A23 102_.. �,,,, ,-< _ �..,�—,.,�-., .-�-- �. _,..- _.,....._,�.. {�._.��...�_�.
�.�.�,�::��._.��....w..,,.. ,., ,..�..,�,..�..���.: , _�� .�W_�...�...�,.�.�...5.�, . �.,�,�,�., ,��...__W_.�.�a,.., _,... �:, �
i�' �4
�
, �,�,� r
' G�uY
. ._.. � >. V r t_,;
--•-•`. ..._
��
, ���
{ �-� ..; � .
- �-� �� ��
��;� 1
;
�� �� �l-.P%
.��� � �
� k� ` (y/� � /\) �
� 1 . � % � " �• /
l/�y/�
t�
��
� � � ��� �
lv � ��--�-�
�
,
/,,� � i.s
�
� Person County Health Department
Sewage System Improvements Permit
Date:7–/���This Permit Void After3 Years of�'
Owner. SR# � �._
Location/Directions:
Subdivision Name: I.ot #
Lot Size: •'rfZ..t �4�e- Type of Dwelling: .
Water Supply: Private: —� Public: Community:
Bedrooms: �{ 7- 24 • 9+F Garbage Disposal
Basement � Basement Fixtures
INFORM 'IED BjY
Sanitarian �..�jif" oa�ner or representative
REPAIR: REEVALUATION:
, —
Size of Septic Tank• gallons Size of Pump Tarilc: Ua �
Nitrification Line: � ' - � '
Depth of Stone: 12 inches b�+ 3w. �
Max Depth of Trenches: �'"" ' � '�
Altemative System: Conv. Pump LPP Pump
Remazks:
Date Well Appmved: Well should be 100 ft, from any sewer
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIFTCATE OF COMPLETION
Contractor. �
------------------------- �
Sewage System location, installarion, and protection must meet state and local '�
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained .��-
by owner in such manner as not to create a public health hazard. Septic tank and't3
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
• ' at later date: Note location of water supplies on adjacent lots.
�
srt�
13u
(� �„ �, �'
1-i � — -
�--'� �� i� �; - � � b�- � i �
3 �v _� -550� z
��� �°` " ` � �
Pe, �!!�I County Health Department �
Sewa -S.ystem Improvements Permit
Date: " " This Permit Void After3 Years o��
Owner: S�'►� � �2v ��t,n4t'P��O�('� SR# 13ZZ
Location/Directions:
Subdivision Name: ' Lot # �
Lot Size: � qJ� Type of Dwelling: _
Water Supply: Private: _J� Public: Community: �
Bedrooms: �-�9•a� Garbage Disposal
Basement Basement Fixtures
INFORMATI IED BY
$�1��: oaner or representauve
REPAIR: REEVALUATION:
Size of Septic Tank: � ��a gallons Si e of Pump Tank: �v�
Nitrification Line: —�~� � � .�
Depth of Stone: 12 inches . '
Max Depth of Trenches: -'�^- �
Altemative System: Conv. Pomp LPP Pump �
Remarks:
------------------------
Date Well Approved:
BY
Date Sewage System Approved: _
Well should be 100 f� from any sewer
Sanitazian
BY Sanitarian
CERTIFiCATE OF COMPLETION
Contractor. '
------------------------- '�
w
Sewage System location, installation, and protection must meet state and local 'i
regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'�
nitrificauon line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S.130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
-�.
� ,� _� ..
Tax Map #: ��
ApP�icant ,� / � G �
I..ocaUon:l��lL' (�yz
�
Improvement Permit
New�Addition Type of Structure ��iv�,G�e��c�i�.�o�-.,c�-
# of Occuparrts �-'6 # of Bedrooms 3 Other �---�
Projected Daily Flow: 3�6o g.p.d. P it V lid For. iv Years No
Proposed Wastewater System: er--� /"���- -�
Proposed Repair.
Permit
�
PIN
"' LottF�
Water Supply ^ � �
System Type��
Owner or Legal Representative Signature: Date:
Authorized State Agent: �� I Date: �- �6 �- d%
The issuance of this peRnit by the Health Department in no way guarantees the issuance of other permits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subjeat to revocation if
the site ptan, plat, or the i�rtended use changes. The Improvemerrt Permit shall not be affected by a change in ownership
of the site. This permit is subject to compiiance with the provisions of the Laws and Rules for Sewage Tr+eatmerrt and
Disposal Systems of the North Carotina Administrative Code.
