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A40 413A�pfication Date: � � � v I Amount Paid: O RecEi�t �: �� � �a � ����� �a g ,�o p� P�. ��, c,A. g��S�o� �K � yZ�� Tax Ma #• �� •`���� �� ���� �� q-�. I ( - __ � � �"1� �"�" �a9_-va a_a-oa�a_--�� ��_��.71 ����.7I.�ILa �arcEl #; .APPLlCATION FOR SERVIC�S � IF THE INFORflflATtOiV 1@d THE APPLiC,4T➢OiV FOR AFd 114�PROi/�f�lEi�T PE�2flAIT IS Ii�9CORRECT �A�LSIFiED � CH�►NGED, �R THE SITE IS ALTE�tED. T1�9EN T�IE IMPROVENiENT PERRAlT dIND AUTHORI�U"i'10N 'TO . COPISTRUCT SHALL BECO�AE INV�►LID. • � 1 Permit recyuest�d by: Ownerlagent/prospective owner :���E� �' G�E�� � Home Phone: 5 9 9-�' 9,b Address: S O v R L T nIG7-� D. � Business P h o n e: o- a . D o C � � 2) iVame and addr�ss of curreni owrner. �� 2QQ�e- �c�s�� . / SC�o J�/a� 2�'�- v.c � .2ai x�,� ��_ 2-�s -r 3 . 3) Property Descr�ption: Lot size: %. a� Township: Directiot►s to the property (lncluding road names and numbers): „� Lot # 4) P'raposed 91se �tructure Description:.answer each of the following questions: � a) Proposed �E:cisting , Type of Structure: �� 1 e�o.0 �'l d,�e//ii� Width: 7� Depth: 3 5 ; b) Number of Bedrooms: � � �. Numbe� of occupants or people to be s ed: � � . c) Basement: Ye�_, No ✓. Will �re be plumbing in the basement? /!C� � � d) 6arbage Disposai:.Yes •�—, No _ - 5) iiiPater �upply� Yype: Private �(new V or existIng ), Public , Comrnunity_, Spring _ � Are any welis o� adjoining property? Yes_ No ✓if yes, please indicate approximate locatiori on the 'site plan. • . � Cnaf" Know�1� /6j Doss your propetty cantain gireviou�sly iclentifl�d jur�sdlc�ional wetla�ads? Yes_., iVo � PL�A�E NO'P'E THE FOLLOIMING: 9 A PLAi 0� THE PROPERTIf OR S1TE PLAtd MllS'P BE SUBMIi'TED WITH '�I�i1S APPL6C.'�T90R1. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. -, ➢ THE PROPOS�D LOCAT10fV OF ALL STRUCTURES MUST BE STA6CED Ofa FLAGGED. 5� 'fHE SITE IViU$T BE READILY ACCESSIBt.E �aR AN EVALUATIOPI BY THE tilEALiH DEPP�RTiViE�T STAFF: � ' ( hereby make application to the Person Caunty Health Department for a site evaluation for the on-siie sewage disposai syst�m for the above-described p�operty. 1 agree that the cantents of this application are true and represent the maximum facilities to be plac�d on the property. I understand if the site is altered or #he intended use changes, the permit shalf b i valid. ' ���� 2 - aaa � � Legal Representative Date PCND. rev. O6l27/02 i���� �� � il. i:i..L7 1�� VJ V� I �_ � � f � �./ � ��� i4. 1.��rn.s-v.s�-�-� r-n-�+ �a-��.�.11 ���►.�1�. T�x Ma� � � � �rcel ; S U,I7 (�iI V 15�1 � 11 F�h�.se;'S�ctio;�a: LQt � . ..