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PERSON CO TY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Tax Map # �%�j Parcel # S
Zoning Towns p � � w�-
Owner/Contractor � �t� n ate .3 -' 3—
� �
Location/Address . —
S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank �
SFD Mobile Home Size of Pump �'ank
Business # of Bedrooms Nitrification Line�a �
_ Max Depth Trenches
Pernut Void after 60 months.
Permit Void if not in compliance with zoning regulations.
Comments: -
Date Installed by �'� ��'hr Q� Approved by
.,, _ . � �
Ttils report is based in part on infonnation provided the homeowner or his/her r resentative in the application submitted for this pertnit The
environmental health specialist is not responsible for false or misleading inf ation contained in the application The cnvironmental health specialist
is also not responsible for concealed rnnditions on the property or for statements in this repoR that may have resulted from false or misleading
statements pro�ided to him in the application Neither Pecson County no� the environmental health specialist wazrants that the septic tank system will
continue to fundion satisfadorily in the future or that the water supply will recnain potable. c:�amipro�erntitsam OI/95 rev.1.0
ORIGINAL
Application Date: S S U� d 1 l� ,� � ��
Amount Paid: p0 . U C) � 3 ���I
Receipt#: 3
� '�" �_`�� ��.� ���� ��
�,yd � -, �- �������
r/� 7�-aawnic-a.a�rn.ira�._arsn-n.d:.u+..Il. 3E`aL.c�.en lld:.ila..
Application for Services
�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
�ptic Systems and Wells
Services Requested
Tax Map:
Parcel #:
v .M��
��11 �
C(�`�1�.�
❑ Construction Authorization
(Fee is dependent on the type of sy:
� Permit Revision
$75.00
❑ Repair of Existing Septic System
No CharQe
Important: lf t/ie information in the app[ication for an Improvement Permit is incorrect, falsified, or the site is altered, then tl:e
Improvement Permit and tlieAuthorization to Constructshall become invalid.
1) Services Re�} -ue�s,te'd by:
Name: �,1'1/� �- Or �'1�✓
Address: Z� Gr� j
�
Phone #(home): 33 l� S� 4�6�1 Z
(work/cell): 3 t,.r 5� 3� 5' �3
2) Name and address of current owner (if different than applicant):
Name: Cv� � ► s
Address: � � o
C� � S
3) Property Description: Lot Size: �j��C rGC�ubdivision:
Address and/or direction$ to Pro�erty: AO Ot,�fi C1�v�.•�
..�v� A /� � . _ . �M 1 � _ .,1
#:
�l � - r :�
'J�.v��1 Qr� Of tM�-,r.�10.�-' �1Zc�� ���j �
4) Propos�d Use and Type of Structure: �
Residential �� Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes _ No ✓�i�vith plumbing: Yes _ No � Garbage disposal: Yes _ No _
Approximate size of building foundation: Length Width
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 plat/site plan of the property that shows property dimensions and the size and [ocation of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that tlie 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): C�� • Date: 5� �
�
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
��� � � ��� � ��� �� T�x M�p ; P�rcel #
� - �� � • � - � - � • Su�bdivision
1 � � , � � , � � � � � � � � � I 1 1 I �
Ph2se Sect�ion Lot #
Permit Valid for ive YE
Type of Facility:
# of Occupants �(� # of
Proposed Wastewater System:
Proposed Repair: �.�
Permit Conditions:
Owner or Legal ]
Authorized State
Improvement Permit
No Expiration
New Addition Water Supply ���
s�_ Projected Daily Flow 31�o g.p.d.
�
Type: L��
Type:
Date: � '����
Date: 7 � 3 �d R
The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernrits. It is the responsibility of the
applicandproperty 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, 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 %r SewaQe Treatment and Disposal 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 plan and additional attachments (�.
Propose astewater System:���� Type��� Wastewater Flow�(QO g.p.d.
