A40 364�� -/-�_� /�u�
. + Tax Ma
Application Date: � ��� S� ������ P' /�
AmountPaid: �-�-� ._..:••�- ������ Parcel#: �lD�
Receipt #: �
�aavirtsra=:aoaiLal g$oali�
A lication for Services
Services Re uest
❑ Improvement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 (if> 600 eadl (Fee is de endent on the e of s stem ermitted
M�bile Home Replacement or Building AddiHon
:50.00 (if site visit
� vVell Permit (New/Replacement/Repair)
❑ Permit Revision
❑ Repair of Existing Septic System
1) AppliCant I�` rma�n:"A S �b
Name . MU
Address: : �
v�
2) Name and ad re of cur ent o ner if differe t than applicant):
Name: �1(
Address: CJ�
No Charee/ CA $ I50.00 or
Phone (hom ):
(work/cell): , " �
Phone:
3) Property Description: Lot Sizet �_ Subdivision: h V)ICl Gt�� Lot #: ��
Address and/or directions to Properly:
❑ yes
0 yes
0 yes
0 yes
❑ yes
Does the site contain any jurisdicrional wetlands?
CzY�er poes the site contain any existing wasteWater systems?
0'ry� Is any wastewater going to be generated on the site other than domestic sewage?
f�� Is the site subject to approval by any other public agency7
� no Are.there any easements or right ofways on this properry?
(if `yes' is checked, please provide supporting documentation)
4) roposed Use and Type of Structure:
�dential
ew Single Family Residence Maximum number of bedrooms: �/ Occupants: _�
O Expansion of Existing System ' If expansion: Current nutnber of bedrooms: '
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-ResidenNal
Type of business:
Maximum 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
Please note any known ground water restrictions or sources of contamination:
6) If apiSlying for �Authorization to Construct', please indicate preferred system type(s):
Ltf'Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other 0 Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccur te, the site is ubsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�1 � ��
5ignature (O ner/ Legal Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved pla�
• A completed `Lot Preparation' form must accompany any application requiriug a site evaluation.
(10/IS) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Application Date: i I"1
Amount Paid: �?Oo'�-
Receipt #: I 1-114�9
ck..-� 15��{
❑ Improvement Permit
��z�il�� ,....
� �o .°a �����.f ������
( 833Go ,.. _ � �����`�
']G,��,�,�,�,�.� ��¢�.11 lE-I[��.A;�]Ea
a�-'tf" 2� '
Annlication for Services
$200.00/$300.00 if> 600 d
Mobile Home Replacement or Building
$150.00 if site visit re uired
❑ Well Permit (New/Replacement/Repair
$300.00/$200.00/$75.00
Tax Map: �-(�
Parcel#:
Services Re uested
❑ Construction Authorization
ee is de endent on the e of s stem ermitted
Addition ❑ Permit Revision
� $75.00
� ❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: rs �I m m� /�k w �i' i�v S
Address: s l `' �' ° t F � ` ` s � �'
e�j �o 0(�6 , aVG �
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): '
(work/cell): S 9 S� - a� a Qi
Phone:
3) Property Description• Lot Size: � A`� Subdivision: G� ��� a � Lot #: ��
Address and/or directions to Property:
� yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
O yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
� yes ❑ no 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)
4) Proposed Use and Type of Structure:
❑Residential �
❑ New Single Family Residence Maximum number of bedrooms: �_/ Occupants:
❑ 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
❑Non-Resideutiat
Type of business:
Maximum 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 property7 ❑ yes ❑ no
Please note any known ground .water resfictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurat'�, the site is subseguentjy altered, or the intended use changes, all permits and approvals shall be invalid.
�
Signatu�wner/ Legal Representative*)
* Supporting documentation required.
�-�- /7
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.
'10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�� " 4 ` f .l1 1�I �� ��
�_� � � ����
7:f����a-��� ��.��.�1 I����.Il�7�.
Applicant: SQ✓Li✓K y l�tw� k� , � . ��
AririrPec/�.nnatinn• _ , � ^�
Permit Vatid for: Five Years ^
Type of Facility: �j3K �1�E'
Number of Bedrooms �/ Oc u�
Proposed Wastewater ystem:
Proposed Repair: C
Taz Map: �� Par el• 3�
Subdivisicn Cr� . �^Q- S
Phase/Section/Lot # ?
