A32 25312 -I£�� z--
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Application Date: 1 � ��- t'2 � �Q �` � � f` ����� � � �
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Amount Paid: 60 . Da � y�_ /�
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Receipt #: � 3 7 I C� C.� � �'` � � ` ����
�'�'� �' asv-na <>xauaaK ani.es� �C_.Czaas�•L�� {
Application for Services
Services Requested
Permit (Site Evaluation)
Mobile Home Replacement or Building Addition
$I50.00 if site visit re uired
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
�.
Taz Map:li 3� 3$
Parcel#: % 3
�� ea t 1 � �
�-o. 1� e e'�'
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Ezisting Septic System
Application: No Chazge/ CA $150.00 or $300.00
1) Applicant I formation•
Name: �Pri- �� /�a���r� .S %.1� n 5�'
Address: �3�i /iiC/%!ti✓�n 7e��ctCf'
�oxbor� . NC a7573
2) Name and address of current owner (if different than applicant):
Name: 1��v� ` �- l�//! �� e
Address: 0 �l� •
�- ' S �V'G 7
3) Property Description: Lot Size: ��C Subdivision:
Address and/or directions to Property: _�,.�+�et�_
Phone (ho e): 33u� � �� -- �SSS
(work/ ell • 36 'Sol/ -' .3i�%
Phone: 33G- 36�f —7�70�
(if `yes' is checked, please provide supporting documentation)
Lot #:
: 1l S �- �arl��e
4�Proposed Use and Type of Structure:
_ ,�Residential
New Single Family Residence Maximum number of bedrooms: _�
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �Q no With plumbing fi�ctures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum numbec of employees:
Total Squaze 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
I cert� that the information provided above is c�omplete and correct. I also understand that if the information provided is
inaccurate, or if tke 'te is s�urbse/p� uentl%%uu altere , or the intended use changes, all permits and approvals shall be invalid.
a' 1 i� _� ��/ _`� /ll/1 .I A_i'1�� r .` d"�
Signature (Owner/ Lega1 R�preset
* Supporting documentation required.
Date
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed °Lot Preparation' form must accompany any application requiring a site evaluation.
t
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant:
Address/Lc
Tax Map: g Z. Parcel: 2S3
Subdivision
Phase/Section/Lot #
Improvement Permit
Permit Valid for: F've Years Non-expiring
Type of Facility: r v New �Addition _
Number of: Bedrooms ! Occupants / Employees / Seats:
Proposed Wastewater System: ,
Proposed Repair:
Water Supply: �f Q,( �
Projected Daily Flow:�� gallons/day
Type: �1__—�_
Type: �
I �" r� � ,/
Permit Conditions: � 9s i,1Tp.� n Gi �� S�t'hGtG1�5
Authorized State AgE
(X) Owner or Legal
Date: �
Date: /Z
The issuance of this perrnit by the Health Departmer(t does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
lmprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the Nort6 Carolina `Laws
nrrrl Rules for SewaPe Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed astewater System: ��C��'�tC l�'�� eduC�inn�('�)Type � Design Flow � gaL/day
New � Repair Expans�on Soil LTAR. ,� gal./day/ftz
Type of Facility: riv�-k Res� d�rL'e Basement: _ Yes _ No
(*) System Types IIIb, Illbg, IV, and V, requireperiodic system inspections by the Person County Hea/th Department.
Wastewater System Requirements
Tank Size: Septic Tank DD gal. Purnp Tank - —gal. i,rease Trap — gal.
Drainfield: Total Area 20 sq. ft. Total Length DO ft. Max. Trench Depth � in.
d, G,
Trench Width 3 ft. Min.Soil Cover �_ in. Min.Trench Separation � ft.
Distribution: Distribution Box ✓/ Serial Distribution / Pressure Manifold
Specifications: �(aee 2 �� Ao��
Authorized State
Issue Date: / � – /3–/Z
Permit Expiration Date: � Z–/3-- � 7
The system permitted is: Conventional /Accepted ✓/ Alternat' Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: � Date: /� ����.
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Name — f'�o��t�' SIrn�nS . . . . ' . .
Tag Map # 3Z. � Pa:tcel # 253
�Sub .on � Section/Lot# .
�/ 7 — /� ��/2 •
Autho�ized State Agent . � Date
Systern cbmponents ne�brerent approximacte �contours only: The contracrtor must,�a► g the system prior to
_ beginning the installaalion to in.sure that pro�iergmde �r maintairled '
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Applicant:
Location:
Oueration Perrnit
Tax Map g32 Parcel # 25.�,
Subdivision
Phase/Section/Lot #
# of Bedrooms �i
System Type (From Table Va): Product (IIIg): (',�, � m de r
Type V& VI Expiration Date: Type V& VI Renewal Date:
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
Autbarization.
