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A40 407. `6_�_0� Apalicatfon Date: � �8� /L ��.}- • Tax Maa #: Amount Paid• O n �' n Rec�ipt #: . 2 R 4 0 1' �� .�,� f-C ParcB! #: �� .��_S� ��..� �� d � - -_ _ �� ,� - � ��.�.a-�-.T- ----- m��.a a��.m.a�� j �,M, APPUCATION FOR SEiZVICES � ��3. � �Q IF THE INFORMATiON IN THE APPLICATION FOR AN 1MPROVE141ENT PERMIT IS INCORRECT. FALSIFiED, CHANGED OR THE SITE� IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.. � � `_ . 1) Pertnit requested by: (Ownedagerrt/prospective ownerj: Home Phone: � Address: BusinessPhone: �36`SD -�/�S ��eY � " 2) Name ar�d address of currer�t ovmer: '- l� a � - 3) Property Description; Lot size: ��Township: Su Directions to the property induding roadf� mes and numbers): �{� Du� r�.�` !? nYF1cr.., � Tutrr� La1`4-' � '.� . � r � �� r! ; __ ' . ' ' - s-ooF �-o� ' 4) proposed Use and Structure Description: answer each af the following questions � yP��ju; �,%6�uy� a) Proposed � Existing , Type of Structure: � i� Width:� Depth: � b) Number of Bedrooms: 2 Number of ocr.�pants or people to be served: I � c) Basemen� Yes , No �/ �11 there be piumbing in the basement? d) 6arbage Disposal: Yes , No _ r0 I �o cJ 5) Water Suppiy Type: Private �, (new � or existing�, Public� Communiiy� . Spring _ I� � b�� Are any welis on adjoining property? Yes_ No _ If yes, piease indicate approximate locatiori on the 'site plan. 6) Does your property cantain previousty iderrtified jurisdictional wetlands? Yes_ No ✓ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SiTE PLAN MUST BE SUBMITTED WITH THIS APPl.lCATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARI�D. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI(ED OR Fi_AGGED. ➢ THE SiTE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTIIAAEi�I'i' STAFF. � i hereby make application to the Person Caurrty Heaith Departrnent for a site evalua�on for the on-site sewage dispasai 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 property. i understand if the site is altered or the intended use changes, the permii shail became invalid. Owner or`Legal Representative % �� Date PC1iD, rev. 06127J02 ��' 7�� `� "'^ � � � � � � I��.a-�� ¢�.7L IL33L��.Il�1� Applicant: 1�Je�.?� A\ Location: � s� q � � � � � / Tax M�� P�.rcel # S�w�bcilivi5�ion Ph��s�e Sect�ian'Lot # Improvement Permit Permit Valid for ✓Five Years � No Egpiration Type of Facility: ��.;1�. ��n9� New � Addition _ Water Supply��,vd� # of Occupants � n�a # of Bedrooms Z Projected Daily Flow zyv g.p.d. Proposed Wastewater System: C`�e�.f.v.�9 Type: `�.t d Proposed Repair: �.�,,o.,�vo.. C'c�5'I �a��w-Z.;�� TYPe� r b — Permit Conditions: � �Owner or Legal Represe Authorized State Agent: � Date: /U - I - D �' Date: I 1- J D- d�l The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. 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 Sewage 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 Consiruct Wastewater System (Required for Bui�c�iing �ermit) * See site plan and additional attachments (�. Proposed Wastewater System: C„�„e„�,�,�...9 _ Type 1qI' �t, Wastewater Flow a Nc� g.p.d. New ✓ Repair Expansion Soil LTAR: , 3� g.p.d./ ft 2 Type of Facility: ��,� i \�. c+� wvQ�;,..n Basement _ Yes �c No �- Wastewater System Requirements Tank Size: Septic Tank: i o� gal Pump Tank: — gal Grease Trap: �- ga1 Drainfield: Tota1 Area: _� sq ft Total Length a co'� ft Mazimum Trench I)epth �_ in Trench Width � ft Minimum Soil Cover: � in Minimum Trench Sepazation: q ft _� Distribution Box Serial Distribution Pressure Manifold Specifications: �c� ��,,F �n Ct9n�.r- �o ho�- �i�Fc,-4� �� !uw w�ea I Authorized State Agent: L �,�,,� Permit Expiration Date: Date: � � _lB-v�/ The type of system permitted is � Gonventional Innovative Alternative. I accept the specifications of the perinit. �� Owner/I.egal Representative: Date: /�-�-o� PCHD 1/17/2003 � . k:P .