Improvement Permit
Non-expiring
��
Water Supp;y: � � �
Projected Daily Flow: 3� o gallons/day
Type: c�'
Type: �
� ' �6 , �
Permit Conditions: � S/ � .il�'��'� � �0.'�"�"� �" �
Authorized State Agent:
(X) Owner or Legal Rc
Date: �~f `�
Date: S/- Z'�
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is th� responsibilit�� of
the applicanUproperty owner ±o insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
improvement Permit is subject tu revocation if the site plan, Qlat 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 l�torth Carolina °Laws
aiad Rules for SewaPe Treatment and Ilisnosal Svstems'(1SA NCAC 18A .1900). Neither Persoa County nor the Environmental
Health S�ecialist warrants that t�e septic system wiil continue to function satisfacto::ty in thc future, or that the water s�pply wi[I
remain potable _ _ ______—
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
x
Yroposed Wastewater System: � •Qr/I �" ���L' �V (*)Type �� Desi�n Flow 3C� 0 gal./day
New � Repair _ EYpans�on _ Soil LTAR: �� 7� gal./day/ft
Type of Facility: �� Y� S, Basement: _ Yes � Pdo
(`k) System Types Illb, IIIbg, IV, crnd V, requireperiodic system inspections by the Person County Health De�artment.
Wastewater System Requirements
Tank Size: Septic Tank 9 to �� gal.
Drainfield: 'total Area �� � sq. ft.
Pump Tank � gal.
Total Lengtl� �3 d_ ft.
Grease Trap � gal.
Max. "french Depth 3 o in.
Trench Width 3 t�. Min.Soil Cover �° in. Min.T�rench Separation � ft.
Distribution: Distribution Box / Serial Distribution �/ Pressure Manifotd _�_
Specifications: �'� Sl � Sk� ��
Authorized State Agent:
[ssue Date: ��l -�'7-� ��'��� Y��r� t�'
Permit Expiration Date: 3^�' z Z
The system permitted is: Conventional /Accepted �i Alternati�e / Innovative . I accept the conditions
and specifications of this permit. � �
(k) Owner or Legal Representative: `- Date: y'ZY-% 7
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/l2)
Person County Health Department
VOLUNTARY RELINQUISHMENT OF ADMINISTRATIVE APPEAL RIGHTS
Date prepared: � ^ �
Owner(s): �LI✓`? 'u/��"�
Mailing Address: �Y�� �t�� �'/'� � 1 S Y�o� �
Property location/site legal description: /� r/O �� � �Q L
�'I-`( �t-►
Original Improvement Permit (IP) # `t 0'— � f9 Y Date issued: 3—(— (
Original Authorization to Construct (AC) #�� t� — 3�j� _ Date issued: ��— i't r/
I, , voluntarily relinquish my rights to pursue a formal appeal through the North
(print full name)
Carolina Office of Administrative Hearings pursuant to NC General Statute 130A-24 and 150B-23 and all other
applicable provisions of Chapter 150B for the above referenced permit(s) (which includes the IPs and ACs) in
order for the authorized agent/local health department to issue the applicable permit (new IP and/or CA) for the
site. I understand by completing this form that the permit(s) for a
iz ,�`C.��J � s�.s�,-'-� -
� (System description)
will be revoked immediately by the authorized agent/local health department.
I understand that the local health department's revocation of a permit can be appealed to the North Carolina
Office of Administrative Hearings within 30 days of the revocation pursuant to the North Carolina Administrative
Procedure Act. I understand that in order for the local health department to issue another IP and AC that the
current IP and AC must be revoked. I understand that the local health department's revocation of an IP or CA is
not effective until 30 days from the revocation or, if the revocation is appealed, at the time that the Office of
Administrative Hearings issues a final decision. I understand that by signing this form and relinquishing my right
to appeal the permit revocation at the Office of Administrative Hearings that the local health department's permit
revocation will become effective immediately. I understand and agree that the revocation of a permit that takes
effect immediately is in my best interest. I understand that by signing this form that I agree that I do not want to
appeal the permit revocation.
I understand that I am not required to relinquish my appeal rights but that this is an option available to me so I do
not have to wait 30 days for the revocation of the permit to take effect.
