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A40 399z � !� T � ' � � ; � s Apaiication Date: �— � � rO � �ax Mao x: �f b Lo'7'"� rJ Amount Paid: �O '. RecEiat #: � �rc81 �� ° % � # ��_ � �� 16� � - - - � � �� a�a.�aa-oaa------�- .D��.IL ?L—�o.m.71.��i ? APPL1CATiON FOR SERVICBS 3 3 IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIF1Efl, CHAiVGED OR THE SITE IS ALTERED THEN THE IMPROVEiVAENT PERMIT �ND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � +. 1) Pertnit requested by: (Owner/agent/prospective owner): .S�l /�t �l % l� Aw k irv s Home Phone: � � � 2s6 �-- Address: s � �� Po�E ftt , +-�S /�p Business Phone: �� q�-t �.g !? 4 Yt'-s�=�4 vs =?S �y 2) Name and address of current owne� S W h, E 3) Property Description: Lot size: ./ o Township: �- � Subdivision: �� h�i ►� �� Lot #%d Directions to the property (Including road names and numbers): `' � o ',4 � F R Y- � N w �� c� n A,N l'i' 7' � rU 0 v p��,,� o�T'%. T on� i� i`�- t- / N S '1' a I�/ . 4) P'roposed Use and Structure Description: answer each of the following questions: a) Proposed _, Existing , Type of Structure: p c�/ z i�.� f�6 Width: � Depth: b) Number of Bedrooms: 3 Numbe� of occupants or people to be served: c) Basement: Yes , No � Will there be plumbing in the basement? d) 6arbage Disposal: Yes . No � ; 5) Water Supply Type: Private �(new _ or existing�, Public . Community_; Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the `'. site plan. ; 6) Does your property contain previously ideni�ed jurisdictional wetlands? Yes= Plo '� PLEASE NOTE THE FOILOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTEfl WITH THIS APPLlCAT10N. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR �LAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department fo� a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the properiy. I understand if the site is altered or the intended use changes, the permit shall became in�alicl. . Representative - � S'-d� Date PCHD, rev. 06127l02 �� S f_ ��.�� . : ' �„!� � � � � � � I��-�a��tD��a11 II�---3I Q1 �.]1�1� T�x M�p : / Pa�rc�el # ;' Su;bdivision � � , , . - : - Ph�se Section Lot # i. , .- Permit Valid for Five Years Type of Facility: ' ; # of Occupants �� # of Be� Proposed Wastewater System: � Proposed Repair: Improvement Permit No Expiration ;h��, New Addition _ Water Supply �e f% ooms 3 Projected Daily Flow �[a� g.p.d. Type: �Q Type: PermitConditions: %►�nin-i'a�v� a�� nr,I�S Owner or Legal Representativ ' ature: Date: 8�a� 'C� Authorized State Agent: Date: � Q'—o� The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It 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, 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 for SewaQe Treatment and Disposal Svste�ns' (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 (Itequired for Building Permit) * See site plan and additional attachments (�. Proposed jA�astewater System: CienvQ�-�-�en � Type � Wastewater Flow, eh g.p.d. New t/ Repair_ Expansion Soil LTAR: 