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A32 244A licatlon Date: � � y� � �p Amount Pald• � Recei � �i `s'� c��0 0 d �.� �1 i3� �6 { ' Tax Man �: Parc$i #: ��_ � ��.� �� : . — — _ � � � �TiQi'��' - .: �sra.�►a.sc-.ma-� �--�--� aeaa��.71. ZL—�.o.m.7l.�a APPLICA710N FOR SflZVICES . � . � � - Petmit (Reconded Lat) - SZU0.0� (MobBe Home R��dAddlUon) 1) Permlt requested by (OwneHager�tl Hame Phone: � l -�g�.�-l{� 8usiness Phone: . 2) Mame ana aaaress of cun�e� owner: 3) -Property Descniption: Lot Directions to the property (�i (�P�) - Cor�strtxUon At�tttoriz�oti for Sepdc 5150.OQlS20o.o0 • Permd Rev�a� Fee - 375.00 ��r��u. �TO � ,Q�� -� ��—?7a3 . �� l � �� 4) proposed Use and Stnuture Description: answer e�� _af th�e following questions: ._. 'a)� Proposed �, Existinn9 _,, l'YPe of Strudure:� f�LL('/l� �dth: Depth: ��' b) Number �f Be�� s: _� Number of o«x�pants or people to be served: � e• . �' C) Basemer� Yes �� No _ Will there be plumbing i� the basement?_��' : ' • d) 6�baSe Oisposai: `fes � No _ . � 5) Watsr Supply Typs: Private _(new _ or existln . Public . Communiiy . Spring _ - � Are any wells on adjoining property? Yes�No ,_ tf yes, piease indicate approximate locatiori on the 'site plan. � . � Daes yaur property carrtatn previously identiflad jurisd[ctlonal wetlands? Yes_ No� . PLEASE NO'i'E THE FOLLOYYING: " ➢ A PLAT OF THE PROPEitTY OR. SiTE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MARf�D. •, ➢ THE.PROPOSED LOCATI�N OF ALL STRUCTURES MUST BE STA�D OR Fl.AGG�. � ➢ THE SITE MUS"� 6E READILY ACCESSIBLE FOR AN EYALUATION BY THE HEALTH DEPARTMEIVT STAFF. ' . � I hereby make appllcatian,to #he Person County Heaith �epartrnent for a site evaluation for the on-site sewage disposal system for the above-desaibed property. 1 agree that the car�tents vf this applicatian are true and represent the maximum faci(ities to be piaced on the property. 1 understand ifi the site is aitered or the irrtended use ctianges, the permit st�al� became irnaiid. � ,� �� . owme�r or Legai Repres tirre � Date PC�iD, rev. OH127/02 Application Date: � � , �Ar:�ount Paid: � Receipt #: � � �� {3�S Ap ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Repiacement or Building Addition $150.00 if site visit r ' ed) eil Permit� eplacem t/Itepair) $300.0(�/ 200.0 . ��,s� I�I�I�.�� :xn-a nn-a�anaxa�.za.d.mll 1C�3Ia�.�.��L-�a. ion for Services Services Tax Map: Parcel#: � � � �x � ��, �� ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Infor ation: // `�a/ Name: �GL , i�`��(.,1.. Phone (home): 3 3� �b�7 �� i7% Address: ss �-(c�r'd(,e . �(S � or cell): 33� 5�jr-/ - 75�YZ �/Q'7 v. �r- ,2 � S /�'G � '� I 2) Name and address of current owner (if di ferent than applicant): Name: Phone: Address: 3) Property Description: Lot Size: Subdivision: Lot #j Address and/or directions to Property: % v� S S c.� v� �l� /t� �( ❑ yes �:no Db�s the site contain any jurisdictional wetlands? " ��yes Does the site contain any existing wastewater systems? ❑ yes no Is any wastewater going to be generated on the site other than domestic sewage? 