A32 24512/14t2010 23:31 9196443018 �RANGE COUNTY R.O.D. PAGE 02104
� '' � � Tax N�a
Applicati�;n i)ate: jo2-1�� � 0 %�7 �� �'� —
Aniount P�tid: OQ .40 ���' � �6 �3� �� � Parcel #:
Rec�ipt#: `1 6� (��� � '`#� IbS` �
r � �� .���_S � ���,.� ��
'���e� l�ou. ��J � � �; c� � l'�,� °'7:C" -Y
J� L'� �I'�171'Tl'1^.7L.1T'R.i �� T�lYa'fa rC^ 71.T �••{n,.�� 1I �C •C^•LR�II. K�I !�
�a � � ��3 N . - •.
� � � �R G nd Wells
-F �pp�xe�tion for Servz�es (Se�tic System.s a )
Se�r�ices
�mPro�'ement Per�ttit (Sitc Fvaluation)
$2U4.401$3Q0.�0 (if> G00_gpd) _
I M1Tohile Home 17ep1aCement or Bui[ditlg Adciition
S t SQ.p(� if sitc visit re nired
�Vcll k'crrnit (NewlReplacementl�cpa�r}
$300.00/$2UO.00/S7S,00
1) Services e ue ted by:� / /�
Name: �i��, l• C1� ��C
/1cldress: ��S �`�G.fC ��l�r �
-� d� �r �- -� - z75�'
❑
�'anstroction Authorization
k'ee ia d cndent on th.e ,e of s s
Permit Revision
��s.oa
RC�.4iC 01'E7CIStlnh Septic System
No Cha�e
���� -- ,
�F
�..�:�_
...e: ��,.�if�.�
Phonc # (home): � � 4 � 6 ���� � �
(work/ccll): �? � ro S$ 3� S13.3
2)N�me �nc� address of currenC owner (if different than applic�nt):
�1ame:
Address:
3) Froperty f�eseri�tiqn:
Address and/or direc tons to P
� �c.� � �i4'vi S
Lot Sizc:�+k4R'O� Subdivision: �,at #: ,,..�
4) Froposed Use a Type af Strueture:
Residenti�l Bu iness/Type: Other
Nwnber �f bc�l,rat�ms 5 / Numhcr of people served (seats/cm�aloyees):
Basement: Yes No `-� (with pluntbing: Yes No }
G��rba�c disE�osal: Yes No ��
5) WaterSupply:/
Plivate Weli 1� (Praposed Existin� �)
Community Well: Public W2�teX System:
Are there wells or thc adjoining prop�rties? No � Yes �� (please show locatit�tt on site �lan)
N�te: A co�a: l.et�ci a l.ication must also i�:clude:
Y A pda�lsite plun of the,�roperty that sl�owsprnperty dime�zsions und tlze sixe rr.r:d locatinn r,f all
proposed structure.r.
� A signerl cr�,�y of tl�e `,Uo#.+PYepu1•atu���'.forna verifying that tlte p�'ope��ty is ready to he evalccafe�X
I�m submitting this a�plicafion to request seKvices from the Persot� County Health DepArtme�t. i underst�nd tl�nt
if thc information provided is incorrect ar if tkte site is suhsequently �IteKed, pr yf the intcnded use ehan�es, atl
permits and appro���ls shal� beeome invalid.
esentativc : G�t/�`''`�' J' ��""� �ate • %� +V�� .,, �
Si�nnt��re (Ownex/�.egal nepr )
l0/i)$ Person Cou�.ty �nvironmental HeaJth, 325 S. Morgan 5t., Su.,',tc C, Roxboro, NC 27573 (33C-597-1790)
� ��� ��i ���4� ��
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1�a-am�.s�m,,.,, ,r-�-:, ���.�.Il I�-���.11�11�.
Applican� C�� �c
T�x Ma�p � �rc�e1 �� .
S�abdivi.s�ion
� h��s�e Sect+io�n Lot �
Impravement �'ermit '
�'�a-s�nit Valid fo� ���ve 3�eaa�s _ 1�'o Eapiration
Type of Facility: -{h+�-���� � New C� Addition Water S��ppiy e)�_
# of Occupants # of Bedrooms � Proje�ted Daily Flow y�� g.p.d.
Proposed Wastewater System:���n.,� AceP�keci (as��o_������c��,n CZ ;-t�� c,r Chc�r.�l�r� Type: � 1�
Proposed Repair: R�n,� ArcP �lec� (��°� v-e�1��e�i�,r. c.Z rl �.,.� or C'{�mher� Type: L�
Permit�Conditions• -��\�`� �i-le(���r�
Owner or Legal Representative Sigaature:
Authorized State �A�en�'c�r��f �-bC-�
Date: � - �� - I 1
D�• ial� I a
The issuance of this peffiit by the Health Department in does not gua=antes the issuance of other pe.nmts. It is the responsibility of the
agplicantfpxoperty owner tn in sure tha# all Person County Planning and Zc�mng and Bu�ding Inspeciions requirements are met This
Improvement Permit i� snbject to revocation if the site plan, plat or the intended use changes. The Improvemeat Permit is not
affected by a cliange in ownership of the property. T7ds permit was issned in compliance with the provisions of the North Carolina
`Zaws and Ilules for Sewasje Treatment and I)isnosal Svstems' (15A NCAC 18A .1900). Neither Person �ounty nor the
Enviranmental �ealth Specialist' warraats Wat. the septic tank system will cantinue ta function satisfactonlp in the future or'that
the water supply wi71 remain: potable. � --.. . � � �
Authorization to Constr�ct Wastewater System (Reqnired for Building Pernut)
* See site plan and additional attachments (�• .
Proposed Wastewater System: ��m�� ACC�f�'�l �F7 �=1a,� ar� ('1�1n-�x�)Type �fSb, e Wastewater Flow �/PC� -g:p.d.
New � Repair Expaasio� Suil I,TAR: �.� g-P.dJ ft 2
TypeofFacility: �l(�; ���14 .�,�lucl��������? Basement_Yes�No � � , .
g -
�Vaste�vater Systean Rea�uirem�ents �
'Tank Size: Septic Tank: i o�� gal Pnm� Tank: l�u o gal Grease Trap: — gal
�rain�eld: 'Total Aa�ea: laoo sq ft Total Length ��o ft 1V�a�mnm Trench Depth tz in
Tremc� d�idt� _� ffi �"ininanm Soil Cover: �9-� in `� 1l�Iinimum Trencli Separation: 9 ft
�istribufson: 13istribution �oa Serial �istribntion � Pressure Manifold
Specifications:
AnthorizedStateAg�nt: �Kc�rzrl�c
Permit Expiratian. Date:
Date: la I� I i�
�U 1��
The type of system permitted is Conventional � Accepte3 Alternative. I accept the specifications of the
p�� � _� �
t�wner/��bal ��preseutative: %� ( � l .�o�-r-- Date: / - �f � f r
' � pGID� rev. l l/10/OS
��� Sf I�I�I�.�S��
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.� navnsoaaaan��ca�m� IF��o�mIl�ua.
SITE PLAN
Name ����(1(k' y �P �OC1� Tax Map #�Z- Parcel # y5
�division Section/Lot#
z�� � _�a 1� J � �
Authorized State Agent Date
System components represent zppmadmare contours on/y. The contncrocmustllag t6e sysrem prior ro beginning the insra/lsrion m
lnsure thatpinpergrade is maintsiaed.
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S.R..�g4 CJack ,�'
' 60' Publfc R�W�S Rd,) -
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�Em.��mm����.�t ���,�. Owner: l�)�Ilnce yPl\a�c�
Tax 1b1ap: _ A� Farcel #: _.,�y� Date: i� 1� I�� -
�,ane '�'a� �a� (Sc�a) Tap �'Io�v �e ��� �ow / �oo�
# ���ei�r(�) . . ( �n) �. '�i) ,
�. '� �� -� 5•5 .o
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3 ��2 c4a
4 '/ �� 7.1 9 0.
$ � �� � -7 . I � O. C'�
6
7
8
9
10 . .
c� ft of line x 65 gal. per 100 ft=��� a< < ; 100 =� h gal
75% x^�I �t�_ ga1= 1 a5_ S�1 pe� �ose �� I gal Per minnte (gpm) =�'!ow �ite
�'raciaon ��si
L�ss: .-•,Z_ft per 100 ft of supply line x�_ ft of supply. li�e =100 = `i ft
�_ ft x 1.2 =�_ ft of friction head �.
I�iani�old Si�e: -� �{ " Forc� 19�Iain Size: ,�„ PVC .
'�o#�I Dy�ic �ead = I o ft of Elevation head +�_ft of Pressnre head +�._ft of
Friction Head = �,'-1 TDH
Pu�p �2eqaaix�e�t�: � GFM @ 1� • ft of I�ead
g��awalo�n: I�rs gai per dose : 21 gal per inch =.�_ inci� drawdown per dose
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]��.w-au-��.,..,,-,. ���.�.11 IE-3L � �.I1�1�
NEMA +�X Simplex Contml Panel
� �-1
4" X 4" Pressuxe Treated Post i
Sloped To Shed Water 12" Separation
\ Electrical Cond�it =
b" Cover • ' � Acc s Covez• •• , ' _ ; � 1 �
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. •. � , � = ' : .'t�. '" . ;
�,. Opening Filled With Anti Siphon Hole �\
Inlet Fmm Septic Tanlc Portland Cement Gmut �� g��
+3" SCH 40 PVC Pipe � �
Check
Valve
High Water A1arm Lev+el
' (6" Separat'von�
Hig�t Level- Pump On -��.�,��
' �Vapor Lock
.' q -
xo�
. .; Drawda4vn �Up Hill)
. Low Level -Pump Ofi -��
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..