27✓-� g.p.d./ ft 2 Type of Facility: Priv �e �Sjo�eh('2 Basement _ Yes o Wastewater 5ystem Requirements Tank Size: 5eptic Tank: o0o gal Pump Tank: —�al Grease Trap: --gal Drainfield: Total Area: I3ag sq ft Total Length �_ ft Maximum Trench Depth �_ in p•G Trench Width �� ft Minimum Soil Cover: � in Minimum Trench Separation: �_ ft Distribution: �istribution Box Specifications: Authorized State Agent: � Serial Distribution Pressure Manifold Date: 7 8'—�' Permit Expiration fi�ate: �—$—/3 The type of system permitted is +/ C tional Accepted Alternative. I accept the specifications of the permit. Owner/Legal Representative: Date: � � �—c�'a PCHD rev. 11/10/OS G •.��+�� ^��J �� •• 1 V V� �y� .iL �lm'P3Y��92.7L2L.Cm.�.E1.8 �pJ�� SIZ'� S�TC�-I � Name Sa Ta.z Map #,4 �a . Pas:�e1 ��`�_ Sub . � Section/Lot# �Q9 . — 7�� —a � � . uthorized State Agent . � Date . System cvmj�o�essts s�e�iresemt u�tipt,oxi��ate�contours only: 3'he coniractor must, fTag the system�irior to beginning the instal�dion to i��saere thatpropergrade is maintained 3 �n�-l�a' s 5t�w� F` � � `3�� S.P. �, 3 b --" �3(�' (�on�cn�a�a� � • �1J'�ax� > �� llv 1►ne S '" Ig" �ehc� ,b��.s Jti(ain`�a�n �e ua� len �i � � �in�S Sc�r�� 1''- �b' "�,,�;,;�,::.�::,,,�"�;�„��J � ,�' "� .�'' JS � �.� `'��•_ , „---�.w` ``c-.-,,,�r �-u ./r��' ,��b �� d � 1 � �-�-.�.�::"` / -� �eP4i� , �ec� ` �'.�� i � , \ l�o �; �� i � � �� .��.', � - �� l \\{ \\\ (:. `� 4 � 1 I _! \� �'1�s ),' � �J�Gf � �J �L.J 1. �] r--�—�1 � � � �� IC��-�� .1t I�3L��.II.�I�. Applicant: � ^^ � �� +^ S Location: i-f ��J(r �;1l s-� � a^ � ( !�J 0'� �P I ( t n �iP �v�J —�� `f- A�- (n � �' ��. ,� � �� 't � �. ;C .�.y `� �f� '��d �f� / ' ' d ��(� � ' � �0i�]�aor� �q r �-� �,�P �+��s G°P�1�`,�o��t�o� � L o f I o 9,�c., �'L �o� o•o 00 3 -�</�') a'� U'�o/`7r/� �f�-,q�bP � Syst�m Type (ln Accordancr Wiih Table Va}: �' THIS S�ST�3�i �3a4� �EE� i1VST�LL�i3 li0t COtVIP�I�►NG� VVIT}i APP�lCA�LE . PlORTH Gi4R�Ll�.� GE�E#�L SiATilT�S, P�U�.�S FflR SEiNAGE TRE�T1UlEiVT AiVD DIS�OSAL, ,a,�iD ALL COi�l�IiD�� C�F � Ti�E 1MP&�Oii�iV1E�lT �ER3�lli' AFlD C�i�STRUGTION AUiHO1�d�,,4TlON. � � �� - - ::ag�a9�a� Authorized State Agent Da#e lnstalled By: �' c� ff' Date:. ��g�b� ' � y = � `� � � '%T�L = � . n� a.,g 3S, � �/ p�^P, �2n� E. d� 1 � a �, l 310� �� '��ly � �.'�t'ra� 3,7�,/� pT�- r� a� � �� ,�` �r'la� �y �� ,.�'� � ,� �, � _ _ . �� 3 � .� ,� � o Q �r �v cd PCHD, rev. 07/29/0� G�� c �-�,�� '�o� ��gs � �-�� a� � �� Tax Nia� #�4� �arca! # 3�9 Sys�e€� T1pe (?abde Va) OwnerlApplicant S�^^M .� �-aw�%-� s Subdivision o�1'c�� P r4��s. Address/tocafiion ti� P�(� �Y�� 2J. Se�/Phase � Lot #" 1� 9� Se��c ��e�� ai��adi�a� N6�a �cataora ra�� n�t¢� /da� State�IDldate Sil,�� ob-r3-�� '�� s �r renct� UVidth � ft. ��-' .