Wastewater System Description:
Facility Description: �,�
Basement? ❑ Yes �No
Wastewater Svstem Requirements
�
Flow: 360 �.p.d. Type: �,v
_ New� Repair O Expansion ❑
Tankage: Septic Tank size �Gbv gal. Pump Tank size � gal. Grease Trap size gal.
Trenches: Total lertgth � ft. trench Width _�ft. Total Area O� sq. ft.
Max. Trench Depth: _l� in. Aggregate Depth:J Z_ in. Soil Cover. �o in. Trench Separation �ft. on center
Perrnit Expiration Date: %- aZ G--
Authorized State Agent: . Date: 7'".26''� %
"See attached site plan and addendum pages for additional permit conditions. �
The type of system permitted C�i dces O does not differ from the type spec�ed on the application. I accept the
specifications of this permit '
OwnerlLegal Represerrtative Signature: Date:
Oaeration Permit � �"�
System Type (in accordance with Table Va) �
This system has been installed in compl"iance with appl'icabfe North Carolina General Stahrtes, Laws and Rules for Sewage Treatmerrt
and Disposal, and all conditions of fhe Improvement Permit and Construction Authorization. Issuance of this permit implies no .
guararttee fhat ffie system installed will funcYion propedy fo� any given period of time.
Authorized State Agent Date -
PCHD, rev. 03/07/01
�� �� �}- P�r3on ��uniy 13ealth. Departmen#
� . � ��nvir�nmental �oait�e 3ectiorn
�ii� Si4E'TCl�
'1'ax �Aap $: ��3 ,
AA
Parc�i �: �
�i��i�l.��r-�-- � ��'�;�,� s/,o ��/�
� Appitcani's Name SubdivisioNSectfbn/Lot#
' ,%� � � �S'. _ � �' r a/ . . �
. Authorized State Ager�t Date � . �
Sy�urt coeipn�te�ds �resent appraurJnto�a carrtours only. The cor�iractar muai, f� the systan �
prior b bagin� tlire in�tallation io i►tipn that prnPer �'ade is nraJstained
�
�v/S`D a( .2 "SC%wo%,,l{ �
/
,�✓C 5���� I,%�
h�.,� Yro ��---
3 �`
��� � (� �+tG
�'r
3i0 �
� ���
� , �y��� �
�V-�' C�X�.57",%eJ .�-6on
[.� en.c� ^ en:s�.
� /.hc�c
'�� ' NCcJ�'�e Cfa�t /hJ/A����
—•— - rejpa�rare4
v—"
3cale: �` _ �
Z'
�f5'
,
�/�_'''�112r'�'�f Lon�l.�.u-
/• �7at�' �;n s�%,�a-� P.na'n��
A��a+���Ao Corirct�ier� �n /JP.c�J
�;.�as o�,�/ �l� /%�.�s s�.L/6��e�.�, ��e�..i
.Z. �Ye� /,i,os s�.//� ,ns�//o�q7��a„
G: f� a�of .��cJP�%Qx,'s I a*.,� • ,
D�l�:� s�,�/ 6� / /
� �a�4,eo�jO/','or J�D �+r9i�fl'!i'r�'j iitS'1u`(�c�s. ,
� r ! , / , � ��O � h. �'�. ,;
3. �¢ �J �i�i�.t,S �'Gv✓��,G�� nS ����e�rlf� J r%�
l �y/'Pnt� a��5f� /`��
°� � m`�'S ✓ ��l'�s'Sr.t'/'e- ��' �d lcl •
1� ° c,dc%r.oLu•� tp es -2-k-��l' �O'"'
C� S ��`� �
. �/�l�v.Pa. P�""� l� � -
�: �%� d�; S �! � dd,.�. S �/.���°�S
���1 � ��//� r,or5�o �;nnln�
2 ���a /�w�i b`n. � I�ec.J�f+�- , .
Sg �
� �/���y.�.��
� ��A�r c�,�aect .
��� , �n"'' [�'
7'7"a� ,�a-hpiswQ/ ��„ /O ��ra+r.
�- _� e� 4 ��/k/
("a�,' t.�+" %t j��-J
/� /�7'
��'- �"�`'L �r,'vc - i
_ � _ -- — �o �P/�✓
_�
t�
:,
$� �t3C�1Ed 3ilE�C FQC d.eCLiIC31 • .
SQecificaC �stg ,; " .
( : .
i
t
6••
0
\ � 1Yi H3� � = ► Zn
=11� = �11= �11 �.