Tax M�a�� � F�rcel #
Suhciivision
Ph•a�s•e Sect�ioii Lot #
Duct SealBoth
Ends Of The Cozubut
� 24" Mininnixn
�. •,
Threaded Gate Valve ;
ilnien / � r'1
Zip Coxd
Ti�� 1
P�cast Concrete Tank 4" Concxete
� ;.; (Material Strenstk>3500 PSn B1ock
••.`..',' : ; .' •._`.• . ':••' ; , , '� '
Concrete Risex
�" Separation
. , .- ' ;s„0�'�'-
�.rPortlandConcrete G:erut
Iviastu • - ' .
� Opening Filled With
Supply ' portland Cexnent Grout
Line � • '
Outlet To Distnbution
2" SCH40PVC Pipe
Float Wues .' �
�r
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Flaats ..
�R.emovable "•�.
F7oat Tzee , ,
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I �� G�LCtN PUNg' TANK
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Applicant:
Location:
Operation Permit
Tax Map � Parcel # Z S
Subdivision
Phase/Section/Lot #
# of Bedrooms �
System Type (From Table Va): �11Ly� Product (IIIg): �Z
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.
i'� � �y'��
(Authorized Agent)
�' � c ��i C C; ('C1/ ')
(Licensed Con actor)
�s'
Scale: �����
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s�Z %Z �Z/Z
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sc%� 0 2' �
Line Length
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z �
3
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Total
Tax Map: � Parcel #: %�j�
Septic Tank System Checklist (Type II-I�
Notes•
System Type: �, a
—�—
Pump System Checklist
Contracted Certified Operator (Type IV +Systems):
Notes:
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Copy of OP e-mail Date:
���,;��� ��t �����
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�.�n�n�ram�.n.�ncc��n.��.�. ��a�.�.�-��n
W�I.I. ]PERMIT (New��2epair�
Taz Map: R� Parcel: �yS
Subdivision: Lot:
Applicant's Name: �,,�czA1.c�,c� `1e11�k
Mailing Address:
Phone Numbers: .� �a -���,� �� 4- �33-v133
Location of Property: }��,r��\� �,�;1\s `�1 -� � C ���ss r� �(� �Ck ('i�Vi ��cl
—�- 1,� � CR_l
I'ermit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply. �
�) Permits expire 5 years from the date of issue.
Other Conditions/Comments: -
Permit issued by:�zx1 �_q �c�' � Date: t'�I� � I c�
� C�R'i'�ICATE OF C�MPLE'Y'IO1�T
New Well Inspection:
Location:
Grouting:
W; l � � 1��We11 Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
�Vell Approved by:
/(
Date Sample Collected: �Q - Z� �� �
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 #:
License#:
I)ate: `f - Z(e - � ( _
Date Results Mailed: '�
Phone: 336-597-1790 Fax: 336-597-7808
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Apr 1811 02:22p
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Barnette Well Drilling
336-598-9275
IIESIDENTIA� WELL CONSTRUCTION RECORD
Nor[h Carolina Departrnent of Environment and Natvral Resources- Division of Water Quality
WELL COn�IRACTOR CERTIFYCATTON # �Y�� %�
1. 4VELL CONTRACTOFL- f� ,�r
ICil�n viar �' ^
VYeil Coniractor (lndividua� ame
�arnette Well Drillina Inc.
WeII Contrador Comparry Name
611 Bamette T�naen Rd
Streei Address
Roxboro NC 27574
Cily or'fown Stale Zip CodB
3� 3fi y 599-00'[ 5
Area code Phone number
2. INELL INFOftMATJON:
WELL CONSTRUCTION PERMIT#
OTFIER ASSdCIAi�ED PERMIT�(itapp�iut�le)
SITE WELL (D#{ifapplicable)
3. YVELL USE (Check Appiicabte Box): Residential NJater Supply p
DATE DRILLED �-lr-I1
71ME COMPLETED_ �OQ AM p PM �
4. YVELL LO ATiOtJ;
cirr: �< �i� counrrY d/s�n
�GiLK 1:�i4w/tS ��. �•a7' on �
(SUeei Name, Numbers, Community, Subdivisio�, Lot No., Parcel, 2iA Code)
TOPOGRAPNIC / LAI�[D SEtfING: (cheek appropriate box)
�Slope ❑Vatley sF�f ❑Ridge ❑Other
LATITUDE 36 `� " OMS OR 3%.XXXX�UCXX OD
LONGITUDE 75 �' " DMS OR 7X.XXXXXXXXX pp
LatiludeAorigitude sourCe: [GPS (]Topographic map
(location of wel! musf be shown on a USGS topo map a�dattached fo
lhrs fa�m if not using GPS)
5. YYELL OWNER
�t%GjwL� �L�t�G+�-
Owner Name
J rLt�% �.vl.u/+� J�o�
SUee Address
���,���.. �Z C. � � ��
C�ty or Town State Zip Code
c� 3s � 3�K- �,ig�
Area code Phone number
&. YYE�i DETAILS: ,/�
a. TOTAi. tiEPTH: �,�D T'�
b. DpES YYELL RfPLACE EXISTING WELL7 YESC NO[�
c. WATER �1IEL Betow Top of Casing: � r' FT.
