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A40 4220 8 -.Z 4 -i z � l�-� � Application Date: �' � (� Tax a Amount Paid: a � • � �' � ' �`�"-�J � �� p' �iSb �� •-.. • Parcel#s Receipt #: 3 7 D� 3 23� � q�, � �� • IE::�ra-s-aa-�ar,.*.,��ndan.� IC�I�,a,lL4,�n Cre��% Application for Services Services Re uested Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 if> 600 d) (Fee is de endent on the e of s stem ermitted ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision � i SG.Oii (if site visit required j $75,00 ❑'�'Vell Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: �- � ,�, Address: � ,ca �Ga.� N. r. Z�s� 5� 2) Name and address of current owner (if different than applicant): Name: � uJ Nt.��i ti' Address: � ..r / �!' � S� 3) Property Description: Lot Size: `�� .Z Subdivisior�: � Address and/or directions to Property: _,�8�,/ �^lio i� Phone (home): �a� -- �C � /i� (work/cell): phor.e: 33C -3� `i^ �9�' #: -- � ►9g4 ' � ❑ yes L9 no Does the site contain any jurisdictional wetlands? ❑ yes �� Does the site contain any existing wastewater systems? ❑ yes 0—'n/o Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �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�) �P posed iFse and Type of Structure: QRe " tia! ew Single Family Residence Maximum number of bedrooms: _'L ❑ Bx�znsion of Existing System If expansion: Currznt r:�mber of bedroo:rjs: _,� ❑ Repair t� :�121fun�tioning System Will there be a basement? � yes � With plumbing fixtures? ❑ yes BZro ❑Non-Residential Type of business: Maacimu:n �umber of employees: Total Square footage of Building: Naximum numb�; of seats: �) Water Supply: C�'New well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If a,pplying for `Authorization to Construct', please indicate preferred system type(s): �rConventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 cert� that the information provided above is comptete ar�d correct. I also understand that rf the information provided is inaccurate, or if the site is subs�equently altere� ow the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. �-2�/ 2oi� Date • Permits are valid for either 60 months or are non-expiring when accompanied 6y an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) ' Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �•. �,�^ � I r,� z N � (�'rv( UK"� � ll (��rd�hr � w�� N � � S�'�1oo�eKS . � - jF ��5�� 1 SYs��-t o� C�o�d�. v��- '1,`S�-q ( � G�c`�� ,� O�.a.�Q �c`��.r s. _ !� /� (�'(�,ps �i o�t S � � � �lf_ �� Lj l ( ��, �-.� ��Lt , ��--(,'Z�f� 3�� 3�a 5� ,�n 33� � C�'e d� �� Ir�c� � j�do 5a( s•T 2Fj � /�� k . -�r� � hr�a� Z w O N O �' W W �W �W � / N59°57'00"E 202.17 CLEARING LIMITS �� — -- -- / C( / � / \ \ \V � f � �I i \ �j�' t I w `N° ; � � Io �I I �'Q � � N � � � ____ — — — --+� oI i � rn J � � � �- � �� / I C � , I- � �i i �' -� � I �s ,.-� � � � , ,� � � , i�/ � � �� i � � �� I � ,� ,, �RE�,�'� ' � � �P � � � I � , :i � ,QP� / � � / � �F��' i tiP� ;� � . �o a� �� . � �Q�� . � . � �� I I . / J4 i� � ;rt � � h� 0 � /•�� I � i � � 201.96 y S � � b /� S59°57'00"w i I I I Z�' �S � � � i � c� i D -_ _ �- I ( I Cli W • O . �� ?� � �� • _ "` (� � �.T1��C'�' IEaavna-�a-�.,r,.,, o�.