�� I��.�� '_yL1J .� �T ' � 'V v +4 V��l� .JI� � ��a��4T 4'II�R �r�1L�� .Jl.. .. Jti ..- . .� • .. . .• � .. . . : �i� _..� . r• � ■ -��a . ' • �� S� S .Yi V 1�1 ��. Tag Ma� # � � �Parcel # � 0 7 Section/Lot# " l�-Lo-o�F � � Date . ` System componetrts r8pr�eserit u�mximate�contours only. 3�e contractnr must, flag the rystesn prior to beganning the itutaJlatwn to insu�e that jiroj�ergrru�e is maintained . � ¢ (Ji:L : S c,.rY: l�tn �� ca �-..,.: � , `a�.,►- 3�M.c,� �a..0 ' ?lo.�an...�-..� m�s�-- b; /1��►+Fc.kc,� -1� �.1 c q,�Fv�' O J �' �� M � / `• � °�j- ��►. 1�2¢p c..s2A1- 1bo �- �'�^^ se.l'�'-�'L a.2. � F"«. �nri. cse.,e� . --� �N��.� J� -. �l/ � ,,� P: -� o s �� Q �`� Q .< �. 6 � se s, �t-P -sc� � � � r �� ° � ��5 i.�e � -� %� bP �� 1 ° LJ,rc.�l j %� n..a 7 /�o'�'l GZ.:��F `�o .�P 4L��f�1PUGa.�s;�.c� -�(-,(� �rr�� r p.,��I S�JS`l-'-'^^• SCa.le: � � `�' ►UU� . �. �� a �� - � aco�' cen�t�.�SZ � ,-r,.a � �" �'Qnc3� '�,C.rl-h �l.l.� 0✓� LIWI�CJ\nr Q/�� ns�-�S2..1 ,4, 1 e�SZ , -�^'e,.cxw,s . `-- .o . _- � �,- � � �. �i cr��-,�.�� . �� ! c � � � s .,n.P l o�l cc-�y Ci Ci PG�, =ev. 09/12/01 �� 1.9..� �� '�/' �. VT �_ '� 1 • "� � �/ � � f V 11 � � �.�a- � -_-+� ,�-�- �s� ��.� �-� � �.Il. �� n . Applicant: d�C I � �a ✓1 Location: � _ _ � .,, _ .. � ... _ a 0 �x M� � / � �rc � Sub � iv�sion Ph,�se Sec .ion at # # of Bed�rQoms � � � . . � �� It C�car�,� Syst�m Type (In Accordance With Tabie Va): � = C �'ll-9 APPLlCABCE . i\IORTH THIS SYSiE�lI f-9�►S �E�N 1RtSTA�L�i� IN COMPlJAN E 1�1 - G'�4ROLIR�A GEi�Ei2�L ST.4TtJTES, RtJ�ES �OR SEINAC-E TREA7ME�T A�tD DISP09AL, Af�D • AL.L. CONDITiONS OF � Tl-aE 4MPROVEi�1ET�T PEF�flti AiVD CONSTRUCTIOf� .41lTI-(O I TIOi�. - . ��.�t �� Authorized St Agent Date lnstalled By: �� c9 I G��av� Date: � �/ ��D � . � . � � �.� � i � v e � I ��'7 � � � N� w 4� � PCHD, r2v. C712Q10=� �; � � ��G �°��K �NS�'�'��0� ��E��B..�ST �'9�e 96 � !� Ta� Nia� � �a Parc�l # 0 Sysiern Type (Tabde Va) Ow�eflApplicant � Subdivision AddressJL�cation Sec/Phas� Lofi # � � Se��c�. �'a�E� �no�a�/�a� Ni�a �a��on n� tn�� c��t� � State�lD/date ��P,a�e'� Trencn Width� 3 ft. s. Ca aci !o 0 o al. � Trencl� De th 8-� in. Tee and Filier - � T,renci� Len ft. Baf�ie � Trencf� Grade � � Seaiant Trenci� S acin Riser ifi a licabie � i/ � Roc�C De th and Quai' ` �f'ank Ou�ei Sesl ✓ Dams/Ste dovvr�� etc. Permanerrt iVlarker Pressure Laterals � � � Paam� Tank � `.. Hoie Spac9ng � � Waterproof ISealant Riser Water Tight � �'uetag� Check ValvelGate Valve �Iarm visable and audible' Electrical Com onents � Rate m .. A roved Pum iViodel Biocf� Under Pum � Pum Removal Ro elC�ai� . ��is�rabaa�aon:Sy�s�as � Serial Distribution Pressure fViani o Low Pressure Pi e � A r. Pi e i�iateriai and Gr Valves �� Sleeve �%qui�ci� �etba�� From� Welis -� From Propertv (ines � � Surface Waters Public Water Su �iies Ve�#icai Cufs >2 ft Water Lines Ve�icle �Traffic � Ad'acent tems � �Easements/Ri ht of V1� / �er . Easements Recarded e e a�erator or . � Commera� . — � � p�:�d r�. sr�3�a� L � . � North Carol'u� Division of Pablic �ealth ' ' • ' ' . � . . . . . Occupational and Lnvironmental �Epidemiology Branch, Epi�emiology Socction •..