A41 150� �,� � � ��\�°� � /
Aaalication Date: � — � �� ' " 0� ��c�� �j" ���� Tax Map #: � � f
Almount Paid• —� �(�, �'�\ ��,� �2a " / �
ecei t#: U` J� Parcel #: l-5 O
� ���
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1 ��.3 - - �- �c � ���-�
7C�+-a-,.-.�r �.-�.�e�.-min.�a,.�.�0.71 7HL m�.cn.11 iE7h.
APPLICATION FOR, SERVIC�S
1) Permit requested by: (Owner/agent/prospective owner):�i�it� ��'�'"'
Home Phone: 3�o�( 3 053 Address: �' s o�nu !,
Business Phone: S/ �/ T'�.1� L�� n/� 2�5�3
2) Name and address of aunent owner. w� ��e "f�r 3c1
�� h I
,�». c� �( 27s �3
, !�- -� �
3) Property Descriptton: Lot size: ��f� Township: ��r�`i-�-Subdivision: l� �+��r Lot #�
Directions to the propet'tj( �Inciuding road names and num ers :
I�-rr�1/ 1 S7 % i-�,.r�lQ Mt�.IS (1�� o m� S�c � (�r_
4) Proposed Use a�" Structure Description: answer each of the following questions:
a) Proposed V, Existing Type of Structure: , S� Width:� Depth: �v
b) Number of Bedrooms: � Number of occupants or people to be served: I-5
c) Basement Yes_, No �II the� be plumbing in the basement?
d) Garbage Disposat: Yes �, No ��
5) Water Suppty Type: Private +�/ (new _ or existing�, Pubti _, Community_, Spring _
Are any weils on adjoining propert�t Yes No �yes, .please indicate approximate location on the
site pian.
6) Does your property contain previously identified jurisdictional wetiands? Yes_ Na_j�
PLEASE NOTE THE FOLL0IMNG:
➢ A PLAT QF THE PROPERTY OR SITE PLAN MUST BE SU6MFTTED WITH THIS APPI.ICATION.
➢ PROPERTY LINES AND CQRNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBl.E FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Heaith Department for a site evaluation for the on-site sewage disposal
system for the above-described property. 1 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 permit shall
become
Owner or
�f '� pS
Date
PCHD, rev. 06127/02
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Applicant:
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T���x �11-�_iC� � -�,rc =..1 " .
5�u'f� cl�i v i.� i c� i�i
('�I�r,:;_;.��'�Se��c-rf���n� � L.o t n
,.. �l� .�,: te -a y t�,
�aparovemmgent �'ermit
Permit Valid for � Eive Yeare. Nq Ezpirat�on �� r
Type of FacilityF: (� '� ; t �2.1; � New✓ Addition W�ter Supply��-
# of Occupanta �,ax # of Bedro Projected D�i1y'Flow �_ g.p.d.
Proposed Wastewater 33�tem: '�n �h�+�� • .. Type:�e.
Proposed Repair. �i�� ��•v,e.. � aSY. r� ��-..�-,� � ' . �1�pe, � .
Permit Conditi,ons: �011� s�� sla..+� clo�.C.�.,. , '
1 V�-�.1� � 2S�C�b:i51��Si�c CA�Jar c�J2r a QNr�Y,� �SS2_i��+� �2� 'FO �r � ,��- QjCh�� _
Ovvner or Legal Represe
At�thorized State Agent:
G�-- . . :
�a
Date• 5� �o —�
�D&tP• , .-, � _,�„ -as-� s
�'ho issuanco of tt�ia permit by the Hesith DeQar� 3n does noi guarantee ti�a issaqnca of other pmnits. It ie tha responsi�ility of the
app�tiPT�P�Y o�ner t�n in auro that aIl Poraon County platming and• Zoning and Bul�ding Inepectione requirements are me� 'PLis
Lnprovement P.ernult ia sub ject to revocation ii the �ite plan, plat or the inteuded use cLanges. The Tmproveanant Permlt is not affected
by a'eluwge in ownersLip of tho propertg. This permit was issued in complianc� wtfih the provisiona of tiie Narth Carolina `Lmvs and
�, far S• e?ireahnent and Dtsnosal S`uatems' (15A NCAC.I8A .1900). Neiti�er Pereon C.'"oanty nor the Enviro�emental IIeulth
gpec�altst warranta that tl�e septic tank 8yst�m will continue to fanct[on satisfactorit�* in the future or that the wa#er �uPplY will remain
Putable- � .