0 yes o 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) �Proposed Use and Type of Structure: l ❑Residential 0 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 on-Residential ype of business: M�imum number of employees: Total Square footage of Building: 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 `� If applying for `Authorization to Construct', please indicate preferred system iype(s): ��❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. �. a,�,_. �� , 1��c.,��i � �'��- � � gnature (Owner/ Legal Representative*) Supporting documentation required. Date 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) ' �� • ' �� .. . . Y � 1 � � �� I -� �rn�-v.��rn a-�s�<c� �n�.�n.]I. �"3L � �n.II.iE.I1�. Tax Ma� i � �rcel # S�ubdivi�sian Fh�Se Sect,ion:' ot � P�rmit Valad for ✓�ive Y Type of Faciliiy: �►vn{� # of Occupants �_ # o: Proposed Wastewater System Proposed Repair: �� Pernv.t Conditions: Y�provement �'ermit 1�To ��piration � ;�, New �./ Addition �ater �npp�y � s,3 Projected Daily Flow �_ g.p.d. Type: ��i Type: Owner or Legal l Authorized State The issuance of this permit by the Health Department in does not guarantes the issuance of other permits. If is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan; pla#'�or the intended use changes. The Improvement Permit is not aifected by a change in ovvnership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for 5ewa�e ?'reatment and IDisnosal Svstems' (15A NCAC 18A .1900). Neither Person �oun.ty ; nor' #he Environmental Heaith Specialist warrants fhat the septic tank system_ will continue to function satisfactorily in the futnre or'that. the water supply will remain potable. �- Autlnorization to Construct Wastewater Syste�t (I�equired for Building Permit) * See site plan and additional attachments (_). : I'roposed astewater System: (�envP,vt�IQ�� Type �q_ Wastewater Flow 3�0 �.p.d. New Repa' Expan ion � SQil LTAR: . as g.p.d./ ft 2 Type of Facility: ri J'�t-{� �� P,nCP� Basement �s _ No �astevvate� Systean Require�en$s 'Tank Size: Sepiic 'iank: �0 gai Pnmp Tank: g�l �Grease �'rap: '�'--g� Drainfield: Total Area: /�{�%D sq ft Total Irength ��D �t 1Vlazimuan Trench I�epth %� an . � � �ft � 'Trench VVidth 3 � 1�'Iinimum 5oil Cover: �_ in Miniffium Trench Separation: 3)ist�ibution: ��I)istribution �ox ► Serial Distribution Pressure I�Ianifold Authorized State A�en� _ _�„�"-_ Date: Permit Exuirati,6n Date: // - 2 - The type of system permitted is onventional Accepted Alternative. I accept the specifications of the permit. - %�D � __. Ow�e�/Legai �tepresEntative: Date: ' PCHD r�v. 11/10/�5.- k � N W W 0 lo iw i v~i ►.. i� .��y 7�1� ��'l.J'�. �1 �' `l�'V� �v 1�J �� ]E�.-.��-��x--�m�.Y ]HC��. � SI'TE S�TCH � .: . Name �a.n /� t'�-c�e�� Taz Map # 32 � P�rcel #� Sub ' ' �n . � Secti.on/Lot# 11-2-Dlo • Autho�ized State Agent . � Date . System camiionen�r r�pros.rent a�i, prnacimate �cont+ours o�ly: Tha conimctor murt flag tha system prior to . beginning the installa�'ion to i�sure thatpmpergrade is maintairud .. _ . .. ._ � .. . . _.-- ._.---�---.. . . ____ ___ _.__-----_--- -- � ------- __. _ . _.