( thorized Agent}
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Scale I� �� � �
PCHD, rev. 12/14/12
4- 2�{-r3
(Date)
- Z�/ - / �
(Date)
� pa,,,,�s are Same ht�c�� AS ��
o� C ham beYs �J
Tax Map: 3 Z Parcel #: �
Septic Tank System Checklist (Type II-I� System Type: �
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.
NEMA 4X Box
Model:
Piggy back lug
Hard wired
Alarm functioning
Mounted on ost
Above grade 12"
Conduit sealed
Pressure Manifold
Number of ta s: �
Size and sch:
Contracted Certified Operator (Type IV Systems): �
Notes•
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`�'' � C� � tCT�T��
1� .�� � � �.�. � � �.�.11 IHC � �►.11 -�.I�.
. W�+ I,I, PERIVII�' ew � Re air
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Taz Map: 3 Z Parcel: Z 5,3
Subdivision:
Lot:
Applicant's Name: a eY`�' _ 1 a�-S
Mailing Address: A e
Rbx6ara _ NG �7573
Phone Numbers: �;(�- S98'- b555 33�- 56�1- ���j29
Location of Property:
r� n � ,.
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I'ermit L'onditions:
1) Se� attached site plan for proposed well location.
2) All applicable State and County regulations governing const�uction and setbacks apply.�
3) Permits expire S years from the date of issue.
Other Conditions/Comments: . _ -
P�ramit �ssued by:
I)ate• � � -�L�f Z,
CERTIF�CATE �IF C�1dIPLE'I�ON
� New Well Inspection: L'nner da�spection:
EH�S/Date EHS/Date
Location: �/ Installer:
Grouting: 3' I�"�3 Depth:
Well Log: Grout:
,�,�p' Well Tag: �S � - Z�l� l3
��;�,�NPump Tag: 75 S-ZZ-�3 Wel1 Abancionment:
:� � Air Vent: � EHS/Date
Hose Bib: - Z�l � � Completed:
Casing Height: Method/Material(s): _
Concrete Slab:
Well Driller: . �-�� SO ►1 License #:
Pump Installer� l� License�'#: .
Well Approved
Date Sample Collected: �'��
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
I)ate: S- Z7_-�.�
,
Date Results Mailed: �
Phone:336-597-1790 Fax:336-597-7808
8/1/08
- s...-..<a-a
�d �rj w• 's. DT
�� = 3��: l�,s`jDErVTIAL WELL CONSTRIICTION RECORD
:� ..` ' :-:�_�- �.
2� L� `' E ti-- A� North Carnlina Departmcnt o€Enviro��t a n d N a b o i a i R e s o u r c e s- D i v i s i o n o f W a t e r Q u a l i h'
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�. '"•a.=„ � /
•h-���;�-' WELI.CONTRACTORCERTIFICATION# 31 �!� -
1. YYE11
ComPanY
I; "FT i^=:
� �/G�. �7��
O E
�y � State ZP C�de
�� �f�I-37��
Atea code Phone nuntber .
2 WELL INFOR�IIA7101�k
WELL CONSTRIfCTfON PERMfT�
011-iER ASSOCIA7ED PERI4A(f�appfir.�e
S!'CEWELLID�a�pl'�bte�A' i'� J� ,PG.iGel �
3. WELL USE (Chedc A�Gcable Bmc)_ Res�dentiat Wafer SupP�Y �
DATE DRILL"ED3-13-13 - .
TIMECOMPLETED �I��v AMp PM�
4. WELL LOCA770N:
�: ��� IP .� �1�- �U����
.�a���iP .����t r��
(SUeet Na�t�e. humbers. C.a�rp�j: �. Lot No.. Pareel. T.iP Code)
TOP0C�2APIi1C / LAND SET7ING: (d�dc a�ppmp�i�e ba�
❑Sbpe OV�'Y O� ❑Ridge OOther
LATfTUDE � � � • • DMS 3X.�OOODOOOC DD
LONGITUDE 75 �'�-' • • • pM$ 7X.)OQOOOO�OC DD
IatitudeAongitude sou�e: �GPS OroPo9�Phic map
(b�li�n of we0 must be shown an a USGS tiopo map andattadted b
this fam iinoE using GPS)
S.1lVELL C?iNNER
ob� S"�an S
Owner Narne
�3G 1�� 11�� �� �.�����
�D�� A�
/�CT[ ��rn /Y(� z%��%i .