Signature of Property Owner:
Date signed:
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790
�� ( f jj�j.C�i ���1V` Name: '
�,,,,� 1["J!e
� �����,� Subdivison:
7Em�somffi���fl ]E��mIl�
�
�-Y "."\
System Type: ,1[1-�, ��C
Septic Tank: � gallons
Pump Tank: — �allons
Total Linear Feet: ��J�
Max.Trench Depth: 'l� "
Site I lar
Lot:�,�
EHS: �
_ Date:
Tax Map: �
Parcel: �
3� 1-�0�
�'�� `� ���`7
.�
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Conta�t ?ersen Ceunt;� Envirenm�ntal Health with any q�estions (336) 59?-1794. ,
Additional Comments
����, ) f ���� ��
�^ � � ����
I��.�aa-�������.Il IE���,ll�I�
Applicant:
Location:
Uperation Pern�it
Tax Map � Parcel # .s!„
Subdivision i , .�
Phase/Section/Lot # '
# of Bedrooms 3
System Type (From Table Va): - Product (IIIg): ��. j,��i �
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
Authorization.
(Authorized A nt)
/l`- �-ul ��
(Licensed Contractor)
. � ..
5��! �i
Scale t1T�
PCFiD, rev. 12/14/12
D�
r
�
V
�
�
v ys r
v�
�� f 7
(Date)
�3 y
( ate)
�L p.�,�/�s �- � s.✓a l��S
3td ��►rL/s t a �.�Ib �5
— �7� �+�1. �'J'
— l5� L�V. �f
�—
33Z'
Tax Map: � �arcel #: �
Septic Tank System Checklist (Type II-I� System Type: `��/
Notes•
Pump System Checklist
Pum Tank InitiaVDate
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 Mani%Id
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Com onents InitiaUDate
Pum model:
Block (4")
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
A proved and secured riser
Su I Line
Size and material: in. sch.
Length: ft.
���.s.f ���.���T
�- � � ����
�na�niramaa�ra-aa�nv.��.Il ����.Il¢�
WELL PERNIIT
(New� Repair_)
Tax Map: �`�� Parc 1: 3
Subdivision: � r�� Lot: �
Applicant's Name: s4�ih�c y l,�I�'irtlj
Mailing Address:
Phone Numbers:
Locallon of Property:
Permit Conditions:
5
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.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: �
Certificate of Completion
�ew WeU: �
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
EHS/Date
>�el� c,e�l:�;�
� y— i't?
Well Driller: r.7�Y� }"�
Pump Installer: t
Approved by: 1M
Additiona[ Comments:
Date: �'—���
Dii.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: - 2-�
Date Sample Collected: _� Date Results Mailed:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Raxboro, NC 27573
Phone:336-597-1790 Fax:336-597-7808
11/26/13
Jun 01 1709:59a Barnette Well Drillinglnc
'i7YELL CONSTRII�RZ�N RECORD
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---------- ! ---- - - ...�___..�—_ _•-._�..__ --- • . __.�.— - - —_-•- -. . .
Report To: H. KELLY
North Carolina State Laboratory of Public Health
EnvironmentaJ Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
MARY HUFF
55 MARCO RD
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sioh. ncaubl ichealth.com
Phone: 919-733-7308
Fax: 97 9-715-8611
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID:
Sample Type:
Sample Source:
ES080217-0032001
Raw
New Well
Sample Description:
Comment:
Date Collected: 08/01/17
Date Received: 08/02/17
Sampling Point: Well head
Temp. at Receipt: 4.5
Time Collected: 10:30 AM
Collected By: H Kelly
Well Permit #: A40-364
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 15 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 4.00 mg/L
Iron 0.12 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 1 mg/L
Manganese 0.170 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 7.3 N/A _
Selenium < 0 005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 5 80 mg/L
Sulfate 10.00 250 mg/L
Total Alkaliniry 43 mg/L
Total Hardness 42 mg/L
Zinc 0.07 5.00 mp/L
Report Date: 08/10/2017
Page 1 of 1
Reported By: Deddie.r�foncn!
North Carolina State Laboratory Public Health
Environmental Sciences
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Microbiology
Certificate of Analysis
ROXBORO, NC 27573
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES080217-0090001
� I��III� �II�I� III ��I�� I�I�I ��II� I���I ���I� I��� I����I ��I�I ��I�� ��I�I ��I
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
MARY HUFF
55 MARCO RD
ROXBORO, NC 27574
Collected: 08/01 /2017 10:30
Received: 08/02/2017 08:22
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slah.ncoublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
H Kelly
Susan Beasley
Well Permit Number:
A40-364
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result
Date
Total Coliform, Colilert Absent os/o3/2017
E. coli, Colilert Absent o8/03/2017
Report Date: 08/07/2017
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
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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.