�pplicant: ��'2C1 �Y�✓'� - . . . .. � ._ T nnn+i�e � . . . . _ � . ��r�nit '��d'ad �or � �'ave �'e Type of Facility: __ `� g R/ # of occupant5r, «X �P ��f Proposed Wastewater Sysi�: Proposed Re�air: �vti.s�i. Y�prar►e,�a�euu� �ermit � I�To ►�Yratian � • r�� �ti� � � �v� s�p��9 wec� �ooms �_ Projei;ted Daily Flow ��vD g.p.d. , , . :� Type: R Type: Q. Peimit Condifions: � SP� �i e� .s��2�CLt . _ . � �� � .i � ' . � - • :� :1� V. � �� !l� . 1 • if- � Y. ' • :i� � � �'�� I�� � _ . , . . .. Tl�e isauancs of this permit by the Health De}�artment iu does nnt guazaniee the iaa�,�„rr of other pernrits. If is the responsib�iiy of the apPli�oPert'Y owner m in sure that aIl Peison Cou�.y P3a�niag aad Zaning and Bu�ding iaspections re� are met. This �mprovement Permit is sub ject to re�ocal3on if the site plan; �pl�i''ot� the intended use changes. The Improve�eat Permit is n�t a�ecte� liy a c�ange 9n owner`ship of the propertp. This permit was issued in compli,wca wit& the pruvisimns of the North Carolin�, .� `Laws and Rules for Sewa�e Tieutment and ID�saosal Svsterns' (7.5A NCAC 18A .1900). Neither Person Conniy;por�=;tlie`.'� Environnaental �ealth Specialist warrants that the septic tank �yst�Yn w�71 caatinue to fnnction satisfactorily in the fntm�e�or:�af. th�water snQply wiII remaia potable. � �• • • • Antlaorizatioa io Constrnci �astewater 5ystem (]�ieqni�ed for Bua'lding Permit) � * See site plan and additional attachments (`). • � � ,=. . __ _ • —_ .. • ��� ' . `: Proposeri Wastewa#er System: � _�dnUr✓►'�7G,�'l Ty�pe �Q Wastewater Flow �� gp.d. New i�, RepaiT Ex�apsian ,_ � ' ,- So� LTAR: � 3 � g-P-dJ fr 2 . Type of Fac�ity: ' 1�� �ES� •' � Basemeat _ Yes k No r . . � • . � • ' �� =�i�-� • ����w8.�' ���iri �IL1I'@ffi�1� . . .. . '��nk Siz�e: Se}rtic'�aak:' ���� gal pnm� Tank: gai Grease Trap: gai . ]�ai�fieid• Total A�rea: � Zc90 sq ffit Totai Length �O o#i • lvtarimtun 1Yenclt IDepi�a 2� in '�rreaci�'9Vid#h � fi �Twimnna Soil Coyer. � in M'uumnni 1Ye�dt Sepaaation: � it �. C. 3�ist�abution: G� �istri'bmtion �oa Spe�fieations: </ �li—rSo?C State Agea� ��C w Permit Exniration Date: _ 5erial Diste�"bution Pressnre lylanifold �.�/�"� 1� .�l � l 0 f� � E��-�e � Date: The type of system per��itted is C ventionai Ac��te3 Altainative. I a.�r,�t the spe�ificaiians of the � l��g�i �8a�res��tata�e: � � Date: �(' S/�'� ' PC� rev.11110/QS_ . �� .. . . 4 . ' ty : S � I '.: ���� r � � . � ���' �'. / , ,� ^ � c;, � �° s` r uy � c.. � �'i � , - � ':' �r ; - -.... . �. '. �� __ • �- _ _ --� � 7 ��,�� �.�- �I�I�.� �1� `_' �= c� � �.T1���Y ]�m..-�aa-���--�s..�rn.Il � I�'S�.a...A�7La. �E PI,�1`7 Na � �/..� Tas t�2.zp #� � Sub Settion/Lot#�,` � __� � Authorized Stau Ageat Date . 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' �b3G �6s� ' • �I+� Z � %��� , • � s �«os 16 os � � L i n.c,. 3=!. o o ,. . � �s.� is�3 ' � �� •�':^-�•Y- r°°� . . . _ �s 6S . �S so . ' G�.