�.Il � I�3L��.Il�]Ia. � 1�I STTE PLAN ,I f N e�d S�>l�� tJr• �T `�� ZZ Taa Map # Parcel #� � Su ' ' n Seccion/Lot# I � 5' Z Authorized Sta e Agent Da �' System componenis rrpreseat appmaQm�te conmurs ady. T6e coauzcmrmust9ag tfie system pdat ro br�in� the insrallatioa av insure �atproperg�adeiama�taiaed S�C2" � A l�� -- 50 � � , I Z - rn � D � i n I n � ;T1 D � � rn v: N m o � � � � i � � i � c,+ �� W � CP Q I z t�i � —� � ��.s� ��..�� l � � �� )[�a��a��.�.-� ��.IL IL��.Il�I� Applicant: ��ac�� Y, Address/Location: . . ,i _ _ . Permit Valid for: Five Yea : Type of Facility: 3 �%� Number of: Bedrooms 3 / Proposed Wastewater System Proposed Repair: �p Permit Conditions: Authorized State Agent: (X) Owner or Legal Re Improvement Permit � Non-expiring S New Addition �ants _ Employees � Seats: �.� i, S�'-�e S�e.d�e+� Tax Map: �4 Parcel: �2Z Subdivision Phase/Section/Lot # Water Supply: �,I/`Q `� Projecteci Daily Flow: 3Ca o gallons/day Type: � Type: Date: Date: The issuance of this permit by the Health Department does not guarantee the issuance ot' other required permits. It is the responsibility of the applicantJproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plap, plat or the intended use changes. The Improvement is not affected by a change ia ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws aiad Rules for SewaQe T�eatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. � Authorization to Construct Wastewater System See site plan and additional attachments (�. -� Proposed Wastewater System: �' (*)Type � Design F(ow �P� gal./day New � Repair _ Expansion _ Soil LTAR: . 21 S gal./day/ft2 Type of Facility: �� $ Basement: _ Yes C No (*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Taiik �� gal. Drainfield: Total Area � sq. ft. Trench Width � ft. Pump Tank `— gal Total Length �3� ft. Min.Soil Cover � in. Grease Ty-a�i � gal. Max. Trench Depth �� in. Min.Trench Separation � ft. Distribution: Distribution Box / Serial Distribution X/ Pressure Manifold Specifications: � �l�� '� � � Authorized State Agent: �i'� �� (��V2r Issue Date: lo ( Z Permit Expiration Date: ! o � The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions and specifications of this permit. , � • (X) Owner or Legal Representative: c � �� Date: �4 -�3 �� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ��.sf ��.�� IE��a-��.,•-„-„ ��.�.11 IE-3L��.IL�I� Applicant: (� �F u s (��c[�u1E c-�- Location: QE�k�rlp � 198'4 F�T' F �1 Operation Permit Tax Map 4 o Parcel # 4a12 Subdivision Phase/Section/Lot # # of Bedrooms 3 System Type (From Table Va): TIL Product (IIIg): E�. ��Low 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. �ER R�c\l. . �,►TN � 11 `1 1�- (Authorized Agent —r (Date) L l t� CoL� ' 11 a- (Licensed Contractor) �n/ W �.�- � ��5 ��` Scale: IJ o�E MoQi�E �{ar►� �g' S 9�� aa' �� a�� , • ��. _ 5 9 �4�� \ s S� 1�� r��`11 s.►,,, � � 3'� `.3�� . �� 's�la' , „ t,'s 1�. ��syx ` � `1 I (Date) v - . �� i : • ��' : � �. � Tax Map: � o parcel #: � a.2. Septic Tank System Checklist (Type II-I� System Type: 11I �E�. Notes • Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: �...