� INORGANIC CHENIICAL ANALYSIS REPORT � � Private well water informAtlon und recommendatlons �. . County: -P-V,l°�► Name; /��°� Sam 1 � 66 r • Id Numti�r. � Location: , Reviawer ��11�i ANALYSIS REPORT Your well water was tested for 1S motals, plus nitrates, nitrItes, and pH. The results were evaluated using the federal �drinking wa�er standards: The pH �s a measure of the acidity of the water. Drinking water may contain substances that can occur naturally in water or can be introduced into the water from man-made sources. (These recommendations are based on inorganic chemical analysis o�.) TEST RESULT5 AND USE RECOD�IlVIENDATIONS Your well water meets federal drinking yvater staadards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering. . � The following substancc(s) exceeded federal drinking water standards. Your water can �e used for drinlcing, cooking, washing, cleaning, bathing, and showering, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water � treatment system to address aesthetic problems: - The following substance(s) exceeded federal drinlang water standards: We recommend that your well water not be used for drinking or cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing, and showering. , Re-sampling is recommended in months. Re-sample for lead and /or copper. Take a first draw, S minute, and 15 rainute sam�le inside tha house (preferably the ldtchen) and if possible a first draw, S minute and a 15 minuto sample at the well head to determine the source of the lead and/or copper. Contact your local health department for re-sampling assistanco. � OTHER CON5IDERATIONS Routine well water sampling for the above substances is recommended every two to three years. Sample your well water when thera is a known problem or contamination in your area, after repairs or replacement of your well, or after a flooding even� Contact your local health department far sampling instntctions, Contact your loc�l hc�lth depArtmentlor more Inforuu�qon or go to httn:i/v�vw,�oi,s�ate.ndeni/olt�±�fg�+■hpp+.h#m' Marc6 30; 2009 Report To: North Carolina State Laboratorv of Public Health 06 N. W?m�ngton St. Environmental Sciences Raleigh, NC 27611-8047 h�://slph. state. nc. us Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 StarLiMS ID: ES123109-0006001 Date Collected: 12/30/09 lnorga�ic ID: Cate Re�eived: 12/31/09 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 2.5 Sample Description: C fi Name of System: JODY ALLISON 2070 FLATRIVER CH RD Time Collected: 2:00 PM Coliected By: J Smith Well Permit #: A40-407 GPS #: ommen . New Well (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Total Alkalinity 146 mg/L Arsenic < 0.005 0.010 mg/L Copper < 0.05 1.3 mg/L Lead < 0.005 0.015 mg/L Manganese 0.11 0.05 mg/L Zinc < 0.05 5.00 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Chromium < 0.01 0.1� ' mg/L Silver < 0.05 0.10 _ mg/L Selenium < 0.005 0.005 mg/L Iron < 0.10 0.30 mg/L Mercury < 0.0005 0.002 ' mg/L Fluoride 0.86 2.00 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L Chloride < 5.00 250 mg/L Sulfate 18.00 250 mg/L pH 7,4 N/A \ Sodium 22.00 mg/L \ Calcium 42 r mg/L `\�, C��k�j �b Magnesium 9 �l� mg/L ��\ es � Total Hardness 140 � �,. mg/L ' , � 1 ti/ Report Date: 01/22/2010 . ,�e � � �°�o Page 1 — �� Reported By: �e�iie �ia�tecl 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 Report To: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES123109-0032001 � �� . ES Microbiology ID: 12516 GPS Number: Sample Description: Comment: Name of System: Jody Allison 2070 Flatriver Ch Rd Col lected: 12/30/2009 14:00 Received: 12/31 /2009. 