__ .. .. . _..._ .._... H U � > W M � F- • �-. a _ 3 ^ .� W �' �m ao C �h'r�'� a I �1�s+e W� �3�� . .� 3 �� Pl `' �� a� _' `I g� �nvev►�'on � 7J— �aX — l 2," �ev�c� b o-i-f��.5 �P�uG�, �e�r—' g�� sat�� Gov,er o�� \ \\ � \ \ \ . � � � ' H / `� V �^ �P/ o`� u1p�Z�^�l �� 1 � �� O � C� . �j l \ ` \ •'`^�/ � . — ,1 b ,� � � h ,.` � ` \ � cn �i`� a• IN^ � �h(/P� . ` � \ ` ~ �� \ � �' � /�'�� ` Jl" � \� \ ;�^ ♦� � \ \ �� \/o� � / � � I oD � O� � v� � �o z w �\ �� \� a�� , �., 8. � � 'p �'b+ � \ ` 0 `� �A ♦ � I � � \ .�o, ��Y � . � � _ — �c° —� � \ _ , _ / o v;s` ,�+� � � l� � �� ! � �`�ti 0��, , � \ ♦ �' \ �V �c'S' �6' . \ � � � �S� s� _. � eb'� \ •y �,v � ` \ ,`4 ��Y� � � � �h� u � °� �O sC(�LE.� � =50 `�� o� \ •,��'�� f s � �d `9 \ \ o�sti \ � � � z �. \ � . � � /�� \ \ ^�"� � � � H 1 `(�0 W NS2•��11n ``�� V � ss.4o F R � \ V N49'3 r `� �� O� V / _ -.�, 89 9�2„F - _ ` R/ , �N � . N4�• � `� cn -r �� 896S9r,F � '`,1r=`��5 � .s � N47��0�34u� - � � • r �� `�, ! 1`�� . � ` � , �X� ,�ei � V � � � ° �z ��tP �!�`�, �Q S J � �4 � �?� � N t�.e, w � - w �. ��« ' �"" :. a , � �� r �, ' J `j ''/'� 0 � �a� � �o �,� � �� s� � �� . � N� �� 2� � ,�L °o .o �� , d � s� . �. a _ �� d � � �� , s - � �� : � � \z ` ,'_� a � , � �. � � ,.� = , � � . , � � .. � � . , � .k r �.� .r- Lr � f�+,�' __ _ o E` ...�%- , % .,n ' i ..' .._� �' ..x ;`. 2 -�. . � -�•'� 9 '.\ a 2,� iA, � � �...� �� .7� qq.4' ,Z� i" � .: �+�\1 �, ^��r'�.1 �L � 1 � . � �, � 9��Q`0,39 � p� ��W _ ` • , � ��%i �d .��,� - � �� ap��'��cil? �i'�:. 1 Q � l�u;`t' QEYi��: �%�O _ �� i��C�3� � rs`r.' 8, �� !._._. C��I(23 !n . /2 �.�,aai 1'S � t9.�li ❑� �� - n � �.t� �� 1��l. t �t�tn'�: s_��=Sr�-�.�.— ~�� J l� .!!. � IE".��.�►� �i! IE3C��li�. n�� Q L�''a2��,'dii �'�s�s3.s�EY6��3'E�idt3,�^.it�,�'s`� Applicatio�3�To Cbarge! CEl$iSO.OD ar�300.OQ '�} I�A�t�6�a ��d�ddi3i: � ) I+Iaitte: �oLrr� ��n �f.�s�.�c{ r.�}; �:ci� � Address: n: � sfir : f1,�.:..�� .:yr,,,-,cL:�.^, � ��S'%u �� 1`Ta,.s�e a�t� 2.adr�s ca� ea�� , �� f �� cant); '�Iazn�: �ddrass: 2'i � � Phone (izame): �33L�� -"t,�T�LL ��rorkl�eII}: !''��&� ��' t��,3(c Phone: 3} �_ ape� �ae��^�stiu�: Lo� Size: �,_, Snisd�rision: Lot �: __. t4ddress and/ar directions to Praperiy: Q yes ��no Does the site coniaia any jurisdictioaal wet�ands? Q ye.s II no Daes il�e sita cantain any �sting �ras�wa�r systea�s? Ct yes II�o Is aay wasietivater �ing to be generated a� th� �ite oth�r t�an damesric sewa,�? Ct yes II no is the site snbject to apgroYal b}r any otl�r pt�iic agen�y�? C! yes II na Are t�ere any easemer�s or r'�rt ai �vays on this property' (ff �'es' is chscked, Please provide supporting docume�) t;) r�ro��e� LTse sm€� ��Se t�� -'e: I�Res;eeatigt � � Ne«► SiRale Fami�y Reside�tce �mu�n number ofb�draoms: Q Expansiaa af"'�sting System If ex��ion: Curr�ut uunib�r or"i�edroams: - C1 Repa� ta ivlalfuac�ionin,� �yssteem WitI thera be a basement`I L7 yes Q no i%f'�th plumU�ig �? II y� Gt no �Rio,� ,�-��3,o�aI ' `• �e �� Toiai Sqttare foatage af Bnildi��: _�r,.