»�_��, _��,= 1
/� 1►I = i il = I 11 � ._ .
, .,�. .. .
, , .•,.
Uadezgraea�d Cable In Caaduit
�1ith Suitahle Sealer In Both
Eads Of Ccnduit
�, _.��� � . _ ... _ .. ,. -
_� . . - .-� . .. _. ..
■�� a� ir�• • r - � • • •�c-
. - -. .. _, . , .- _...� .�
Ng" �2i
m
- / -o i
.ri/s'v j�1],e -'' S3ngle
;��fercye%Q- ��
/ �j,�
�
A / 1 _
= 11 � �`
�t
SubQersible Ssnrd�
Effliient Pt�a4 ��
8" Concrete
Bloc�c
���-��� �
�r N� r_i�-� ci �• -'� -1 .�� n�
F: , .� : �r_«� u1 _� • '�ar_• c�
i ■ -� r �i • ��r, �- _
�
Grade
� ��► = ��� _ ,�� _,�� = 1l� _
._��i=�q=��t-�t� _��(
i 11= 111,= ! 11= I lj - j�.;.�..,.�--..�_
_ �
. - . . � :r.-�:
. . 30" > Df�D calloa T�k
., . I
� .
.
.� �
. F–�'P�IY � _� �� � oa �
t► Dianeter Schedu.Te 40 PVC
� ., '. pl�
• , lrn R�c�Q Pe�al. i�
�' � Gate valve
'�readed tJnia�
• . �ec1c Valve
3/16" SyQ�n Bre�lcer Fiole
� Ioddix� st�s--P?r__�xl A,u os*is
— � �►la=m Floac (elevation)
--- "Rs� On" Flaat (eievation)
' ' "pu� OfP' Float (���-Qn?
y, .
�� '
, PtJItY RA_TING
pump Hust Be Rated To DeLiver
� ad � GalZoas Per Hinute
� Against l�Z�Feet Qf 'Ioca
�" Dynamic Head (TDH)•
� � � �.
d . .• . , a a
e e � , � � . . en • . • • • . • • a • ' •• • • s •
`Ilzis �lt SrsLl 1� c� d Sia� ��P `� ,�
Ik�ign �1 �11 L-e I�k �� Ctrri� .
See Fcllowing Sheet For
Additional Specifications,
Noces, And Explanations.
PUMP SYSTEM DETAIL SSEET }
*Black, Brick
or paured
*Cteanout Plust
*Note: Cleanout olus adapted to accomodata
stand pipe to adjust pressure head, or and
additional tap may be used to accomadate a
stand pipe for pressure head adjustment
�/
in. Threaded Tap or
saddle tap Sch. 40 PVC
Sch. 80
PVC
Pressure Head to be set at �_ fe.
�_ —
-�
Taps and �
vaives
Gil�+-��t� orr
�i/� �
J2�r 3c�% �'.
Mechanical
Connector
Nitrification
pRESgUgE 111ANIFOLD DETAIL
S1DE �l1E�V
Support Straps
Canctete Pad. Le+•el
END ViE�V
Suppott Block I .
Concrete Pad, Level
TOP VIEW
3in. Manifold
. _ Sch. 80 PVC
From
-�_Dosine
Tazilc
Gate Valve
=� To Nitrification Lines
Support Strap
ig
i
ng
�F� p:essa_? :rzated "..'.••
pest •?: ?QC:V3:er.t l
NBI�& �% ..�
�nclosure �
�atEr tlqht ,
+
corrasian
;stall ? circait resist� �
.sconnect saitcfi � �
panel does nat
:ve a dead front _ .._..._:a `
Lh �anual uiscoauec.. _,.. : - . /
ote: A 6r:aker �iues �._.. :
� ��oustitste a \
scannectj > >�• �Q
fiaish grade
aa�p .;upplp circui� �
Ylars C::cuit
iater "ight �zai — — _�
3ydrauiivi ce�e�t� � �
Schedule �0 ?VC
aapoly �— -- --
�ic��4�back plucz and Receptacle
- r.
4z� pressare t:eated ���
post or eqnivalent
,yg,� �!b
�Q�'-�S��n
iiatet �i9at
. �
cottosian
�esistaat ' �
Z' iiniin■
� �as "iqht
Coaduit
>li' to finisti qrade
. paip sapplq circnit
alari control
.