City or Town Siafe ZiP Code
r 33�� 598' - os55
Area code Phone numbe�
6. VYELL DETAl1.S: �/`
a TOTAL DEPTN:_ I O..J
b, ppEg WELL REPLACE EXISi1NG WEl1.? YES ❑ NO�
c. WATER LEYEL Below Top of C�sing: � Ff_
(Use `+• if Above Top of Casin9)
d. TOP OF CASING iS �, �• �e � S��ce�
"Top of r.�sing tenninafied atlor belaw Nand surEace maY reRuire
a variance in aocadance wdfi 15�A NCAC 2C .011$.
� METHOD OF TEST - . /
e. YIELD (9Pm� �_
f Q�su��cnoN: -rype anou�t 21 b
9- 'W,LATER ZONES (depth)-
ToP11� � O c TOp B�om
T� g� _ Top Bottom
T� Bottoan ToP �
7'hiclmessJ
7. CAS�IG: Depth � N Diameter Weight llaberial
T�_, Bottom� Ft� �� UG
Top � �-
T�p Botfiom Ft
8. GROl3T: Depth � ��
Top O Bottom oZOtFt G � TOuQ
i'op gpttom fL s/�%11�
Top Bottom �t-
8. SCREFN: DePth Diame� Sbt Sipe ti�erial
Tpp Bo4tom FL_,___�n• �-
ToP Bottan Ft in- m- �
T� g�m Ft. irt. In.
10. SANIDIGRAVEL PACK:
pe� Siae AAaberial
'�op Sot#an �-
Top � �-
-�op Bot6orrt Ft
11. DRIWNG LOG
Top �
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12 REMARKS:
Formation Desaiption
8�
G��•�, /
/'r,r�.� �" _
t DO HEREBY CERTIFY THAT iHIS11YELL WAS CONSTRUCT�D IN
ACCORbANCE WITH 1aA IVCAC 2C. WELL CONSTRUC710N
STq(1ppRpg. /Wp IHAT A COPY OF'ililS RECORD HAS BEEN
PROVIDED TO 11iE WELL O
i�, � -�� 3 /.�
SIGNATU OFCERTIFIEUWELL R DATE
�
PRINTED NAME OF SO CONSTRUCTING THE WELL-
Snbmit within 30 days af comple�ion to: Di�vi.sion of Waber Qualit�l -�at� Proces�ng. � eu►-�a
Report To:
_ A3�- �s'3
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
ROBERT SIMONS
HURDLE MILLS RD.
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sloh.ncaublichealth.com
Phone: 919-733-3937
Fax: 919-715-8610
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES052213-0022001 Date Collected: 05/21/13 Time Collected: 11:00 AM
Date Received: 05/22/13 Collected By: J. Smith
Sample Type: Sampling Point: Well head Well Permit #: A32-253
Sample Source: New Well Temp. at Receipt: 5A GPS #:
,..
Sample Description: '
Comment: �
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 3 mg/L
Chloride 11.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 _ 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron < 0.10 0.30 ' mg/L
Lead < 0.005 0.015 mg/L
Magnesium < 1.0 mg/L
Manganese . < 0.03 _ , : , , 0.05 mg/L
Mercury < 0.0005 ° 0.002 mg/L
N itrate ' 1.30 ti 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 12.00 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 24 mg/L
Total Hardness 11 mg/L
Zinc 7.80 5.00 mg/L
RECEIVED
Report Date: 05/31/2013 JUN 0 7 2013 Reported By: Arno/d Hall
BY:
Page 1 of 1
North Carolina State Laboratory Public Health 4° Dstnc�Drve
Environmental Sciences Raleigh, Nc z�s„-so��
htta://slqh.ncpublichealth.com
� I C i0 b 1 O � O Phone: 919-733-7834
g y Fax: 919-733-8695
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH ROBERT SIMONS
325 S MORGAN STREET
� �--� I� HURDLE MILLS RD.
ROXBORO, NC 27573
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES052213-0056001 Collected: 05/21/2013 11:00 J. Smith
IIIIIIIIIIIII'IIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�llllll Received: 05/22/2013 09:25 Angela Heybroek
ES Microbiology ID: Sample Source: New Well ; Well Permit Number:
GPS Number. Sampling Point: Well head A32-253
Sample Description:
Comment:
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present - - HLBRASWELL 05/23/2013
E. coli, Colilert Absent HLBRASWELL 05/23/2013
Report Date: 05/24/2013 '
Reported By: Susan Beasley
�
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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.
PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant 1� o��er�' S� rv►a�'13
Address �1nr���, %�( ��5 �_ County p�r�o�
Collected By � �
Date Collected �— ZO � 1� Time Collected q: `��
Source: L�Well
O�No Charge
0 Spring C�Well Tap � Other
❑ Charge
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��**����*�*���*�*�����*�**�*��������***��������*��*�***��*�*�*����**�*��
Results
Present Absent
Total Coliform �
FecaUE. Coli. 0
Reported By
Date
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