— �um nnmber oiemgIayee� 1��tum number o'Fseai�: �) i�,T��e�' S��sy_ Q N�w ZveII Ci Enisting S?ireII D Cemmuniiy Weil Q Pvblic Water Q�pring Are there any existing weIls, sPrin� ar eris�ng u�erlines on this luoAeriy`t I7 Yes ❑ nu 6} a..: a��g fo� °��r�e�a � Cc€��e�y �a�e�s� �� rred �a� �E(�}c C► Canventional C! Aceepted � InnavaUUve Q Alternative Q Ot�er Q�Y 1' ce�trfy �liat tlre �orrnatiar� pra,rided above ir complete and crn�ec� 3' also z�t2ders�2d rhtu' ff F32e it�`'oP,7i�ula� pFouided is uiaccurute., op if the su� is szrixr��ae�ity altered, or the irttended zs�se ch�tges, a71 permi�s ar�d approvals slzaIl b� ir�uulid. ; q —1 D��.-- �?s�e �PP�� docame�atinn reqnired. �e� �e v� 30� ei�er� bD ��€� �� e ��-��-�� e�o��a�e� �y � �p�r�d g� A s�mp� `�t�repar�ior�9 0� �� a�s�� .� a��i��? a e�� . sa�e �;t2�v�. - — - - --- - - - -- .. .. .. .. , ---- �.*.t.,-.r�. ry�c rn� i�nn� � �� 1.3..l.S ��iJ `1.J' �T ` � 11 � �� m�-aa-�-�-n n-+m ��.��.� ��.��n � /1 _ T / �(' ' / � • / %�' �►' �;'� � Applicant• �a� � � Location: � . � e / �x M�p � P� c-el ; Subd!ivision Fha.se Section ot # ':' of Bedrooms � . �r�t��s� � it � System Type (in Accor�ance Wiih Table Va): `��'^�� THIS SYSTE3VI HAS BEEA9 INST.�LL�i� II11 COMPLIANCE ifUiiH APP�4CABLE . NORTH �AROLdNA GEf�ER�►L STATilTES, RU�.ES FOR SEVIIAGE TREATME�IT AND DtSPOSAL, AND - ALi CONDITiONS OF � THE 9iViPROVEi�ENT PERfVftT fAND CQi�lSTRUCTi�f� AUTHOf2 T10N. - . . � � ? ?v 0 S� - . uthorized State Agerrt Daie � Ins#alietl. By. , �� L-�(.(/�c� ❑ate.. ! �f �Y/ �% . � . t1�u�r�� 't,' �j-� �ii� � --~-� r��C�csro � �j� to� �,lnP s � �� 1�2 � �c� �� t5 � � - J� r �� . G' . 2 .� ' \ � r, � �� n' � ; �� 3� .� R �� m Sr u� w��s��f Y��` �' � �nr a l� �. ?Cl-�D, rev. 0 i 129/0=� � fEl �. _ ^ . ` ��G T��K �N��'3O� ��9E��SS �'�Pe 91 � !�'p Tax Ma� # 3Z Parc�! # z Sys�tesn Type (Tabie Va} Owe�erlAQp{icant � Subclivision AddresslLocation SecfPhas� Lot # � � Se�a�c.'Fan� 1nifi�a�/Da#� Na�s oa��oaa in� Ina�� at� � State�IDldaie � 1-�? ST�3 1'�Z Trencfi Wdth� � ft. 5 Ca aci r s l�. al. :� � Trench De th /2- in. Tee and Fiiter - • f Trenc� Len a� ft. Baffie ✓' � Trenct� G�ade � � Sealant ✓' Trench S ac9n Riser ifi a iicable � � Roc� De th and Quali T'ank Outtef Seal ✓ Dams/Ste dowm� etc. -� Permaneni Marker ✓ Pressure Laierais � =-- Pur�ap Tank � � Hole Spacing � --- State date o-i (-� s S,/ o e ize Ca aci S al. t/ Pi e. Sleeve _ Watemroof ISealant � , Turn-upslP.rote�tors --- Riser Water Tight � � } � �a�e�a� Checfc ValvelGate Valve Antt-sip on o e �larm (visable and au�ible Electrical Components Rate (gpm) _ . Appraved Pump IVlode( Blocic Under Pump � PumQ Removal �RopelCt�ai . � Dis�vi�u�aon: Sy��n Serial Distribution Pressure Man ol Low Pressure Pipe Appr. Pipe 1�lateriai and Gr , .-,- -_- .. `� Fte uirec9� Setba�� c� �r4re� From� Wells From Property lines - �1--�-----�--=�---_- .. Surface Waters Public VVater Suppi Verticai Cuts (>Z it Water Lines VeMicle �Traffic � EasementsJRighf of 1!1 O�e� Easements Recorded Coc�aanera� pc:�d r�v. 3/'13/Q'1 PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT _ - �Z-l�-p� 32 2� Date of Inspection System Installation Date Tax Map Parcel # ��5� Ff4r��F, �i��5 fc� � Property Address Instructions: Check yes or no for appropriate items and explain in space provided for rerrarks and comments. If an item is not applicable, indicate by "!v'A". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks 7 Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pum�ing ? Inches of solids:�� Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operadng properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose t cj:� Elapsed time readings ? Counter readings ? Drawdown rate: � �/ N / 'l�I ■ ■ n DISPOSAL FIELD: Evidence of efEluent surfacing 7 ❑ Evidence of effluent ponding in trenches ?� Surface water effectively diverted ? Diversions/swa(es pronerly maint�ined ? ❑/ Vegetative cover maintained ? [��/ Protected from tr�c/unauthorized uses ? [a Distribution devices in good condition ? � Field free of settled or low areas ? / / / / / / / PRESSURE DISTRIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessibte ? / ❑ Pressure head properly adjusted ? / ❑ COMPLIANCE: Compliant Non-compliant lv'eeds Maintenanca ADDITIONAL EHS u► ■ ■ REMARKS � . . � . .�-- • • � . • o �� ' � , � � �'� �� '� � � . � � ��. � . . � � � � . � � � y�� , � ' . �� .� � ��. � � � � .� .�� . � . � . � �� . �. � o �. . �� c� � � . � � , �� . �' � ;- � . . . � � � • . � � � . • � . , � � � � � �. w ' � o � . . � � . � '� " • . , • . � . . . : �.�� • . . •. • � • • � . , � .�+ . ' . d � ' o� • � . •' • , �r ' . � 0 0 0 • . . � � � � 1 1 � � . • .• �� Sf �� ._. c�� 7��a-�� .Il .IHI�.�.Il�II� WELL PERMIT (New�,Repair� �� `� � Taz Map: � 2 Parcel• 2 Subdivision: Lot: Applicant's Name: �� ?�'� t � Mailing Address: Phone Numbers: Location of Property: Permit Conditions: 1) See attached site plan for proposed well location. 2) AII applicable State and County regulations governing construction and setbacks apply. � 3) Permits expire S years from the date f issue. � , Other Conditions/Comments: � � J`� �� v� � s�� '`1�,L, �v, �c-�/ii.Lr, wr . �k S Permit issued by: Date: ____�� CERTIFICATE OF COMPLETION New Well Inspe tion: HS/Dat Location: i� Z ( ( Grouting: �i Well Log: Well Tag: � Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): Well Driller• �►��'"� License #: Pump Installer: License#: Well Approved by: Date Sample Collected: Date: Date Results Mailed: Person County Environmental Health 325 S. Morgan St., Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 8/1/08 -�P�1' '�Z�z ;"�''' .` "Y. �.; ++.,n'- �>. .� � - - . Da. � ..+ :1�,.,.,..N /C i�..�.-: �: _ �'t tt.ac�=N� . 1. WELL CONTRACTOR: North Carolina WELL CON � n C�� Well Contractor (Individual) Well �ontrector Comparry Street Address City or Town 3c 36 i 599-0015 Area Code Phone number 2 WELL INFORMATION: � WELL CONSTRUCTION PERMIT# l/,lY' � OTHER ASSOCIATED PERMIT#(if appiicabteJ S17E 1NELL ID #(dappiicab►e) n of Environment and Natural Resources- Division of Water Quality t CERTIFICATION # ��6 !"� g. WATER ZONES (de th): Top.�f� Bottom� Top � �s _ Bottom i � � Top Bottom ToP Bottom Top Bottom Top Bottom Thicknessl . 7. CASING: Depth Diameter Weight Material � Top_Z Bottom� Ft. 6��Y SO(L-Li �C.. NC Z7J�74 - Top � Bottom Y Z Ft. ��Y .