�
Simplex Control � "�'� �%
Panel Wit:�
Built In Alarm
Hate: ftiis is
oot a Yirinq
diaqrai! Cansnit
an glectrician! "
Duct Seal
�
' ;aciciaq St:.�s
3araess Sz�°ss �a:is
�
�eceptacle �nst be
aatar :ated
�oy-voltaye alara
' coanectian
Quct Sea�
�ater Piqht Seal
Hydraalic Cenent
Harness gzcess Ca:ds — _ ._._I�
� Schedule 40 PYC
• Sapplq
--�
0
" 6e a:aIl 3cs� 5e
�onctea :� :5e ::a:�ae;
livi�g �:ea a� :he
dve'_'_:sq ;sot ia t�?
crani space qaraqe o:
aude= i �obile �one;
P5e raee: aust 5e aad:�ie
and �is=51e to spstza :sers
���
Lackisq straps • '
���.sf ��I�.���
�---= -�--�- � � ����
�aawnsr��n.�rnn�g.a��.� ��a�.�.���n.
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �� Parcel #�� Township �(l Y1 � V���
Applicant: 1 f�2 [;��C�-4 �
Subdivision: � � �� Section• Lot•
T nr��tinn• �I V\� ����5 1"\'�, \� �[1Jl � i ` �L1
Ty�e of Water Su��ly: Individual
Rec�uirements•
Site Approved by
Grouting A proved y �� 9'D�
Well Log �
Well T
Air Vent
Hose Bib
Concrete Slab -/g�0�
Comtnunitp Public
O�L'r� .�
l� f.Q-Q
�.oe.�to�
Well Driller.
Well Approved By: Date: �� � `��S
'�°5ee Attached Site 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 anq building foundation.
Other conditions:
n �� ; GL�, � p � � � ,�t ri_.. _ �ZS � ��% �/� ♦ �il
i �.�� � �d�r
�� ao��� �� C�P ���' ?�
PC�ID, rev. 09/07/01
�.��� .) f ���� ��
�_ . �j � � ����
I���a��-�•-� � ���.�.]1 IE3L��.11�I�
T�x M�p - F�rc�el � -
S�ubd!ivision r
Ph�s�e Sec�t�ion Lo�t # �
Appiicant: �d��� (l��D� 3 ���d tiI
Location:
Operation Permit
System Type (In Accordance With Table Va): .
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF T�iE IMPROVEMENT PERMIT AND CONSTRUCTION
AUT O IZATI
� _ 1����-0�
Authorized State Agent � Date
Installed By: -�l �°� � Date: �s -15-��
�
.s
/20 a.�t « _� ��..e, �i'� el �r, �►�-e-
� � , „ � �a
l
� _ ►� R � �' `� �2 ; %`� � �, _ f . 1
,�� „ , „
l�- ;� �o
' g'�" ', � $ i}�'�
, �
� � ��
�'��� R��/1N ��/�r.
T�- �
� ��o os��1 �
.t._r �
l Vw�'`'S e
. „ � � ,.�' o'``
PCHD, rev. 07/29/02
S���'lC TANK 11VSPE�C�ON ��iE�KLlSi' (%/pe il - IV) �
Tax Map #-�� Parce! #�/b� System Type (Tabie Va) �'s6
Owner/Appiicant reo�f �'li�a9o,,-� Subdivision �Q�� poq'�,�-P .�,/n
Address/Location Sec/Phase Lot #
an
State ID/date
Tee and Fiiter .✓
Ba#fie ✓
Sealant
Riser (if applicable) �
Tank Outlet.Seal
Petmanent Marker /U ,�-
Pump Tank
tate ate p�.S� 5 G.��_
nes
Width
Trench Length
Trench Grade •
Trench Spacing
Rocic Depth and
Dams/Stepdowns etc.
Pressure Laterals
Hole Snacina
capacrty gal. Pipe Sleeve
Waterproof /Sealant .� Tum-ups/Protectors
Riser ✓ Required Setbacks
Water Tight � o� ��rve . From Welis _
Pump
Check Valve/Gate Vaive
Anti-siphon o e .
FioatslSwitches � �
Alarm visable and audibi�
Electrical Components ;
Rate (qpm)
Model
Blocic Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
lines
� � . = .� . .- �/ SurFace Waters '
Public Water Suppl
Vertical Cuts >2 ft.