�.�� . � � g6 � y� • , c�pq -�ed�(. ��.�� . y � �yBG . u,..� ' /� o, . 6S • .` • � ' ' • . . � (�ox� � . . . . . t �� . ��' ' y� ... . y . S�,l.,�.(� � Yo •.�. � 3 Fo�,�.(�,,�ro., p�,�.�� L;n e.s lo.•,1�� N��P` � ofil ba�k co�.►1� ��lo�� � �Z=/S'. ' -, . ov t t4�cti� �-�- t,�..af � St�dt c � •� � ���'� �r- � o(.-��. �1,►�s . T�,•.�.y _�G�;� rk�( pa� � . -.V {�.� w1<( a�,r�c Di..�k G�«.. .,ro � . , � � . _ Rt- dl,-�� � d�. t„�s . � . �' � - . � .. � . . . ,, . or�y �. �o��w -�� � 7'6 - El�.�. M��s ,e� t� , ` � r�+� T�,�� ��5���� ������°' �� �� A � . � . T� Nla� � , . �! Pa�� # /y 3 . � . 5ys�n Type (Tabde ��) c�- . O�r�er1AP�:lic�t c�e G��er� Subdivis�an � Addi-ess�t.�r�iian Nv�dk ; � 5��� �o# � �: � 0�. � o� �' �/� �. ' '. .. . ' — - - -- • a – s�� � �� �} , ' . 1 . . �� � ; ���� �� �. � 1 ,.. � V�� ;. ,.: .. . :�..' �::�.� �������. ; �1 �1 �p� �7I:?�i�'7�7L`�QD]C7L1K�71.�07K]L��:iIL �aP�.tD.Jl��rn'''.. WELL PERMIT - PLEASE SEE ATTACHED PLAN FOR WELL SI.TE LAYOUT Tax Map �� Parcel # Applicant: �v�2t�C Subdivision: T..,.,..:,.�. � 3 Township: � � Lot # S4e.� kb(� --'r ^- Type of Water Supply: � Individual _ Community Public Requirements: Site Approved By:�i� g,����`I Grouting Approved Bv..`�+ � Bla`�I�-� ___ Well Log:'��1 a�'���-1 Pump Tag: v'h�me owne�- � n�,�-) a�/ Well Tag: Air Vent: Hose Bib• ✓ �,� I`� � Casing Height: Concrete Slab: Well Driller: �� �V nS Well Approved by.��� ��n , a �� ****See Attached Site Sketch**** � Liner: Installed by: Depth set: _ Grouted• _ Date: Water Sample: Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet &om any building foundation. Other conditions: Date: �U I c� rhi %C w► � PCHD rev O1/27/04 � .�.._. .. _ �.. _ . . _ `r�,�, ; � � ,/ �.� �� V � ���� � � �....._.. -�--•.-.' � �'C7 �']C'`Y` �'"�'� e�°°�' . .�.�.a�.!'..�'�'' 1l•'"S ff?". x� �•• i �c- ao �ca►�sa�. �er sa i�r 1 1�3I �a+ w. i��s ��...� _• - I l- c 1 r? _ -- Gw�cr: _.._.Q�,.r.�. �__ �* G�. �.._ Gi�t LK �P.�� Pwcal +� .1 �.�.3 -�.., :,ots�t�oc►. _,__,�.r►�� r��du.S.�s�.�.-...,.�.-»--- .�.....�.-..-. . �6div�ao�n. . _-_.__. _ __ ,.,., Lat #1. W+�ii Cesrtssel�s Diotatrce From ceo�,rest PropmRy 4is�s (Minimum t0 tc�t) �' Datanco f�om 3cptic 3yssana (Mioir�m 60 ) i'�xal Dmptt�: ..,�a_ � Yiatd: o PM Sttda Watrr L�evei: �.,,_� fl Wat�r Hesrin� ?.uRe�� Dvpth tt tt ,_,,,_,,,�,,, !t ___,_�„ !t +Cs�iry: D�epth: Fran � wL�_ R. Do�neret• 6 y, ia Type: (ialvsr�ii+cd f�el / Wei�E+t: �._,,,� Ttuc:�a�ea:1,�;,� Hei�ht abtfwe OrounO: ,�...._, fn Driv� �hna: _ t/Yea� _.._.'`iu My �rabts� irn�au�tad while r�� ca�in�? ,_,,,_Ys� .._.... _ I�o If "j�`� �tv�a rtslo�n • _. ..�...._ _.�____..� _ �...�. _ Gts�t: Nest: 3�sndi['rrta�� � C.w+� 4nveUt:smr�at -_ �4rusular Spa:e Widtt� _�_„_,_ u+o� 'WV�ea ilr Awu�lar �prce r Y� ._+��► Method �f (3rout: Purre�ed -- -.. Ps�cu+e _ j�Pouted �. 