. Il�lla Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) � Construction Authorization $200.00/$300.00 if> 600 d (Fee is de endent on the e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 if site visit re uired $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Re uested by: Name: Address: � �J f� -C�i�° Q/Lf- �'�',C.—.�?� ��o � Phone # (home): (work/cell): ��,3� �/ 3- � j` l� 2)Name and address of current owner (if different than applicant): Name: Address: 3) PropeMy Description: Lot Size: Subdivision: Address and/or directions to Pronertv: ��%/ r� C/�" � d #: 4) Proposed Use and Type of Structure: �� $ t�� ` Residential Business/Type: Other j\ Number of bedrooms / Number of people served (seats/employees): �J Basement: Yes No (with plumbing: Yes No � 7� �X %� Garbage disposal: Yes No 5) Water 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 pladsite plan of the properly that shows property dimensions and the 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. 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): � Date : , �o l 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ' `�. � � `� � � I, ' � )� �� r i �� . �� 1 \ j ti � � �� :� : >,..� . � �, � �-- ��d� y �� " �� ' `' -}�-{� 1,.3 I�( �^ T j �a ..-l��i.Z.`� li.�.��:��J'�1�.S�a�.J1. .ii��<�..1 ti.... �a�a�d�� m��/ IY��b�� -I�agne �e�fl�a��a��n�5 � Ta1� Ivlap #:�L Parcel#:� �ddress: �' � 7 � �q�r'`� e �-o � - �� ' .��r 1e �� 1lsT �1 c, 7s'4 � Approval Requested for: Applicant Name: Address: Phone �#'s: ��/e- Z/�- 11�Iobile Home Replacement _ /� Building Addition 7D'x �a' �o�� v��✓�j' Z Permit Located: � Yes Tlo Installation Bate: z p Design flow: �� (gpd) Current Contract with Certified Ope:ator on file (if required): N/L� �-�-� — Water �upply: � Well Public or Community Wastewater system shows no visual evidence of failure on: // (date) (Applicant's signature if site visit is not required) �ir1��m�l��p��a�e�at ��v�e�l Environmental Te Speciaiist � // Da PP:son Ci�un�i Environmentai ;� eaith; 32� S. tiiargan St., Suite C; Roxboro, N� 27� ; 3 Fhcne: ��5-�47-??9C/ ra ;: �� -�9�-780� � �-v�:��,�i.�ersoncount�i.i,e� North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH StarLiMS Sample ID: ES052511-0075001 � �� ES Microbiology ID: 27368 GPS Number: Sample Description: Comment: Name of System: PHILLIP WHITFIELD CHARLIE LONG RD. Collected: 05/24/2011 13:15 Received: 05/25/2011 08:50 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htto://slph.ncaublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 J. Smith Angela Heybroek Well Permit Number: A31-86 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent ' Darneice Lyons 05/26/2011 E. coli, Colilert Absent Darneice Lyons 05/26/2011 Report Date: 05/31/2011 � Explanations of Coliform Analysis: Reported By: Susan Beasley ,r � .; .- a ; J 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. Nort State Laboratory of Public Health 06 N. W?m� gton St. Environmental Sciences Ra�e�9n, Nc Z�s„-soa� http://slqh. ncp ublichea Ith. com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH PHILLIP WHITFIELD 325 S MORGAN STREET CHARLIE LONG RD. ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES052511-0037001 Date Collected: 05/24/11 Date Received: 05/25/11 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 6.5 Sample Description: Comment: Time Collected: 1:15 PM Collected By: J. Smith Well Permit #: A31-86 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 9 mg/L Chloride 6.30 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron ' < G'10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate r .�:00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 6.5 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 5.50 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 51 mg/L Total Hardness 40 mg/L Zinc 9.60 5.00 mg/L Report Date: 06/10/2011 Page 1 of 1 Reported By: �a�ie 71la�ceol