' Water Lines
✓� Vehicle Traffic
Low Pressure Pipe •
Appr. Pipe Material and Grade
Vaives
Easements/Right of W�
Other
Easements Recorded .
ert' ed perator on1
Tri-Partate Aareement
Comments
ft.
in.
ft.
pct�d rev. 3/13101
��J.�e. iV�i•1 ��.�..i.. � �� � 1 � �/Y/� . . ... ... ..,. . ..i w�..�: �.n. .0 J.ObJ:.uJS . .
V Y " \
�._..,`�� � ' �.� � �� °� �Q � .�o .�� � -
,.. �
�� +''�`� � � ��� i� ���j +��Lw-h.� i,cl� �� �r-�i h`t
1Esa�ax-ou�.a�.�+.��ca�.a,.l �a.a�.'l�llz � � / ' �^,b�� �
WCIl LOg
0��; �� Tax ��ap� Parcei n_� o�
Location: � � c,
SU�1V1510II: ��q n.� � v._�. � � r� V t.� I.OL �
��f.0 COa.422'QC�OII
1?istance Fr�m ncarest Property Line (l�finiinum IO feet) 1�
Distance from Sephc 5ystem (Minimum 60 feet) '`� !�
Total Depth: (o c� ft Yieid: �� GFM Static Watcr Level: `�`-✓'� ft
Wafer He$ring Zoncs: Depth 31 � ft ft �t ft
c�g: G��f ���'
Depth: From (� to �.�'' ft. Diamc,�tez: � in .
Ty�e: Galvanized Steel ,/ .
Weight: /3 - Thickness: 16'�6 Hei�t ahove Ground: in
Drive Shoe: �Yes Ivo Any probiems eucountered w1vle setking casing7 Yes iNo
If `j�es" give reason: •
Grout:
Neat: Sand/Ccment � Conc:cte GraveUCement
Annular Space Width 3 inches Wat.�r in Anuulaz Space� Yey �- ;Vo
Method of Grout: Pumped Pressure +�oured Depth O to �- �J _ F�
M�►terisls Uaed: .
� Na. Bs�s Portland cement Weight of 1 Bug �� y`' Pounds . �
If mixture (sanc, gravel, cuttings) - Rario _�-t� f �
ID plates: �!�es _ No 4 x 4 slab �;10
1, DrIlling Log i.oc�liun Dravring
I hereby certify that the above infomiarion is corrcct and that ttus wcil was constivctc:d in uccordunce•wicti regulations
set forth by the Pa:son County ealth Department.
Signature of Con,tracto �# _� 4 3 1 B�te 7.. �� y-a �
__ r p�HD rev O]f1biQ?
Application Date; .�
Amount Paid: 0 � 0 0
Receipt #: ) �33
�4�P�t � �
�
-�-
��� i ��/ �/}�.i� ��-��
`^` "' �..���1���
1�".uavaa-�m,.TM+�,.,TM*aean.��n ��.si.��,�a.
for�Services
Tax Map: �
Parcel#: l 0 �
��
-D�i `�
� 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 Replacemen or Building Addition Permit Revision
$150.00 (if site visit re wr $75.00
Well Permit (New/ReplacementlRepair) Repair of Esisting Septic System
$300.00/$200.00/$75.00 Application: No Chazge/ CA $150.00 or $300.00
1) Applicant Infor} �ation:
Name: (� d �t � �( k � t�� . Phone (home): �j� �j``�Z - 3�Z�
Address: � (work/cell):
2) Name and addre s o current ow9�r(if different than applicant):
Name: Wt°!O S - Phone:
Address:
� �
3) Property Description: Lot Size: .� Z- Subdivision: �G�-� � . Lot #:
Address and/or directions to Property:
❑ yes o Does the site contain any jurisdictional wetlands?
�-}ces � no Does the site contain any existing wastewater systems?
� yes �'no Is any wastewater going to be generated on the site other than domestic sewage? �_ p��
❑ yes .C�no Is the site subject to approval by any other public agency? ��- G'`
O yes �no Are there any easements or right of ways on this property? q a,ra �
(if `yes' is checked, please provide supporting documentation) i\
��� � X � �
4) Proposed Use and Type of Structure: . ,
�Residential ' 4�'���`'�'
❑ New Single Family Residence Maximum number of bedrooms: / upants: �- � ti! Ir0 OM
❑ Expansion of Existing System If expansion: Current number of bedrooms:� �� x��
0 Repair to M a l f u nctioning Sys tem W il l t here be a b a s e m e n t? ❑ y e s �( n o i u m b i n g fi x t u r e s? � y e s O n o
\.
❑Non-Residential
Type of business:
Maximum number of employees:
. .