�Autho�ization to Construct Wa�tewater S�ste�ii �atequired for Bnildi�g Permit) .
* See site plan and additlona� attachments (�. .. .
Proposed Wastewater System: ��x, nk, x,o9 Type`�i1 Wastewater Flow 3c�_g.p.d.
New ✓ � P.gpansinn Soil LTAR: .�� 5 g.p.d.! ft 2
Typa of Fa�ility' ;�,�•�.•� �• ��,.�e 4 l � ��Basement �Yes �c No
�astewater SyBtem Rsqnirements . �
Size: Septic Tamk: l� gai .. Pan►p �ank: —' � g�l � . Grease Trap: — al
. s ft To� L� � yyv ft M[az�dmum Treuch Deptla y� �
field: Total Area 1 txi' q, �
ch W�dth �„_ ft Mini�um Soil Cover: �_ in Minimum Tr�nch �epazation: Q ft
tbai3oa: � Distn'b�tioa Bog �_ Seri�l Distriribution �Pressure Manifold
Specifficatlons: �l - / �O' /� ►�.s cY 5 - 90 '
Anti�orized State Agent:
Per�it ExPiration Date:
�z�s-�s
Date. �'1 •� ��r / c/ zs-o5
The typa of system pennitted i Conventional Innovaiive Alternative. I accept #he specifications of
the permit. ' � ` f ' -J,�
Ow�terlLe a1 �B.e rese�:aiive: U,��-e ... Date: S s G�J�
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. . � � PCHD7/30/2002
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Subdivision � �ection/Lot# �
��s . . . �.� _ oy
Autb.o ' ed tate Agent • Date .
�� Systesr� comporrents �epresent ap�imxima�te�con�ours only. The rontr�tct+ur mrrst, ffag the system prior to
Tregiraning the i�stallatzan to insune that pr�upergmde rs maintained ;
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WELL PERMIT �
PLEASE SEE ATTACH�D PLAN FOR WELL SITE LAYOUT
Tax Map , AU 1 Parcel # I5 Tovvnship: __t IG+ �,v�,-
Applicant: C�� l,;w� E�iv,�{►s�
Subdivision• Lot # D �
Location• 15� 5� L �, Ca�c� �,11 (2.Z � Ic��-s w, �-�- l/a �,.•:l�
--� �l� I�k.
Type oi Water Supply: ✓ Individual
�tequlrements:
Site Approved By:
�Grouting App ve�
Well Log:
Pump Tag: �_
Well Tag: .15 _
Air Vent: �
Hose Bib: � j5
Casing Height: sj,;
Concrete Slab: �
Community Public
-17 - �S Liner. `°° Jt
�- I'1- 05 . .Installed by �
�— Depth set• �---J
Grouted:
Date: �
Water Sample:
Well Driller: �osorv i�Lc.c_ cL12� Lc...,�1� �
� �
Well Approved by: Date:, Z�19
****See Attached Si Sketch**** �
Wells must be 10 feet from pmperty lines. �Q
�Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev O1/27/04
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IE�.P��-��,.,..,�;.��,E.�.Il �-3'I��.Il¢la
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LA� WIARRl1l!! / %n �✓ ti�
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Tax
Loca�tion: /� S� o S�-t. .� eit �
Subdivisioa• — Lot #
Well Coneti ncsion
Distance From nearest Property Line (Minimum 10 feet) /O �
Distance from Segtic System (Minimum 60 feet} �(, D�
Totat Depth: /�_ ft Yiel •�6 � GPM Static Watcr I,evel: �5 ft
Water Bearing Zones: Deptk ` 36 ft f� ft ft
Parcel # �
C~asi�g: �'�
I7spth: Frorn � to �� ft. Diametes: � in
Type: Gatvanized Steet
'Weight:, r��,S� Thichiess: .0 £� Height above Ground: in
Drive Shoe: _� Yes No Any problems enr.auntenci while se�tttiug c:asing? Yes �o
If `�►es" give reason•
Graut: � /
Nea.t: SandlCement V Cancrete GraveUCement
Annular Space Width inc}ses Waier in Annular Space Yes No
Method of Grout: Pumped Fressure Poured �, Depth U to7� F�
'_4luteriAls Used:
No. Bags Portland cement ��}. Weight af 1 Bag �? Poundq
If mixttue (sand, gravel, cuihngs} — Ratio to ,
ID plates: Yes i No 4 x 4 slab , Yes � No
Drilling Log Locatlon DrAwiag
From To Formation
d �v 6 .