(Else'+' h qbove Top of Casing}
d. TflP OF CASING IS �_ FT. Above Land Sur(ace'
'Top ai casing terminaled atlor below land surface may require
a variance in accardance with t5A NCAC 2C .0118.
e. YIELD (gpm): .�� METHOb OF TEST BI01M') ZOfI'i
f. DIS►NFECT]ON: Type_I"'I�H AlflO�rtt � �2 {�iUD
g. yVATER ZONES (depth):
: Top 20 8ottam ! L�
� Top Bottom
: Top 8ottom
p.1
.� �-�' �
,� 3 a
Top Bottorn
Top Bottom
Top Botiom
Thicknessl
7. CASING; Depth Diameter Weight Matertal
Top�_ Battom �� Ft. � �l� ��� �%--
Top Bottom Ft.`T
Top Bottom Ft
8. GROUT: Depth Material Method
7op�,_ Bottom_,7� �t. SandlCement Poured
Top Bottom Fl.
Top Bottom F!.
9. SCREEN: Depth Diameter Slot Size Matarial
Top Boriom Ft. in. in.
Top 8otlom Ft �n. in.
Top Battom Ft. in. �n,
10. SANdlGRAYEL PACK:
Deplh Size Material
7ap Battom Ft
Top Bottom Ft
Top Sottom Ft.
'11. DRILLING LOG
Top Bottom
'fi / 3
�_! 2s
2ti / �+{o
/
/
1
/
I
/
,
/
�
12. REMARKS:
Formaiion Description
�•f
N �.I�
! DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE W{TH 15A NCAC 2C, VYELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS R�CORD HAS BEEN
PROVIDEO TO THE WEtL OWNER.
4 �
SIG UR F CER FIED WELL CONTRACTOR DATEj
�
O n � ^
PRtNTE NAME OF ERSON CON UCTING iHE WELL
Submit within 3a days �f completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-'l6f, Phone :(919) 807-6300 Rev. 2/09
� `1
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North Carolina State Laboratory of Public Health
-_— --- -�-�� -^ nvironmental Sciences
a ._�J \I �J.:. �.� r-�1�.'/
Inorganic Chemistry
JUL �� 201i Certificate of Analysis
�3X:
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH � WALLACE YELLOCK
325 S MORGAN STREET JACK CHAVIS RD.
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES063011-0024001 Date Collected: 06/29/11
Date Received: 06/30/11
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 6.5
Sample Description:
Comment:
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
htta://slqh.ncpublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
Time Collected: 1:30 PM
Collected By: J. Smith
Well Permit #: A32-245
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 47 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 < 0.1A , _ , 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 8 mg/L
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.1'� �� � 1.00 mg/L
pH 7.7 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 11.00 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 157 mg/L
Total Hardness 150 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 07/14/2011
Page 1 of 1
Reported By: �e�le �Keol
,"� ,�'_-----
•_ . --'•-':y:� .- --
JUL� �% ��11
���,, .
North Carolina State Laborato Public Healfh --��P�o B°X28°4'
� 306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
htto://slqh.ncaublichealth.com
M i c ro bi o I o Phone: 919-733-7834
gy Fax: 919-733-8695
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
R�XBOP.O, NC 275?3
EIN:566000331 EH
StarLiMS Sample ID: ES063011-0091001
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ES Microbiology ID: 28329
GPS Number:
Sample Description:
Comment:
Name of System:
WALLACE YELLOCK
JACK CHAVIS RD.
C ol fected: 06/29/2011 13:30
Received: 06/30/2011 08:51
Sample Source: New Well
Sampling Point: Well head
J. Smith
Angela Heybroek
Well Permit Number:
A32-245
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte
Test Result
Analyst Date
Total Coliform, Colilert Absent a � Darneice Lyons 07/01/2011
E. coli, Colilert Absent Darneice Lyons 07/01/2011
Report Date: 07/05/2011
Explanations of Coliform Analysis:
r. • Reported By: Susan Beasley
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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.