`!�•- AF •. -�-
�..__.___ _
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �Existing Well ❑ Community Well � Public Water � Spring
. Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccur te, he si is quently altered, or the intended use changes, all permits and approvals shall b in alid.
7 � �
Signature (Owner/ Legal Representative*) Da e
�` Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A�or�pleted `Lot �reparati��' fnrm must accomnany any applicati�n rec�uiring a site evaluatinn.
(10/15) Person Count.y Environmental Health, 325 S: Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
!) .` �� � � .
, . � 1
\
< <�� � \ � 1, � �
�-��,..,� ►-,�-:���►�
Building Additions/ Mobile Home Replacements
Tax Map #:-��?� Pazcel#: �o v Address: ' �Z.
� ' ,��v
Approval Requested for: Mobile Home Replacement , �
_�1 BuildingAddition ���� L��� �5i��-
�v►�ii2.�� 12 �� 1 `i- '
Applicant Name: �TE ��}-�—rC �Vf ��,—��
Address:
Phone #'s: � �
.,. ����'/
Permit Located: �✓ Yes No
Installation Date: a � Design flow: 7-�, (gpd)
Current Contract with Certified Operator on file (if required): �,(.�_
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: y i (date)
(Applicant's signature if site visit is not required)
Addition/Replaceraiea�t Approved
Envirorun ntal e Specialist
f �7
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-17901 Fax: 336-597-7808 www.personcounty.net
420'
CONTOUR �
i
�
i
i
� �
t
. q6�
�1
PROPOSEO
AODIT[ON
LOT 17
"OAK POINTE��
N86' 47' 1�"E 82. 12
�
Sl
SEPTIC � 'c
CAPS A
8 PUMP
o p � �� CONCRETE
BELOW ,�
.y1 •
RpCK POR�N'
C�N�
2 `
`�i�.
'��.
���
�
ASPHALT
DRiVE
o. �2
ACRE
LOT 16
"OAK POINTE"
P. C. 4, P. 231
Person County Environmen4al Heatth
325 S. Morgan Street
Suite C
Ro�o% NC 27573
V ���
s/r�/� �
LOT 15
"OAK POINTE"
�� _ ��
IF .���
_ �' � � `�i?
,�..- � ps I� � �
TRANSFORMER .. �"�� ' CPRIVP�E�
_�-�S R /�
' _,_ � v�s 146�79�4» W O�
��� � / �p S� g' � � � .-
�v --
� ' t� SR
f EK D r -
�__„_- � �RE J��-,�_-
-- - � p,N ,. _
__-- -
_ .--- - -
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
ROY COOPER
GOVERNOR
Onsite Water Protection Branch
May 16, 2017
Steve Webster
126 Cane Creek Dr.
Semora, NC 27343
MANDY COHEN, MD, MPH
SECRETARY
DANIEL STALEY
DIRECTOR
RE: Approval LOE140
Existing Well Located Less than 25' From Proposed Building Perimeter [ISA NCAC 02C .0107(a)(M)]
126 Cane Creek Dr.
Semora, NC 27343
Dear Mr. Webster,
On May 12, 2017, the On-Site Water Protection Branch received your request for a variance to rule 15A
NCAC 2C.0107(a)(2)(M) to allow an existing private drinking water well to be located less than 25' to a
proposed building perimeter on your property.
Records provided by the Person County Environmental Health office document that the well was
constructed in 2004, and was permitted and inspected to meet the construction standards at that time.
Based upon information provided by the Person County Environmental Health office and well variance
application it is my finding that you meet the conditions necessary for approval of a variance as specified
by 15A NCAC 2C .0118 (a) (1) and (2). On that basis and provided that the following conditions are met,
the requested variance is approved:
1. The well shall be sampled for the full panel well water sampling kit (microbiology and
inorganics) at the expense of the well owner.
2. No pesticide treatments (i.e. termiticides) for the structure shall be applied within 25 feet of
the well unless alternative methods are approved by the local health department to ensure
contaminants do not enter the well.
The approval of this variance does not affect any of the other requirements or limitations of the Well
Construction standards or your responsibility to comply with any other applicable Federal, State, or local
laws or regulations.
WWW.NCDHHS.GOV
TE� 919-707-5854 • Fnx 919-845-3972
LOCATION: 5605 SIX FoRKS RD • RALEIGH, NC 27609
MAILING ADDRESS: 1632 MAIL SERVICE CENTER • RALEIGH, NC 27699-1632
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
The granting of this approval is for the well location only, and in no way relieves the owner or agent from
other requirements of the North Carolina Well Construction Standards, or any other applicable law, rule,
or regulation that may be regulated by other agencies, nor does it imply sufficient water quality.