�� i .1 � �� b V `.r�= � 1 � �/ � �� 11 Il��n�n.a-��n��n.�.m.Il �I�.�.11�1�n. . W1ELL PERNIIT (New�,Repair� Taz Map: T � Subdivision: Pareel• �Z'�-- Applicant's Name: (�(�� Y. Mailing Address: Phone Numbers: �.,ocation of Property: Lat: -� �C� v�er C4 � Permit Conditions: 1) See attached site plan for proposed well location. 2) Alt applicab:e St�te and CQunty regudatio��s governing construction and sQtbaclus apply. � 3) Permits expire S years from the date o, f issue. Other Conditions/Comments: - Pex�mit issued by: I)ate: � 8 �2 C�RT�FiCAT'� �F COMg'LET'ION New Well Inspection: E�iS/Date Location: r� ( ! Z. Grouting: t Z Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Dept�: Grout: Well Abandonment: EHS/Date Completed: � Method/Material(s}: _ Well Driller: . �1�,,,Q,� ��..�, � � License #: � , • pump Installer: �� License#: � Well ?�pproved by: ✓U-e,✓ liate: l � Date Sample Collected: i�2 1'ot I'�- Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: '" Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 Report To: P.O. Box 28047 North Carolina State Laboratory of Public Health 306 N. Wilmington St. Environmental Sciences Raleigh, Nc z�s„-ao4� htta://slph. ncpublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: RUFUS BLACKWELL FLAT RIVER CHURCH ROAD ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES121312-0057001 Date Collected: 12/12/12 Time Collected: 3:15 PM Date Received: 12/13/12 Collected By: D. Smith Sample Type: Sample Source: New Well Sample Description: Comment: Sampling Point: Well head Well Permit #: A40-422 Temp. at Receipt: 1.5 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 16 mg/L Chloride 18.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate 3.70 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 6.4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 13.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 43 mg/L Total Hardness 56 mg/L Zinc 2.00 5.00 mg/L Report Date: 12/28/2012 1��1,"1 V L� JAN 0 3 2013 BY: Page 1 of 1 Reported By: �r.cold s�ctll North Carolina State Laboratory Pubiic Health Environmental Sciences Microbiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES121312-0085001-- � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: RUFUS BLACKWELL P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph.ncoublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 FLAT RIVER CHURCH ROAD Collected: 12/12/2012 15:15 Received: 12/13/2012 08:40 Sample Source: New Well Sampling Point: Well head - D. Smith Angela Heybroek Well Permit Number: A40-422 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Total Coliform, Colilert E. coli, Colilert Report Date: 12/14/2012 Test Result Absent Absent Explanations of Coliform Analysis: Analyst Susan Beasley Susan Beasley Date 12/14/2012 12/14/2012 Reported By: Susan Beasley ��„�.�..,%"�� '.E�EIVE]Q DEC 1 � 2�12 BY: 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. .. .. � SiAfT'.; � �::�—:'• ••,� �:, .�.s -� ♦ �>;r': • —" i � :;' i; � � `-: ;,;�� ,�. i%1�.�_ a� �: y'`�'. f� �C,. -. ��: - 'J` �11..J�.^••�r:-.r� II� {: riiJJ'l�:.i��I�7i'�'iUL'r;'lIl': L�::/�1..:.i�S'r_L� Norih CarolinaDeparimentofEnvironmentandNaturai Resou�cs-Divisionof�l�aterQuality 4:r�.e'..