New � Repair Expansion _ Soil LTA�! . g.p.d./ ft 2
Type of Facility: P,-;�e e5� r� e. Basement _ Yes _ No
Wastewater System Requirements
Tank 5ize: Septic Tank: DDO gal Pump Tank: ---�—�al Grease Trap: -- gal
Drain�eld: Total Area: D$D sq ft Total Length .3� ft Maximum Trench Depth � in
Trench Width �j ft Minimum Soil Cover: �( _ in Minimum Trench Separation: 9��ft �
Distribution: � Distribution Box Serial Distribution Pressure Manifold
Specifications:
ri
?�
Authorized State Agent:
Permit Expiration ate: 7�
Date: ��'�d�
(�
The type of system permitted is Conve 'onal v Ac epted Alternative. I accept the specifications of the
permit. q
Owner/Legal Representative: Date: 7/— �g
PCHD rev. 11/10/OS
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System cvmponents s�e. pi�erent u, ppmacimdnte �contours only.' The contmctor must. flaS the system, prior to
beginning the i�utalYrrt'inn to i�sure that propergrade rs mar�tai�red
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CaQaciiy PrS-- �o�, asl.
Tee and �ilfer �
Bafiie
Sealant
Riser fifi applica�le)
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Pertnanent Ma�ce�-
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Ris�r
Water Tighi � .
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Pressi�re anrrfld
Law Pressure Pi � '
A r. Pi�� Ntaiesiai and G�-ad� �
i/alves �
UMl�dih
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Tre�cf� S ac�n -
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Pi�e. Sieave
Tu�-u�slP.roge�to�s
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From� VVeils �
Frorn Prap��ty Iines
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Tax Map Pazcel # 5�� _.. Townslup:
Applicanf:
Q,.L.�:�.:..:_�. . _
�y�e of �a�ea-�Su g : �/ Individual
�P Y _ .
�e�anir��ne�at�:
Community Public
Site Agproved By: ��� a8� �� I ��
Grouting Approved By:
Well Log: � �
Pump Tag:
WeII Tag '
Air Vent: � �
Hose Bib: 9' 'OS
� Casing Heigh� �
Concrete Slab: � :
Well Driller: (�c�, r � Pfi'P
Well Approved by: �
���*���.A$�aC$flet� �i�e �lie$Clfl*py*
Liner:
'Installed by: _
Depth set: _
Grouted•
Date;
Water Sample:
�Vells musi be 10 feet from property lines.
Wells must be 100 feet fram septic systems.
We31s must be at least 25 feet from any building foundation.
Other canditions:
Date:�� �- � — D`�
�'CHH� rev 07!27/0�
Owner:
I.ocation:
Subdivisi�
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Oa�� � . r3�6 � � �
�q�.3��,� �Q l,�e�l ( ���r(���
O�f�l �-2�-�8 - -:�-
c,��at r.�
- WeII Cunstrac�on
Distance From nearesi Pmpaty L'me (1ltiinimum 10 feet) T�� �'
Distance from Septic Sys�an (M'mimum 60 feet) � o�
Total Depth: � zv ft Yteld: '� GPM • St�tic Water LeveL- 7 j $
Watee Beazing Zo�ne� Depth � f O ft ft ft ft
�5�
D�►ep�h.- �From . to 0 3 ft. niametec: 6// `6 in - .
. t�I' .
�� Weigi� Thiclmess: 5 -2 I Height above Grouad: . i Z m� ;
Drive Shoe: _,e,� Yes No An}r problems enco� wb�e se.tting casnng? Xes �o
If `�►es" give reason: ' — �
(�out: . - ' -
. Ne� SandlC.e�t `� Concrete Grav+eUCement
- =- Annnlaz' Spaoe �V'�th ' inches Waber in Amiular Spac� Yes ✓ No '- :
Meti�Ocl of Gmu� Pum�ed Pressure � Poured s� DePth '� � to z o Ft
r�uteri�als IIsecL - .
No. �ags Portiand �t " Weight o� 1 Bag Po�mds . -^�: �
If mAhu+e (sand, gravel, �) – Ratio to -
ID piat,e� �Yes _ No 4 a 4 slab ✓Yes No _' ''
Linter. " - —. — �;:.
. _ .v
�epth: Dat,e Installed: Grot� 7nstaIled by: .
Driiling Log
Location Drawin�
F�rom 'To Rorn�atiAn . -
3 orl
2 S � '. -
�f Z 2.c� ru c.�C . .