If you are dissatisfied with this decision, you may commence a contested case by filing a petition under
G.S. 150B-23 within sixty (60) days of your receipt this decision. Should you have any questions, please
feel free to contact me at (336) 590-1219. �
Sincerely,
' � •� �
Leslie O. Easter, REHS ,
On-Site Water Protection Branch
� Il
� � �
�... � ► � i J'
♦ •
.r�. �
urturing a healthy community
355 A South Madison Blvd • Roxboro, NC 27573
May 17, 2017
Mr. Steve Webster
126 Cane Creek Drive
Semora, NC 27343
RE: Variance from Person County Well Regulations —
126 Cane Creek Drive, Semora, NC 27343 (TM#A23, Parcel# 102)
Dear Mr. Webster:
The North Carolina Division of Public Health, On-Site Water Protection Branch has
issued a well setback variance for your property at 126 Cane Creek Drive. The variance
allows you to use an existing private drinking water well which will be located less than
25 feet from a proposed building perimeter on your property.
Person County well regulations also include a minimum well setback (25') from a
structure. Based on the variance issued by the State and the accompanying conditions,
the Person County Health Department also grants a variance with the same
stipulations.
Please feel free to contact Environmental Health at 336-597-1790, if you have any
questions.
Sincerely,
�����
Janet O. Clayton, MPH, REHS
Person County Health Director
phone 336.597.2204
Fax 336.597.4804
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
All water supply wells not considered "Private Drinking Water Wells" and including irrigation, industrial, and commercial wells.
V✓ELLS OTHER iHAN WATER SUPFLY JNDER 1�Ei NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type information. Illegible submittals wil[ be returned as incoinp[ete.
DATE: /j�A�/ 12- , 20 i? PERMIT NO.: (to be completed by DWQ/DPH)
OA. WELL OWNER - For single family residences list the property owner(s). For all others, list name of the business,
organization, or government agency and person delegated signature authority:
Q
C.
5 �v-� 1
Mailing Address: �OC l�_(�.lVle C..�V �IC _ U V� l�
City: SU��V�G- State: �L Zip Code: 0�13�
Day Tele No.: � b3 � Z� a� �
EMAIL Address: � Q � . D t�v Fax No.:
�
Cell No.:
�.e �rs a �
PHYSICAL LOCATION OF �VELL SITE
(1) Parcel Identification Number (PIN) of well site: /� 23 - l. O Z
County: I�-►.�'2S c5 �
(2) Physical Address (if different than mailing address): � 7�(� G'L�*i t= �G2.L=�--� -i� .
Cit} : �Er. �� State: NC Zip Code: 2� 3 i 3
,
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: "5A �, � JAt� � �'17 c C E�� E Q�_
NC Well Drilling Contractor Certification No.: ��� �
Company Name: �/d � ' G=- �� �� � t � i N�G Contact Person:
City: State: Zip Code: County:
Day Tele No.: _
EMAIL Address:
Cell No.:
Fax No.:
Fc:m GW-22V Page 1 Revised February 2013
, ,�
D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constxucted; rule for which the variance is
being requested; description of how the alternate conshuction will not endanger human health and welfare and the
environment; and reason why construction and/or operation in accordance with the standards is not technically feasible
and/or provides equal or better protection of the groundwater.
� �� 4 ��> � �. � �_ � •
� � � . i �� _,* � wi • w_
L� � L'; � r � ► �� '
. �.J r - ,,
E. ATTACFIlVIENTS — Provide the following information as attachments to this application:
(1) A map showing general location of the property (including road names, NC State Route Number, distances,
any key landmarks, etc.) su�cient for finding the well location.
(2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building
founlati�ns, property lines, water bodies, potential sources of contamination, other wells, etc.
(3) Submit a copy of the local well permit application and site evaluarion map (if applicable).
(4) Any other information relevant to the variance request such as a well construction diagram showing proposed
well liner or atypical construction materials/methods.
F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS
For water supply wells, approval of a variance will require that additional construction requirements beyond those
specified in 15A NCAC 02C .0107 be met. Minimum addirional conshuction requirements for Coastal Plain and
Piedmont and Mountain region wells aze referenced on Attachments A and B on pages 4 and 5 of this application.