( 8Y vnMztcj State Zip Code . : Top Bottom Ft. 3. WELL U5E (Check Appficabie Box): ResidenG I Water Supply � DATE DRILLED �Z � /' �� TIME COMPIETED �OO AM ❑ PM � 4. WELL LOCATION: cmr: �oxbo•, couN e� n _ /�X�� ttrirO�t /��j�S TOPOGRAPHIC / � SETTING (chedc appro pSiope pVatley lat pRidge ❑Other LATITUDE 36 "�� DMS O. LONGITUDE �_• n� • �� DMS O Latitudeilongftude source: [�PS Qfopograp (locaiion of.weil must be shown on a USGS fopo ihis fam if not using GPS) 5. YVELL OWNER � Owner Name Parcel, Zip Code) � box) 3X.X)OCXXXbcX DD 7X.)OOOOOOOCX DD ; map ap andaftached to � o�B w rt -��s . r. a7s7 City or Town tate Zip Code c 33 � � � �f — lY7� Area code Phone number 6. WELL DETAlLS: � a TOTAL DEPTH:__ l'O� �t b. DOES WELL REPLACE EXISTING WELL? c. WA7'ER LEVEL Betow Top of Casing: � Nse `+' if Above Top of Casing) d. TOP OF CAS(NG IS � �, q� 'Top of qsing tertninated aVor below land a variance in accordance with 'I5A NCAC e. YIELD (9Pm): � METHOD OF TE f. DISINFECTION: Type HTH pn NO Q Land Surface' ace may require .0118. 1 2 Cu 8. GROUT: Depth Material Method rop�_ Bottom 2.O Ft. Sand/Cement Poured Top Bottom F4 Top Bottom FL 9. SCREEN: Depth Diameter 51ot Size Material Top Bottom Ft. in. in. Top BoBom Ft. in. in. Top Bottom Ft. in. in. 10. SANDlGRAVEL PACK: Depth S'�ze Material Top Bottom Ft. Top Bottom Ft. Top Bottom Ft. 11. ORILLING LOG T�l B�ttom / �� / S / a� / / / / / / / � / � 12. REMARKS: Fo ation De aiption ro/� 5�, s (d..� - Q`ia/�ec.� I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. � L- 2- -1 SI ATURE OF 1 WELL CONTRACTOR DATE �� PRINTED NAME F SON CONSTRUCTING THE WELL Submit within 30 days of completion to: rvision of Water Quality - InfoRnation Processing, Form GW-1a '1617 Mai! Service Center, Raleigh, NC 2T699 161, Phone :(919) 807-6300 R�. �pg C � 4 � T C ry ti ..j } j. c"' � f � � � � . O C � � O i A 4 � h S a � a , , ; (T' �i � _�7_ �; � � �� 1 I + IGr' � + ` i ; \� � ± ' i , f � i , i � i ; ; { ` � � + ��-_-�._. �_..�._.i _. �-i � 1 � � s.�i y t � ; 1 I �� ; � ''� �?�,�E � i � �' �-�� ` � ? , � � t � I � � � � • � ' !A �_ �_ �. � + � � � , +. �` � � 10 � ' �/} v � r � � fi � -�� ; -�� j�. �� r �� v 1 it � o � � ��i � 'y.�__�._L�_I� L. i � � � w S s � a' � r � ;� p � � i � N ;'! � w � �� ¢ �� . � �� x p � � !; �. P � G ' � � `'.c � , � �:�i � r� �. � � � � � 4 r � • � t � � �� , � � � ° � ~ .�� M � � � � � � . .� v � '� i � �� O �! � . w�� ,°�s; "O�� : �� -� �� m � p �� w C i � C o � �� ° °; e � ..'i' f �' i � � �.. g � �, � , .u- { �, c � � ;c Z� a �� 7 � � s ��.�� .. f �---�= � � �� 7� �ca�a�r�aa�o�ra��o.lL ��all�ll�a WELL PER1Vt� (New _ Repair _ ) Tax Map: ,� Parcel: �_ . Su6division: f AA.'�_I..II Applicant's Name:� ari �► � Mailing Address: �� AA�� i s� j �5 y J - Phone Numbers: - Location of Property: � Lot: �-. Permit Conditions: 1.) See attached site plan for proposed �a�onsatoverning construction and setbacks apply 2,) Al1 applicable State and Counry regu g 3.) permits expire S years from the d�ate�otf isaueotable water supply 4.) Issuance of a permit does t gu P . A Other Conditions/Comments: � Perarit issued by: �Tew Weu: EHS/Date Location: _— Grouting: Well Log: �- Well Tag: _— Pump Tag: _�- Air Vent: _— Hose Bib: �— Casing Height: __ Concrete Slab: __ Well Driller: pump Installer: Approved by: Additiona[ Comments: Date Sample Collected: EHS: Date: 9 - /y- /� Certificate of Completion Liner: EHS/Date Depth: �} � � 5 � -l�'I S Grout: ✓ DAbandonment: Date: — Method/Materials: — License #: ___._ License #: �- Date: .