��-ay-� Capaciiy lc5do .caai. ( � ( • Trencf� Depth -_l�___in. Tee and F�iter � Baffie Sea4ant Riser (ifi appiicabie) Tank Outiet Sea! Permanent Mar�er Pua�a� �'�nk /Sealant Riser Water Tight , �'a�na� Checic ValvelGate Valve � Ant�-si on o e FloatslSwitches �11arm visable and audible Electrical Comqonents Trencii Grade � Trench Spacing Rock Depth and Quadi Dams/Ste dov�ns �fic. Pressure Laierals � �V/ � Hoie Spacing � � Rate m A roved Pum� 1Viodel Blocic Undes� Pum -- ' - Pump Remo�al RopelCi�ain /� Low Pressure Pipe Appr. Pipe l�iate�iai and Grade_ Valves Sieeve �ecguie�d� Se�ack� From� Wells From Property lines Structures/Basernents Surface Waters Public Water Suppi Veriicai Cuts (>2 ft. Water Lines Ve�iicle �Traffic EasementslRighf of �' �46�e� �ase�nents Recarded C�mmen� ��' � �c:�d rev. 3113/01 .:��".�'� � . .. .:� .:�:��..:.'��:,�' ��/ .�.�`�.1:' ai'J:: �.� � •.�•��'+,-�-+ •� . . . . V,�.:�...•;..;:.�..,.:•.• �� . v. �•' �g'q '•�'i�.`:�.' `':..'0}� . � � � ' �'"�. . "� ��g, . .:�.•'•:�� ' :•.:•.. ...:;;::i. � •.;....:'i'.;;.::.:;i?'f ::.;;....,,..:':,:,` `��.'p1Y:,, �� . , .,-.:�::: � ..: :.... . .. . . ::::..:.... . ... . .. •. . . Y: , ... ..........,• . � . . .:.....:......•. •:;�:• ..,. . � .. . . •-...,.,... . ... ..• 7�� ..: • .7L7i;4'�9:77i`]L� Q'D �?'++"?�T::9Ci31.�'�.#il:� T� .v ... ..... . .:.. ......:.... ... .... :................... .��.u�:'wy3..1L'�-��•.'. �'i 1I� � p .� �.�Y�� - ��JlJ('�11�LJ Li�:1a�.7 ��V.r.�6.LL.LJ�.'J �y�-SlY ��$ �/�'�j11../SJ I�IlS:IJ.yJCSY ��.J Ji Tax Map T l� Applicant: _ �, „„ m Subdivision: hA K Parc�l # .3qq _ Tovvnship: � 1 �i. Lot # �� of �atea��Supp�y: � Individual _ Communi Public tY ��ia�e�en�s: Site Approved By: � Q� � g��v� Grouting Approved By: � Well Log: � Pump Tag: r.J 09' �o�t�o� Well Tag � Air Vent: ` — Iiose Bib: � Caeing Heigh� Concrete Slab: � � Well Driller: _ Q� �„� `,�i`f Liner: �Installed by: _ Depth set: _ Grouted: I�ate: Water Sample: ��?log �ell Approved by; � �i� � Date:, ��l ��l �� *�**�ee t��ac�ned Sate S�etch�� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other canditions: PCHD rev Ol!27104 � -s-.�•-•----' - av.c��.:.•._�•-: _f._. ,l�%/ `- =; - �r-;,-y:.;. . . _ � • •,•. ,� :'"L , . .y } - o � :� ` ` ��:� M1 >' ^ c.. -!} -. :;� ' - LJUWIII�f ilU � J / ��,�� , � ':��:�� .' . ��:--��:. . _ � � = �� `l��nP��l� w�e �l `� �(1;,) :.- . : �r ��:. =_::�: z:s:.:' :�::�:=��:�� - r :�.� .... . _. - -. -- - -. : _ . .. -�-. - � - : ��-�;�,�.�-_�:�.�:�:: - �e�� . D� C�I �1-�6 -o � . .: - - �5 crout I.og . � ��- T� �p�� Paz�el # �i / �-i �� b�i� I'LC ✓�� Lot # I � - WeII Construciion Dishance From ne�rest Propeaty Line (Minimum 10 feet) / 0 r i)istance finm Septic System (M"mimum 6o feet) �� Total Depth: ��- ft Yeld: �O GPM - Static Water I.eveL- Z S $ iiVater Beazing Z� Depth�_ ft 1 j� ft ft $ Depih: From . � to 6� f� Diametr.c: 6�� in - �: -�'i V� _ _ - Weigit� Tfuctmess: SD�-L � Height above Grouad: � Z in - � Driv+e Shoe: ,�/ Yes No Any problems encotm� wb�e setting casingi Xes ✓No If `�yes" give reason: . - (�ou� _ / : . - - '. - . Nea� SandlCem�t ✓ , Concrete Grav+eUCemcut _ -•. Aimular Space Width • inches water m Amiular Spac� �es � No Me�od of Gmu� P�. Pressure Poiu�ed �� Depth O� to � � Ft l�sat�eriats IIs�L• � Ianer: No. Bags PorHand ceur�t " Weig�t o� 1 Bag � Pounds . _ I€� (s�ad, gravel, cu�ngs) —ltatio to ' - - � ID pla� � Yes _ No 4 a 4 slab ✓ Yes _ No - . � - .:,. � Dat� InstaIled: �� - . D�g � � . - Location DrAwinE F�rom To Rorimaf�on -- - �t `F� s�: � � �a n � � /v�!C•C $ Zo � �pL(� . . , . _ � � [ l�reby ar�y that t�e above� iafa�ati�t is c:osect and that tius we.11 was c� in a�nce a►� regulation.s set f� b� ti�e Person CounfiyHeat�h L�:p�t •�, n �� n n�'1 �are of Co�or � ID# �<<%� Da�. � ��'"�� Pamp Ins�limeat ,'� Pump Installation Cflntractar; �' A��L C` � �C� I 1 fl/�� "� State Registrafion Numbez: �� / � � �l � $ s�� w��: _ �Zr � - ° E'ump Make & Moc�e1: %� �2 � s � Piunp Sizs and Ratin�-�hp < c� gpm j herehy ceitify tiiat t�is pump was u�stalled a�d the well he� c�mplet+ed a�g to t� Persan Camty Well Rules in effect xi t�is date and fi�af a cc�y of t�s ne9ord has been p�ovided to-tt�e weli ownex . �r � � ��-- (" /�l'J � �: � � 6 - a � r� � ov2�ro4 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: Hawkins, Sammy Address: Yellington Rd Zip: County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street (336) 597-2371 Roxboro, NC 27523 Courier: 02-33-15 Collected By: J WILEY Date: 10/7/2008 Location of sampling point: Well head Remarks: Permit # A40 - 399 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 2:40:00 PM Parameters Results Units Date Analyzed: Silver <0.05 mg/I 10/8/2008 Alkaliniry as CaCO3 19 mg/I 10/8/2008 Arsenic <0.001 mg/I 10/8/2008 Barium <0.1 mg/I 10/8/2008 Calcium 5.2 mg/I 10/8/2008 Cadmium <0.001 mg/I 10/8/2008 Chromium <0.01 mg/I 10/8/2008 Copper 0.09 mg/I 10/8/2008 Fluoride <0.20 mg/I 10/8/2008 Iron 0.14 • . mg/I 10/8/2008 Hardness as CaCO3 (Ca,Mg) 20 mg/I 10/8/2008 Mercury <0.0005 mg/I 10/8/2008 Magnesium 1.7 mg/I 10/8/2008 Manganese <0.03 mg/I 10/8/2008 Sodium 4 � mg/I 10/8/2008 Nitrite as N <0.10 mg/I 10/8/2008 Nitrate as N <1.0 mg/I 10/8/2008 Lead 0.009 mg/I 10/8/2008 pH 6.1 Std. units 10/8/2008 Selenium <0.005 mg/I 10/8/2008 Zinc 0.97 mg/I 10/8/2008 Date Received: 10/8/2008 Today's Date: 10/29/2008 Report Date: 10/28/2008 Ref: 14100 Login Batch: Reported By: ��Y �,(.� Sample Number: A679492 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 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: Hawkins, Sammy County: Person Address: Yellington Rd ZIP: Source: Well Type of Sampling Point: Well head Collected By: JW Date: 10/7/2008 Time: 2:40 PM Signed By: Wiley, Jonathan Analysis Type: Private Report To: Person Co. Health Dept.,. 325 South Morgan Street Roxboro, NC 27573 (336) 597-2371 BACTE�RIOLOGIC ANALYSIS ` � CONTAMINANTS - RESULT � Total Coliform (ColilertRoutine) Absent Sample No: AB13435 Date Received: 10/8/2008 Time Received: 9:35:00 AM _ _ _ �/�� Date Reported: 10/9/2008 Today's Date: 10/9/2008 � Comments: New well permit # A 40-399 � Person Co. Health Dept. ATTN: Wiley, Jonathan 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 aze 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