Approval of a variance will not be considered in cases where the specified minimum additional construction
requirements cannot be met.
G. SIGNfLTURES
Signature of Person Responsible for Well Construction (typically the weIl drillerj
Print or Type Full Name of Person Responsible for Well Construction
(typically the well driller)
�
Signature f County E' onmen Health Specialist
�4-2�7(�t� �l; L— l_
Print or Type Full ame of County Environmental Health Specialist
Per 1 SA NCAC 02C .0118 the Secretary of the Division of Water Quality or the Division of Public Health may require
submittal ojinfornzation deemed r.ecessary to make a decision on the variance, ntay impose cazditiazs as part of the
decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance
applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as
clescribed in G.S. 1 SOB-23 within 60 days afler receipt of the decision.
Fo:m GVJ-22V Page 2 Revised February 2013
��
��
nc department
of health and
human services
� � a
���_ � ���� ���' ������.��� � ������ �������
� �� � �
t" -�, W
� � d! �` ���`' � �� �'���� � �'6 �� ���� t � F',!�'� �' 4�"�` ��°�"`�� ��'� �t'� � 8g ,��
� r'� � � y''vr",� �� �ta3'' �� � `Si �ay' �.:e���e� �� � � � t3 'se,:,� � � � �i � 3.�i�' �� �
For lnorganic Chemical Contaminants
County: c�1 Name: C •7-�"�
Sample ID #: ',I .� !p Reviewer:
TEST RESULTS AND USE RECOMMENDATIONS
I. � Your wel I water meets federal drinking water standards for inorganic clre`nicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inoreanic chemical results onlv. You may
have other water sampling results that are not taken into account in this report.
2. � The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
levels. The North Carolina Division of Pub(ic Health recommends that your well water not be used for drinking and
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 based on the inorQanic chemical resalts onlv.
Arsenic � Barium � Cadmium � Chromium � Copper Fluoride Lead Iron
Manganese � Mercury NitrateMitrite Selenium Silver Ma�nesium Zinc oH
3. [+�a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on
the innrPanic c/:emical results onlv.
❑ b. Levels over 30 mg/I may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferab(y
the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the
lead and/or copper.
6. ❑ The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inorQanic chemica! results onlv, 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.
Barium � Cadmium � Chromium � Fluoride �[ron Magnesium
Man�anese Selenium Silver pH Zinc
For nrore infor`natioi: regarding your we!/ water results, please ca!! tl�e Nort/i Carolina Division of Public Kealth at 919-707-5900.
North Carolina State Laboratory Public Health
Environmental Sciences
�iicrobiology
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: ES052517-0076001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
STEPHEN WEBSTER
126 CANE CREEK DR
SEMORA, NC 27343
Col lected: 05/24/2017 12:30
Received: 05/25/2017 08:14
Sample Source: Well
Sampling Point: Outside tap
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph.ncaublicheaith.com
Phone: 919-733-7308
Fax: 919-715-8611
H Kelly
Angela Heybroek
Well Permit Number:
A23-102
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Absent o5/26/2017
E. coli, Colilert Absent o5/26/2017
Report Date: 05/30/2017
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
/ � �
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.
North Carolina State Laboratory of Public Health 43012 D�stnct Drve
Environmental Sciences Raleigh, NC 27611-8047
htta://siph.ncaublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH STEPHEN WEBSTER
325 S MORGAN STREET
126 CANE CREEK DR
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES052517-0023001 Date Collected: 05/24/17 Time Collected: 12:30 PM
Date Received: 05/25/17 Collected By: H Kelly
Sample Type: Raw Sampling Point: Outside tap Well Permit #: A23-102
Sample Source: New Well Temp. at Receipt: 3.0 GPS #:
Sample Description: -
Comment:
New Well 1(Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium
Cadmium
Calcium
Chloride
Chromium
< 0.1
< 0.001
52
8.90
< 0.01
2.00
).00;
250
0.10
_ ._
m
m
m
Copper < 0.05 1.3 mg/L
Fluoride 0.72 4.00 mg/L
I ron
M
Selenium
Silver
Total Alkalinity
Total Hardness
< 0.10
< 0.005
15
< 0.03
< 0.000:
< 1.00
< 0.1
8.0
< 0.005
< 0.05
22.00
11.00
220
N/A
�
mg/L
Zinc < 0.05 5.00 mg/L
Report Date:06/07/2017 Reported By: Deddie .�toncol
Page 1 of 1