08:00 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta://slph.state. nc.us Phone: 919-733-7834 Fax: 919-733-8695 J Smith Angela Heybroek Well Permit Number: A40-407 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley o1/05/2010 E. coli, Colilert Absent ••-� � Susan Beasley 01/05/2010 Report Date: 01/05/2010 Reported By: Susan Beasley 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/I 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 .:!.'�.`:'��'':.'�'.��.:?��..`: �: � . .. .. .. .. , `� , .. ��. :'.� 1l �:A��.'�.�' �7 . '� �•�.. . . . -.��::Y.�::;:;: • :.i . . . .. .,... . .. . . . k:�i.�..��;�.� , .......,..,..v:::::.::•�,,:•.,.•:,;:::..,,�,.c:�:::••. .. ,,. .., .<. .... �. . •:. . �,., . �:.,.. � .:, ..:...... . . ... . ,4 q . 7��:L .��'.��,.�,"�.:71iai-4�:D��i^tr�� `R'�+�',�I�;ui.:�Jl:� ��;,,.�� .1l��LLr�': WELL PERMIT � � PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Ta�c Map A� Parcel #�-i� 4 7 Township: �,�►,�,�,�tu.. Applicant: 1,�� A��'s�. �-- Subdivision: Lot # � Location: � s�5 -� (� o•, C�aaQ �wk.,� _ � -�_ b��c. _�.. _52.� Type of'Water,5upply: � Individual �equirements: Community Public Site Approved By: _Sb � j��a�� Grouting Approved By: � Well Log: ( Pump Tag: H �— '� l � Well Tag: � Air Vent: � Hose Bib: /' � Casing Height: � Cancrete Slab: � Liner. �Installed by: Depth set: _ Grouted• _ Date: Water Sample: 12 - 3a=aR 'Well Driller• ��J 4r, S W P 1 -� r7 ��l� Well Approved by: � � ****See Attached 5ite Sketch**** 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 conditions: .► --� � �� 's�-e. sl�_fr_J., Date: � Z � PCHD rev O1/27/04 �; � _ �:9rq�, �,.�... . . � /1.� i� ,..._.. `7 . . � :I�'.l�lh�:� �..D:�.. `°�1°� � .._._. � i ._.._.- . �� ..�� -�t �1��..J.1..� r • � �' •' � ..� :.. � .. .�� aC�a�.��''�''Y' ]�'��ra.�va�r•m�:s��z�i�r.d:.r.lk' lE'3%�.+aYL�3a � � / /', � /� J � Cront Lo� Gwner: � Tax Map��Q parcel � �` Location• �,v►'�a , S�tbdivision: _� � � _,.�.._ ' WeU G�yt�trc�ti�A Dis�ac�ce Fmm near�t Property+ Lina (Minimum' 10 feet) Di�tu�cc �am Scptic System {Miaiaxim 60 f4ct) v-" iotsl Depth: ft Yie1d: GPn� s�sna w�cer Le��i: `U ft Waoer Ba�� Depits ft ft ft ft ' Ciuia�a . Dcpti�: �'rom ,.�� to _� ft. Dinmobcr: � in Typ�o: Ci�em�e�teel �•n 2 � WeigLr Thioiness: Hci�ht tbove C�muttd; ;�,a,�_ se Drive Shoe: Ye� t-'"No Any probleu�s oncountcrod wrh�'�e aCtting casin�7 Yea �o if •'ycs" give reaeon: Grott: Naat: Ssaid/Cement i�' Conar�e Grravel/Cement .Atmul�r Sp�ce Width ,.� inchaa W �n Anau,�r 9pace Yea �No � Mati�od of Qrou*• Pu�npod Prese+a�e �o�arod �� Dapth _„�, to �J,_. T�t M�teMalr U�ed: No. S4�a Pardaad cement �.,,,_ Werigltt ot 1 aa �_ Pounde If mixtinre (t�aqd, �tsval. cuttin�s) — Rado _� tn � ID plates. ✓ Yta ,_,_ No 41,�!' alab ✓ Yes ` Na Y1oar: �f X3 . nepth: Date �ctlled: � Grout: � Instat�ea b.y; �� „ �� .� /I��.°'� � , � - � � r�i! � �'�i -��•'�'�;�'�il�� %lT"�f:�?.!"�1 . � �,�.r� � �� Yaicatba D�xwiet� I her�by oerdfy thst the abova infornurtion is corroct and that this well wns caasaucted in accord�e with re�ulationa � fcut i by thc Pereott County Heal� Dorpertr�ont. � Sl�nat�as o� Car�trsctas ,�i� � �'�e''' ID # _,�{� � Dste / � -_ �a — U � 1'amp �t�llmaat Punzp Instailrtion CUntrtctor; 5tate Regitiration Nu4x�bcr: _ Pump Dcpih: !t Static Wetor i.evel: f} ' i'ump Make & Modal: Pump Size end Ratin�: hp ., gpm T hereby oertiPy that this pump wus installcd �nd the well head ooiupletcd eccord'm� to thc Ptrsou County Well Rults in affeet on this �ete and that e capy of this nscord hae been providod to the wc11 owncr. • P�tnap xnstnller Sl�nature � Dste: PCHD rev 01121/04 Tla 7C1M.] R1JTw1.l'7 1 i AIMn AIf1C1l7J Of701 ! Cf".00C � 1!CT O(.1f.17 1f17 IQT