, •
. �
[ hereby ceatify that the above� iafo�mati�t is cou+ect and t�at tius �vve11 was cons�ted 'm a�x�Ce wifli reg�ilatians set fo�
byt�e Pe�sonCoimtyHeatihDe�rit - -
S�Sxtsre of Cmmhxc�or _
�
ID# �3�fb � ��. -`6' 2S-o�
Patmp Ins�limeat
��ac�: a� � I r�1 �,, sr�R�onx�: 66y �
Pu�mp 1�h: Z � v � ft shdtic wates L�we1: � s g
?um� 1�+tak� � 1K«�eL• r�,;� �� � si� and �tatm�- �'l y� `7 �
� hereby certify ti�at ti�is pump was mstalled and the well head. cample.ted acc�+dmg �n ffie Person County Well Kules in effer,_t
xi t�is date a� tha# a oc�y of t�is nacord has bee� pmvided to�e weII ownear. .
�°p � � � Date: � �2 � �� � PCffi) revOU27I04
`��
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM
Name of System: Chandler, Chad
Address: Munday Rd
County: PERSON
Report To: Person Co. Health Dept.
325 South Morgan Street
Roxboro, NC 27523
Courier: 02-33-15
Collected By: J WILEY
Location of sampling point: Well head
Remarks: Permit # A35 - 556
Zip:
ATTN:
(336) 597-2371
Date: 11 /4/2008
Source of Water:
Source of Sample:
Type of Sample:
Type of Treatment:
Type of Analysis Private
Time: 2:30:00 PM
Parameters Results Units Date Analyzed:
Silver <0.05 mg/I 11 /5/2008
Alkalinity as CaCO3 158 mg/I 11/5/2008
Arsenic 0.002 mg/I 11/5/2008
Barium <0.1 mg/I 11 /5/2008
Calcium 51.9 mg/l 11 /5/2008
Cadmium <0.001 mg/I 11/5/2008
.:
Chromium <0.01 mg/I 11/5/2008
Copper <0.05 mg/I 11/5/2008
Fluoride <0.20, mg/I 11/5/2008
Iron 0.20 ° mg/I 11/5/2008
Hardness as CaCO3 (Ca,Mg) 175 `' mg/4 11/5/2008
Mercury ` <(i.0005 � mg/I 11l5/2008
Magnesium 1 ��.1 . mg/I ' 11/5/2008
Manganese 0.24 . ,mg/i 11/5/2008
Sodium 11 mg/I 11/5/2008 -
<0.10 mg/I 11/5/2008 --- ; :, �� +�"'-���'�
Nitrite as N _ -- .
_ : ,>
Nitrate as N <1.0 mg/I 11/5/2008 ���'�`-' ��
Lead <0.005 mg/I 11/5/2008� -� 2���
F�10� 2 �
pH 7.7 Std. units 11/5/2008 _----�--'
Selenium <0.005 mg/I 11/5/2008 ��� `�—
Zinc 0.12 mg/I 11/5/2008
Date Received: 11/5/2008
Today's Date: 11/20/2008
Report Date: 11/19/2008
Ref: 15612 Login Batch:
Reported By: �.�����L
Sample Number: AB80917
Explanations
Coliform Analysis:
If coliform bacteria aze Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
, , . �
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28407 - 306 N. Wilmington St. - Raleigh, N. C. 27611-8047
COLIFORM ANALYSIS - PRIVATE WATER SUPPLY
Name of Owner or Tenant: Chandler, Chad Counfiy: Person
Address: Munday Rd Z�P:
Source: Well Type of Sampling Point: Well head
Collected By: JW Date: 11/4/2008 Time: 2:30 PM
Signed By: Wiley, Jonathan B Analysis Type: Private
Report To: Person Co. Health Dept.
325 South Morgan Street
Roxboro, NC 27573 (336) 597-2371
BACTERIOLOGIC ANALYSIS
CONTAMINANTS RESULT
Total Coliform (ColilertRoutine) Present
Fecal/E. coli Absent
Sample No: AB14347 ` Date Received: 11/5/2008 Time Received: 8:55:00 AM
Date Reported:11/6/2008 Today's Date: 11/6/2008
Comments: New well permit # A35-55B
Person Co. Health Dept.
ATTN: Wiley, Jonathan B
325 South Morgan Street
Roxboro, NC 27573
Courier 02-33-15
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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 supp�y.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/I
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1