13eptb r._._... �� _.__._..._ �3 ��s� u�: " Na. Bs� Patiand cecr�cnt Vdl�et�t af 18sj �. Pound� Jf mixture l��arsrel, curiin�} -� 1�tio _,,,�, to _��,,.� 1'D pl�t�a. ��Yss � No 4 x� t!`b I%Ya� __.,_, No lJt�er: � � � �' _ _. .._.._ Uate l�uullad; Cfrout: .....,..__ .. _... _ in�o►ll�d by: ......�.- Qrilltc�g I.�t 1 b�reby aeRi�} thmt the sb+ave tr,f��tio» ia �y th�e Ptreo�n Caunry Fiasfth t]cpsy�n�¢rE,t, � ` 51s�twrs ai t:oa�r��tsr rred thst thi• �eli wor c�n�n:�s�d �n a�:cc�sdauica arith re�tanoas� �e: fart ID #i �.,�,�,,, Date ST_ /_�► � _ � �] 1�`la�p l�t��tt i'ump it�t�ltstion ('untraetcu: Stste R�sirtra�ion Numhe�r ihsenp C�th _ !!. Scati� Wo1ar Lsvel.�' � �t Pump Make � Maie! _�_ . . . _ _,_,,,_ �' Pump �Sizt tnd Rstin$ ...__--- .--.-.......,..,..._. _ _ ...hp ...�----- �"r' 1 hcreby certity tki;t thin pt,mp waa tn�tsllsd and ti�s wo�) hw�ai �orrsplsud accotding to ths P�rvon Lt�unty Wtll Rut�� in cf'tec� ' on =hi� dstc sn�i th�t a oopy otthis racard h�s becn providod tea t!►e woli oarr+es. Po�no l�t�tl� SieA+�t�r� i?at�: PC`NU rev O!!'1����a PERSON COUNTY HEALTH DEPARTMENT 355A S. MADISON BLVD. ROXBORO, NC 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant �rQ ��r1�e� Address �. I�u . County Qer•=,�,� Collected By� � S Date Collected �� �3—�3 Time Collected /d <� 3S Source: �Well ❑ No Charge ❑ Spring ❑ Well Tap ❑ Other �S Charge *����������������*������*�����**������*�***�*�����*�������*���*�����*��� *�***�����*���*����**��*�*���������*�*�*���*���*�����������*�*��*�*����* Total Coliform FecaVE. Coli. Reported By, Date tP 1 � ( ( � Results Present Absent Report To: 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: DEREK GREEN P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 296 OMEGA FOUSHEE RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES060413-0002001 Date Collected: 06/03/13 Date Received: 06/04/13 Sample Type: Raw Sampling Point: Outside spigot Sample Source: Ground Temp. at Receipt: Time Collected: 10:35 AM Collected By: J. Smith Well Permit #: GPS #: Sample Description: � ' ' Comment: � �� � � � � -� . Inorganic Chemical 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 13 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 0.42 0.30 mg/L Lead , ' < 0.005 0.015 mg/L Magnesium 6 ' mg/L Manganese �`0.03 . _: 0.05 _ . mg/L pH ,;6.7 ' N/A Selenium ' < 0.005 0.05 mg/L Silver , <, 0.05 ;. 0.10 ' mg/L Sodium 10.