�— Date Results Mailed: _ Person County Environmental Health , Phone: 336-597-1790 Fax: 336-597•7808 325 5. Morgan St.,Suite C li/26/13 �� ) � 1 � � �, � � ,., f ��. � `_ -` � � � �T��'�°� 1L�1 �rnv* �i n� a s u�n ��n �c� ltn lC,�. ll lE-1[ �.:.r,a. �� 11.Iin Date: �l l 24 /1 � Tax Map: 3 2 Parcel: Z� Name: Q.� ; �-C � l Address: 1� $S �}�t� � Re: Bacteriological Test Results Dear ��' ��i��""<<l Your welI water was sampled on , i/��/ ��I , and tested by the Person Counn� Health Department for bioiogical contaminants (total coliform and fecal coliform bacteria). The results of your water sample are noted below: No coliform bacteria were detected in the satnple. Your well water is safe for normal use. � Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detee#ed in the sample. Tatal coliform bacteria are naturally found in the soil. Fecal coliform bacteria are associated v�rith animal and/or human waste. The presence of either total or fecal coliform bacteria in ��ell water may indicate that a new or repaired well was not property disinfected pr�or to use, or that contaminated ground�'ater ma�' be entering the well. If coliform bacteria are present in your ivrrter saitrple, the water may not be safe for use. Young children, the elderly, and individuals �vith compromised immune systems are especiall�- varinerable and their physicians should be notified of the test results. A x�ell that tests positive for total or,fecal coliform bacteria should be prope�•lv disinfected and retesred nriot- to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. � well contractor or plumber can assist you if needed. Once the chlorinateci �vater has been thoroughl�• flushed out of the system, please contact the Health Department (597-1790) to request a re-sample. For additional information, please feel free to contact Environmental Health at 33b-�97-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincer ly, C\�b?vv�I Ejivironmental Health Specialist Person County Health Department Person County Environmental Health, 32� S. yiorgan St.. Suite C. Roxbaro. \C ��"�. Phone: ==6-:9 �-1 �90. Fax: =�6-��"-"SOg (revised 07/29/13) PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant ��ltr` � ttG��P,�) Address %a�� v�� • County � Collected By �� Date Collected ��A-L� _Time Collected �� 2� Source: �Vell ❑ Spring ❑ Other Location: ❑ House Tap �'Well Tap ❑ Other ❑ No Charge ra' Charge ..............................................................................� ******�*********************�**************�*****�********************�***** Total Coliform Fecal/E. Coli Results Present �� ❑ Reported By �%�� Date Reported �I ��9 �l� Report Called �YES ❑ NO Called To ��-�"""�� 3 Absent C■7