^�c`D�iaS�A�sOi�.��'E'z�a.�^.�'i'^_�IV� Z'—_�Z..�i t� 'I. lNG'�L COPi i P.��i OF- - .lar�es � Sietifienso►� Sr. Weil Confracfor (lndividual) Rame S�enhenson's Welf �rilline. l�c. �FVell Contr2ctor Company Elame 1 t 58 Gash ao�d 5tr2et Addrzss � C� eednoor F�iC 27�22 City orToY�n State t�p Code 9c '� 9 � 528-�fi �� Area code Phone number , z. ,�r�.�. �1=a�.r:��a�3: �/' �/' �NEl.L CONSTRUC7ION PF�1tlIT= � "�!� ` �'7` r�- � OTHERASSOCI?riED PERilltl i�('dsp�,*:�te) Si i C WELL 1D'z[d �pIIt�fe) ' 3. tffiELL USE (Ched: AppGcabte Box)_ Residsn5at WaterSuppfy [� ' DATE DRILLID ' `� / -iIUE COMFLEfED ��_ Ai1t p P� Q' - g. i' C� a� �O;ilES epih - p� iop_�Bo�om /Top��N BoLLon Top ,L�� Sotiom ST��Boitom iop Boftom Top Boitom 7. C�$is��: Qet.in t772�t% i2t' r ?op�_ Botiom Ft-�� Tna��Z @oHom Ft r� Tap Bofiom FL TnF�cr.essi t�• i � � ci� � ' 8. GROEi i: Depfh iv�ate -�� -r �thod 10�_(� SOtI0R1�_ �/ e Ta� Ho�am Fi. To� BotCum F�.O J.8C��'1i- ^y��_r 7�n=;.a: Si�Sca G9..��r�! Top,�� BoFfam Ft in. in. Top Ba�am �� in. i2 Top Bottom Fi in. in. l. WEL! L Ct�ss IV. 'dQ. SI ��t�! i?.AV'C!. P�.CS:: Cfi`!: , . a. ,,/ U�}3?h 5� i'��1 /� .. Top'Y Ba�om FL � /Lr � � / ! � � / '� / � a I OD $O�OTlI �. (Str� t�e. t�wm6ers. ramc�nity. Su�divis�'nn. Lot ta.. P�I.?�p dP) . Top Botfom FL iOPOGP.APNtC/lAND�SE7't1IdG (che�apProP�b�? ❑Slope pValtey �i-at DRidge pOther LATtiUDE 36 �'�_Q�14S OR 3X.�`..^.""',....OD � �OUGffUDE�� Dr`!f5 OR 7%.`.�....":^^^�' pD - La6tudeHongitude source: (�3�S �i'opograpfuc map (loca:ion of �•ra11 must be shovm on a USGS topo map andaCached to this form �ioot using GPS) Ar2a code Phf�ne numbrr 6.�t7ti�ll.S: � l a. TOi�`LDEaYH: :�. ?QcS L"d'� ?�i L!-:CE �:FS ►tCdC- L�c.'iF ? YES ❑ id0 y(�/ a W�i � i.�-'V��L Belo1rTop oi Casing: �� F(: (Use'+' ifAbcveTop of Casingj cL s OP C= CI�Si:".� iS "� Ff_ Above land Suriace� `fop oi casing terminaFe� aflor baioti:� tend suriacx may regui,� a variance in sccordancz rrith 15F� f�CAC 2C .OiiB. e. :�iELD �m): ,� G7EiT3Q�J OF t rSi ;��iiC� '�' � �. DiSiC1FGCatQItL•iS2aa H��-i tl��o:sn:�� 11. DR1lUNG LOG Top BoHo � ! �/ / / / 1 1 / / / / / / ! 12 i2EMAR{t5: "� �cri tion GG � � ! DO HEtZEBY CER'ifFYi'fi�;T'i�-IIS ll�EL!_ 1rVAS CDiVS� RUCTEU Ii�I tlCCORDANCE lNiT1-315A WCAC 2C, YUELL CO�lS7RUCT10A! ST 'DARDS.AiVQtHATACOPYOFTHIS RECOF20HASBEEN F IDED TO ll-lE VJELL �JAtEP � ' �-, /�SS.�o2- SI D!A t L" OF C TiFt@ 1 CO��TP.r>C OR DAiE James D Sfephsnson Sr. PRINTED NlARdE OF PERSOAI CONSTRUC7U�IG THE lll�Ell. 3�:��ii �r��ri:t 3� �ays o; C05F1(]IEEFfl�c EO: QIVISiC� a31.11lFiie:' ,,r'-.'L�-'3I(il�j - I370ii3l3«Ofl Pi0C2SSii7�C, Fortn GVl►-1a �t6 i7 fJiaii �ervice Cen�r, p.aleigh, I�iG 27G99-16 �, s�hon8 :(9 i9} t3D7-S30Q Rev.2/09 . �� Z�� 2 ��f � �(� +l.Y V'C._ Y"' ' st� 1 kr )' fi Q r"'� ��Q✓�'. f� �t i Qtip� � � ' J �:d-�P �n s�"Q.� �� 4�:�.� . ��A j��P � '� ��c� i �►c�s� ��"' �� °�f�'` �--° � � o� .� rQ �-'� s rt S�� ►a� l r� w�- �� '" ' ,� � �p� t., s �,,1 t ( ��..- �. �. ,�c � �a�' ��- �''�� ,S�q,G�et,.�- ,�te��. ��'� ��' �� ` � � � `�`'� �l(c� � ,��` �`y�� ''s��j'-- � �� ; -�-- �� c (_ �-{�� C s�'�`�'1L �Z�� P`��