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 83 mg/L Total Hardness 58 mg/L Zinc 1.40 5.00 mg/L Report Date: 06/13/2013 Page 1 of 1 Reported By: Arno/d Holl North Carolina State Laboratory of Public Health Environmental Sciences Organic Chemistry Certificate of Analysis Sample Group: ES060413-0104 Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 �'���`� �3 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph. ncqublichea Ith. com Phone: 919-733-7308 Fax: 919-715-8611 GREEN,DEREK 296 OMEGA FOUSHEE RD ROXBORO, NC 27574 Attn: County: PERSON Well Permit #: Sample #: ES060413-0104001 Collected: 06/03/2013 J SMITH Received: 06/04/2013 09:26 CHOLMES Sample Type: Water Sample Source: Sample Description: Comment: Sampling Point: _ Client Sample #: 130627 Temp. at Receipt: 6.0 DEG C GPS #: Organic Chem - PESTICIDES Method: EPA 508 Pesticides Drinking Water Analyte Result RL Units Qualifier(s) Aldrin Not Detected 0.1 '`'. ug/L Dieldrin Not Detected 0.1 ug/L Endrin Not Detected 0.01 ug/L Heptachlor Not Detected 0.04 ug/L Heptachlor epoxide Not Detected : OA2 ug/L Chlordane Not Detected _ 0.2 ug/L Toxaphene Not Detected 1.0 ug/L Hexachlorobenzene Not Detected 0.1 ug/L Hexachlorocyclopentadiene Not Detected 0.1 ug/L Methoxychlor Not Detected 0.1 ug/L Lindane Not Detected 0.02 ug/L Trifluralin Not Detected 1.0 ug/L Propachlor Not Detected 1.0 ug/L Report Date: 6/21/2013 Reported By: �� RECEIVED JUL � 2013 BY: Page 1 of 1 =��EST��l���.. N.C. Department of Health and Human Services Division of Public Health State Laboratory of Public Health P.O. Box 280�7, 306 N. tiYilmington St., Raleigh, NC�7611-8047 Environmental Sciences Analysis Report . � Name of Owner, Patient � � � � Or Supply: � ' ' � . ' . : . . Telephone # 3L 3� �Ot,/— (� �� . Address• �R � � � � � . . : , COunty:_�P;rtin✓1 . . �Oor Zip: t . . . --- _._... ■ra���������������i.��r����������a������,�������� u �������������������t���������t��t����a���■ . . � Repart to: � P@i'30f1 COU11iy Er1ViFOMt@�1t81 Hgg►th ' ' . � .. 325 S. MdfQ�1 S� Collecfed By:���_ . � Telephone # ( ) � . � � . .. � ' � Telephone # L� Address• �� Roxboro, NC 27573 � . . . � '. Date Collected:_ (p ' � _ I � � . . . � � . . ' Analysis Desired:�f S� r , �1 � S . . � . Iaboratory Number � Sam le ,� l �! � � . � Sam le Deseri tion or.Remarks � Results In : _ � �. �I l ;-�,.�;2� . _ _ h � .� : � � ES060413-p104001 . . 130627 . 06/03/2p 13 � Pesticides Drinking I/Vater � . . 9 :1• . . � . . � , • . � �. - � . . o� . Date Received: ' U � L0�3 � � � � ��• . 1e��$ z �1 ��Q13 .. . • . . . — . . . � . . �. , Date Reportedc • � •' . Date Extracted: '� � � l� � . . � . . � . �.. . ..D . . . . . , ate Analyzed: `C'� � /l % � ' � � . ' . . - . .. , .. ` _' ' . . � . � ' .�� . . . . . . : � " . Reported By: �r � ' . DHHS Form 2364 . ' ' • • . : • ,,: � . • . . . ` Laboratory (Rev:06/99) • ' � . . • ' ' . ' . • ' . � . . F anlrpt ' . . . �. ' .' . . � . . : • ' ' • ' ' �• ' . � . . � - .. . .. �. .. ' •. ., . '�: • . . .,. .. . : , • . _•