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I hereby certify that the above information is correct d that this well was constructed in accordance wlth reguiati�
set forth by +he P�rson Coun Health Degartment
,
Sigauture of C',untract ����J�� �� ID #���'� / Ds�te ��� /� C�-
PC�ID rev Ol/1610�
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���..�-�sas��n.����.Il. ����.�1.�I�a
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'��J �_ � � ;� � �' ;�
e
�x M�p � F�rcel # �
Subcilivision
Phase�Sectio�i;`Lot #
# of Bediroom•s
System Type (in Accordance With Table Va): �
THIS SYSTEM FdAS BEEI� INSTALLED 1R1 COfUIPLlA1�ICE WITH APPLICABLE NORTH
CAROLINA GEIdERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AIdD ALL CONDITIONS OF Ti-�E 1NIPROVE�PlEiVT PERfUfIT AND CONSTRUCTI�N
AIJTHORIZ�►T10M. � �
. 4� .
. Autho St Agent
Installed By: /� , �i�Jl�
'� � �� �
Date '
Date: '�� S'
�C -a�-o�'
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PCHD, rev. 07/29/Q�
�
SE$�3'iG TAN� i��P�'��'���! �"�r'IE+��C�.9��' (T��� 61-1�
Tax Map #� Parce! # tSZ� Sysiem Type (Table Va) �
Owner/Applicant Subdivision
Address/Location Se�fPhase Lot #
Sepiic��'ank Inet�aUDa� �t� ica on anes nt�a a$e
� State�ID/date �i d $ � Trencn �dth " ��3 ft. �
Ca aci o a. � Trench De th/� - in.
Tee and Filter � Trencti Len h ft.
� Baffie � Trench Grade � � •
Sealant ' Trench S acin
� �� Riser if a licable � � Rock De th and Quai' �
• Tank Outlet Seal Dams/Ste downs etc.
Permanent Marker Pressure Laterais � "
. Pump Tank � Hole Spacing �
State D a e o e ¢e �
Ca aci ai. Pi e. Sieeve �
� Wate roof /Sealant Tum- s/P.rotectors �
Riser Requires�� Setb�ccks
Water Ti ht From Welis �
� Purra From Prope lines
Checfc Valve/Gate Va(ve StructuresBasements
� Ant�-si on o e tt es raina e a �
Floats/Switches ' Surface Waters
Alarm visabie and audibie Public Vlfater Su lies � �
Eleciricai Com onents � Vertical Cuts �2 ft. � �
� Rate m � Water Lines �
A roved Pum Model Ve�icle �Traffic � .
Blocic Under Pum Ad'acent S tems
� Pum Removal� Ro elChain - �Easements/Ri ht:of Wa �" .
. �•Distribu�ion. Systetrn ' Other � -
� � Serial Distribution . Easements Recorded
� ressure ani o e e era or on ra -
Low PressUre Pi e 7ri-Partate A reement
A r. Pi e�lateriai and Grade � � -
Valves '
- Co�raments . .
pct�d rev. 3113l0�1
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant
Address 33�13
Collected By Ss
County PERSON
Date CollectedT_� �i Time Collected $� � �
Source: C�Well ❑ Spring ❑ Other
Location: ❑ House Tap ❑ Well Tap
❑ No Charge • �arge
�ther
........................................................................�
******************************�******�**********************************
Total Coliform
FecaVE. Coli
Present
❑
❑�
• , .
Reported By �
Date Reported T � `i'
Report Called ❑ YES �NO
Called To:
Results
Ab�nt
�
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
EIN: 566000331 EH
Courier # 02-33-15
StarLiMS ID: ESO42914-0004001 Date Collected: 04/28/14
Date Received: 04/29/14
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Inorganic Chemical I (Profile)
Name of System:
GREG HOLMES
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://slqh.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
3373 CATES MILL RD
ROXBORO, NC 27574
Time Collected: 08:30 AM
Collected By: J Smith
Well Permit #:
GPS #:
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 31 mg/L
Chloride 6.20 250 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 12 mg/L
Manganese 0.13 0.05 mg/L
pH 7.5 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 9.20 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 138 mg/L
Total Hardness 130 mg/L
Zinc 0.15 5.00 mg/L
Report Date: 05/05/2014
Page 1 of 1
Reported By: Arnold Hvl/
I'�CEIVED
MAY 12 2014
BY: