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A23 181z ' Person County Health Department � Sewage System Improvements Permit I Date: ' ' is Permit Void After 3 Years Owner: Location/Directions: �F-� SR# /3ZZ Subdivision Name: Lot # Lot Size: Type of Dwelling: Water Supply: Private: Public: Community: Bedrooms: �� Garbage Disposal Basement -� Basement Fixtures INFORMA N R D BY $�1��' owner or representative REPAIR: REEVALUATION: ------------------------- Size of Septic Tank: _�� gallons Size of Pum Tank: � s Nitrification Line: � 3 � �tin - onl Depth of Stone: 12 inches �., 'TM t�. ,•n Max Dep[h of Trenches: J�"to-yd Altemative System: Conv. Pump �� LPP Pump Remarks: Date Well Approved: Well should be 100 f� hom any sewer system BY � Sanitarian Date Sewage System Approved: BY Sanitarian CERTIFICATE OF COMPLETION Contractor. � Sewage System location, installation, and protection must meet state and lceal � regulations. Septic tanlc 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'� niuification 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 permit is subject to revocation. (G.S. 130 A-335F) L.ocation of sewage disposal sewage system sketched on back. i (OVER) 22£ J �S �' 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. Aaalication Date: Arrr•�unt Paid• ` Receiqt #: Person Countv Health Department Environmental Health Section APPLICATION FOR SERVICES Tax Maa #: � � � Parcel #: � ` � � � � 1) Permit requested by: (OwnerlaqenUprospective owner):_ Home Phone: Address: Business Phone: .3 46 � S97 SSy� 2) Name and address of current owner: _____i�/� ��vr,r�� 3) Property Description: Lot size: ,,��, Township: __C^�iYG/ Directions to the property (InGudir�g road names and number�'j 4) Proposed Use and Structure escription: answer each of the following questions: a) Proposed 0, Existin b) Stick Built-�; fVlodular o, Single �de ❑, Double Wide ❑ c) Number of Bedrooms: � d) Number of occupants or people to be served: e) Basement: Yes O, No � If yes, # of basement fixtures: � Garbage Disposal: Yes ❑, No ❑ g) Dimensions of Proposed Structure: Width: Depth: 5) Water Supply Type: Private 0(new � or existing �), Public ❑, Community 0, Spring ❑ Are any wells on adjoining property? Yes ❑ No 0 If yes, location 6) Please Indlcate Desired System Type: (systems can be ranked in order of your preference) �onventional _,Modified Conventional _Aitemative _Innovative Other (specify): �oT /3o�/f O.�if'�.;v�. � CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make appfication to the Person County Health Department for a site evaluation for the on-site sewage disposal 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 permit shall become invafid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to condud their evaluations. I understand that I am responsible for notifying the Health a ent if y property con ins any wetlands as desi nated by the Army Corps of Engineers. � wn or Leg epr ative Date PCHD, rev. 10/12/99 . �OaGpUNiYGp�� , 4� Si�i # p� * # * u v w yQ Gb PERSON COUNTY �°"`°""�� December 1, 2000 Mr. C. R. Pointer P.O. Box 796 Roxboro, NC 27573 PERSON COUNTY HEALTH DEPARTMENT ENVIItONMENTAL HEALTH PROGRAM 20-B Court Street Roxboro, North Carolina 27573 . (336) 597-1790 Re: Application for lmprovement Permit for wastewater system for property owned by Jim Stovall at Oak Point S/D lot 13 . Person County Health Department File: Tax Map #A23, Parcel #99 Dear Mr. Pointer: The Person County Health Deparpnent, Environmental Health Division on October 2, 2000 evaluated the above- referenced property at the site designated on the plat/site plan that accompanied your improvement pennit application. According to your application the site is to serve a three bedroom residence with a design wastewater flow of 360 gallons per day. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, ofNorth Carolina Administrative Code, Rule .1900 and re(aie� rules. Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is IJNSIJITABLE for a ground absorprion sewage system. Therefore, your request for an improvement pemvt is DEI�TIED. The site is unsuitable based on the following: I. Soil depths to saprolite unsuitable (Rule .1943). 2. Topography and Landscape Position (Rule.1940) 3. Available Space (Rule.1945) These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directiy imo ground water or inside your structure. The site evaluarion included consideration of possibie site modifications, and modified, innovative or alternative systems. However, the Heahh Deparnment has detennined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSIJITABLE, and an improvement pemut shall not be issued for this site in accordance with Rule .1948�. However, the site classified as UNSUTTABLE may be classified as PROVLSIONALLY SUITABLE ifwritten documentation is provided that meets the requirements of Rule .1948(d). A cogy of this nile is enclosed. You may hire a consultant to assisst you if you wish to try to develop a plan under which your site could be reclassified as PRUVLSIONALLY SUTTABLE. J You have a right to an informal review of this decision. You may request an informal review by the soil scientist or environmental health supervisar at the local heaith departmecrt. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for an infom�at review must be made in writing to the local health department. You also have a right to a formal appea( of this decision. To pursue a formal appeal, you must file a petition from a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrarive Hearings or call the office at (919) 733- 0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statue 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a forn�al appeal, you must file the petirion form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. ff you file a petition for a contested case hearing with the Qffice of Administrative Hearings, you are required by law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Department of Environment and Nawral Resources. Send the copy to: Office of General Counsel, N.C. Departmerrt of Environment and Natural Resources, 1601 Mail Service Ceater, Raleigh, N.C. 27699-1601. Do NOT send the copy of the perition to your local health department. Sending a copy of your petition to the local health department will NOT satisfy the legal requirement in N.C. General Statute I50B-23 that you send a copy to the Office of General Counsel, NCDENR. You may call or write the Person Cow�ty Environmental Health Department if you need any additional information or assistance. Sincerel , � l � �" �S. � , Michael E. Cash, R.S. Environmental Health Program Specialist Environmental Health Division Person Coumy Health Department Cc: Janet Clayton, Environmental Health Supervisor Marc Kohlman, Health Director • `. T -�.,�: � .t . . • ' Appiication Date: ��I I �� Amount Paid• o�� RecriQt #• �I' 736� . � � � Z✓�� ?,�°`0Z c� . . SU.�� 1 �� ""'%er �ra-� �� 1 Y � � � [2✓� G�/�n t,(�U'�1 � l C�� 2 C t�i' . � 7� ��`?�� - - _ z � � �T1�\T � � � a��aa-�s��-�-� oaa.-cEm11 �3L�m71�1�a. APPUCATiON FOR SEi�VICES Tax Maa #• � �� Parcel �: IF THE INFORMATiON 1M THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED. CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AiVD AUTHORIZATION TO CONSTRUCT SHALI. BECOME IMVALID. . 1) Permit requested by: (Owner/a ent/prospective owner): ��e �� I�ZCe- S�ve and Sheila Wailace Home Phone: 336-234-oZo'� Address: � ��1 S. Madison Blvd. Business Phone33G-s�Q-s ��3. . boro, NC 27573 2) Name and address of.current owner: Steve an�+ shPila Wailace .. �� ►��„-�Ivd� ' 3) Property Description: Lot size: ,� l� Township.�r11�' Subdivision: Vu �C 1'Di I'11 � Lot #�� Directions to the property (I�cluding road names and num __): • � � 4) Proposed Use a d Structure Description: answer eac of the follawing questions: a) Proposed � Existing _, Type of Structure:�a I�SC Width: � Depth: b) Number of Bedrooms: _� Number of occupants or people�to be serv��i: c) Basement: Yes , No � Will there be plumbing in the basement7� d) Garbage Disposal: Yes . No � . 5) Water Supply Type: Private V(new _ or existing�, Pub jp . Community , Spring _ . Are any wells on adjoining property? Yes_ No ✓If yes, please indicate a�proximate location on the site plan. . . 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No ✓ PLEi4SE NOTE THE FOLLOWING: ➢ A PLAT OF THE PR�PERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPL1CATi0N. ➢� PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ' ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR APl EVALUATfON BY THE HEALTH DEPARTMEAIT STAFF. � 1 hereby make application to ttie Person County Health Department for a siie ev.aluation for the on-site sewage disposal system for.the above-described property. I agree that the contents�of this application are true and represent the rrtaximum facilities to be placed on the property. 1 understand ifi the site is altered or the intended use changes, tFie peRnit shall became irncalid. / Owner o� Cegal Representative (l/ / ' d Date PCHD, rev. O6/27/02 � `s��;,�� la �A��.J ��.. V �1 � � �� I��.�a-�� .��.]l IE��,�.Il�11�. Applicant: Location: . � T��x ('li:�lC� j � �rc-c1.i � � . S�u.f� cl i�v i�s�i � ia /� F ia•;;i_� c�:'S e c ti:o•i�� La t# 0 �pr�veffient P��t Permit �Ialid for �ive Years. _,1�1q Eapirai�n �� y , mi Type of Facilit�: ,' ' ��u ' � s�ol.�_ � New ,/t�ddition _ '��ier �u 1 �1�.�1% � � , � PP Y # of Occupants �� # of Be�rooms 3 jected I�aily Flow 6o g.p.d. � Proposed Wastewater System: .z.� � v o . Type: �,� Proposed Repair: � ' �� _ ,-�a � . 3sG 'T�rPe: - � Pennit � �or Owner or Legal Representative Si Authorized. State Agent: _� Date: Z�zs� � Date: 2 / 7- � � The issuance Qf thia pernut by the Hesith Department in does not guarantee the issuaWca of other pennits. it is tha responsibiliiy of the applicant/property owner to in sure that all Person County Planning and� ZoninS and Huilding Inspections requirements are me� ThIs I�►provement I'ermit 3s subject to revacation if the site plan, plat or the intended use changes. The Improveanent Permit is not affected by a'change in ownerahip of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and gules.,t'or SetYaQe Treatment a�d Disnosal S`vstems' (15A NC�iC. 18A 19Q0). Neither Person County nor the Environmental Health 8peciallst warrants that tl�e septic tanl� system will continue to funclion satisfactoritx in the future or that the water supply will �emain pota6le. � . �AAt�IO,Y'1ZS�Ol1 t0 COII�t�'IIC� �a��W�$e�' ►5�3��ffi �gteqnired %� �uildi�ng Permit) . * See site plan and addi#onal attachments (�). j�r�ssti re> Proposed'OVastewater System: �-'� �Q�ype �_ Wastewater Flow 6d. .p.d. New �1 Repair Eapansion 3oa.'1 I,TAit: • 3 g.p.dJ ft 2 Type of Eacility: '�,� S;�l �.��, ' c v�s%��. Basement Yes �No Size: Septic Taxilk: � gal field: Total Area: � sq ft i�astewater Sy�tean Reqnirements .. �p Tank:�Qo.o g�l� Grease Trap: — gal Total I,engtl� �_ ft 1Vlaumuffi'I'resgcii Dep�a � in '�rench W�d#h �_ ft 1dlinimiran Soal Cowcr: �_ iHn Distribe�tion: Distributioa Box Seri�l Distribution � Minimum Trench Sepazation: 9' ft ✓Pressure Manifold � �� Aaa#laor�ed State Agent: .,��_�� G� � Date: �' -� -O 7' Pennit Expira.tion Date• „-/ 7- O The type of system permitted is t/ Conventional . Innoyative Alternative. I accept the specifications of the pernut. � �1,,/�. Owrnea�/�.eg�l�pa��se�tutqve: • ��'� �• � Date: Z Z�j� �✓ �'12 �` /� /�`'l�� PCHD7/30/2002 �� t�J' � � �'�"'� , . 1 .� � G�- � � � � ,�� / � � c�� ; 7Y11_1V']L]�Q:D7Y11_�r�rn c�1C]LtE:.,�A.� 1L ��..�II.�LiG� SITE PLAN Name s�✓� Gtlo��l�_ Tax Map # a3 Paxcel #%�9 Subdivision ��e;� ;�_ Section/Lot# / 3 t�� '�--i - D �- Authorized State Agent Date _ _. _ __ _. _ __ ___ ____ - --_ . _ h .,., . �.<< .. , , , , _ ._ __ ^._ . ; � ', , . QAK� POI�1E `DRI'VE ��. f�� . , , --- -. - -� - � - ,: ; ., . �F38.93 . � .. , :` 4�2.�E3 . / . 1 E�6 . / � , °� %. �% ��R�� .� E37 ;441:09 � ;. . �� / - ' �35 �38 . �D1�AIN=FIELD FOR � 1 . , . � . �pT 13 �. E39 .-'' A�42.8 � ��EN��RLINE� � . . . . ��2.ZE�.4 Q,37 QGRES •� / ' . �F BRANCH�'�a�.,:. `�-A�4�.35 / / STEV�' W: WALLAC� ,& � . `� �3', E.40 / ; � SHEILIA �G WAL�AGE ' ' `��. / - . / E4� `. E 1 � `r 4��:04 . :� 4 \ � o D.B. 410-382 ' , E:3Q. . ' � 445.�"7 . , ,. . . 4:44 9 <<v .s __ . � �3012'./ 427,4� . , �. v E��. � � � �� \ . � CENTERLINE 0� . � I � gQ . . � � / 4� o E29 ��! . h2�° ��, . 10 . pRAIN . EASEMENT, � 4, �' � . FQR �:OT 1�� . � c.� . , F'� , �� ^� �; . . . ��.: �32 ,�� "� � � . . � c� f �. ��lr. .. . . ! 1 � • 425��7� ry „� . � . 23.:88� � � �;. � �,� . ;. , � , � E3�, �� . . . E�8 DF�A11� :�FIELD 428.A�U .; � � � FQR L�T 14 � I 2� � . I ---- � `L`L . // � � _ .� �. . .. � : .Q1 , . . .. �25 �429 29' . � - �. � � � 421 , . � � � F2� , ,�2� �� . � .. //�� .k '��. � .� � .� . ". 'n. . . �L� ... . ' ' . . I . 421�.04 �1 : ��N�`Rp�9 X :;.� ; �- q.25 �g' � . . 1 1 � C�NTf�OL ' �!�RNER � , r .; . . �. .CENTERLINE 0� � � I COF�NER� / �� . � , _ 20' bRA�N EASEMENT � . . ` ,� � ' � � . � � �.. 1 I �:.� 438�. ' ..�. . FO.R L4T5 13 & 1!#�. � � � � f � � � . �� . I �. L4 . ,�q�. .�y. . � �: � � . ' ' . � � I , � � , .. . � � � / . .. .L5 `� �� 57EVE'�lU.�. WALLAC� & � � " I � '� . ,�4�� St�iEILIA G,. WALLACE. > � � � � �:17 •:L6 , � - � � � `v� . . Q.e. 4� Q�--.382 � . �,� L1 � , - 23.: ` 439.713\� / v ,�., / � / � �� , ��. �h� l� . / / � � L15. •:. ��9.41 ,. .,��,; . . . , � ! f. I �� E2�22.7�'." � �� ` � r' �.f � f i� � � � � �` � , . � � � ..� �� '' L14 i .: 4�3.59 ;,; �. � , .. . , . ' E20 .... � � �: / � CENTEfZLINE UF . � `�6 : . ^ �: i 10 D�AIN. . �o � ' .. f � . L13 : : � � , . . �,� 5�,, . i i EASEMENT '' ,, , . --,�"4�1,98' . �. . � . \��, f., FOR LOT 14 E19 . � � . ;:'� � Q'¢ : � � , � � ,,� ��_..�_„__._;.RRQPOSEtl f. ��C�{<r .�� ; . ) LAKE 422.22 yous�� . . . . ` .��. � 4+ . I._12 m .. � � . �� Gp �,, . � , . �, l_7 .. -- ------�- - _ f�_� _�-��..��-�.�..� L.9 � L.10 ' �a j , -`'''� �. L11 S� . LOT 13 '�'"� �. L 10 • � 2.4�2 ACRES � � / . �. �l / �-.-�-_. - r , �S �._._._._,.-- ,,� � /� �429-.48. : "�2b,,, . � c,, � �l>9 �'� , �' � � , •s L11� ,. � �L�ca. � ..F l,o . �/ .�p� ' o,r�, � � � �r' �l. � SO� RROPOSED 2S' �j � /' �� pO ' , ��i� s�,, �ious� . � �' `�' . - � . .. ..1. .. . . �O1 14 � �" � ` l_4T . � � � ,.� . - ' ��.. . : . . . ' � SITE �/ o,�� acR�s ,. . � ti��". f-ious� ELEVATIONS M. �A4<LEY JfZ. • �� . . . L8 �. ti�`'ry . � 26�--368 �, . . � �.. , . � � , . .r:__._:.--------�-""�-�� , ./ .. . � Scale: �� ' / 00 C2 . . . . ` � � ,/ TAtJGEPJT____T.._� -�-" . RADIUS , LENGTH - _�_�—'Y. . / , CURVE �.___-_—; .. - 22�05' _.11,03___-•----_ ,,/ . . . � � .C1 5�� ,60 - � , 48.13' _._._._._-- . -��z7 70 . �. , 95.81 0 Name ��ve. �t/u ��c+-� °t� Subdivision a ' Authorized State Agent ,� , `..._.�� ,` � f �� \� �, � � � � �� I��a��.,.-„-„ ��.�.11 I�3L�.�.11�]h,. Tax Map #_.�� Parcel #�� Section/Lot# /3 �i' —/ U �- Date , � , �� _� �.� C/[/�1�►ti12.n f ��i%"�11�� 11'"_�' �Q.�t� �--�---- I�e 2< aG�c,�Blt�Gl �1��o��'S ,2' •�� r��t n�i/J� P/'P.�,S'�1%�' -/�t6?i�i ��`r"/�'� . (/ ��t{i^d��f��'� ��^'�'t� �'r��r't�,�x�" , . � � �/�SNrt� �9� 5�� 46�� "��*�,�0 �iN� Ql� /!r�'r7r/�� / f � ' 1 ? ` � � l p�.,rr e f � �-� C%�/ ��-'`� �� i��'.S �!'�.. �.. `J � /'��a'I .>dI � ,..�. �,s,� � j"S i�11 . (nJ � ��n -^r.trVQ.c1 PG� C�'C'/?c�!�� 3%�.J On � �age.��J �r J 3 �llo� /� ou.--�QyG-�- l ��s s ��' , ��' �l�s are �,.�-,:� , y ,.,� � ./�� ( �JQ tn,�s � �� p' Gt �/-E'c��/'%p/''.��? �e� /!'J �I «'1-� /9'Sf � .i �. �- �e _��s'�i^r�t d �`? �n� I"G'f � /" P,/ f r�e � r��'I S•� � .� (,�l i � - ��'ca QS-e�� v2 � �1�{.� �l� �'n�� Se , '�S� 5/=P�t �' � � � � � C�n f/'�r �r�'� ��o i�rS� l D�'I• �f , �. L�no fa ��r�p� � ,r,s ' �'/�'s, � . /',� �. t�c�� " / ' ra � Yl �F� s'��it, (ilh6/P�' ►t/ /l ��4/��,� ,.� _ ' -- �,�-, ___ � - �, :� �. 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Oatb�t To Dists�ntiax +4" SCH 40 PP� Pip� "'� �� Z" SCH40PYC Pipe Valvs �� !]nat S�T�e� � Hi�t Watax Alarxn Lawl :, '. . �a. Sep�� .` . :.. , Hi�k Lev�l- Pa:e�p On ; •� . � ; �9apcs Lock . F7oat� • . . . ,. N`D r, Hola . • •• R.amovabla '• • ' � % Dr� (�P �1 F � r' Float'Tr� , . Lo4v Level -Pamp Off . � f . . • . �P ; - . �:.� S �. y. ' P:ecait Coacrete TaAlc �� CO�tg •' P[1HP RATING � . ; ; Matetial Stre »3500 P �loch ' I � " � ,� -• ''' Pump Mu�t Be Rated To Deliver ��'`.;�•� • �.. ' � • '. .+' � .• y � � ' 1•' 1 . ' • ' � a.s Calloas Per Hinute . � ' Agains[ Sp Feet QE Tota DO GAZ.L�NFU1�/IP T�TK Dynamic Head (IDH) . C�� /„sc�� %� f v� T� s� v�t/c��S rPpU,�'2o� << •e � � Profile View of Pressure Manifold for Sloping Site Installation (not to scale) Plan View of Pressure Manifold for Sloping Site Installation (not to scale) http://www.deh.enr.state.nc.us/oww/LOSWW/manifolds.htm 2/19/2003 �G': ��5�.: :rl�Ll.l�4 .��R 6�/B / �785L ): ?QG'_P3:�II� / K H� 4% . ..� 8uclnsnre � �at8i tlqht � , � �stall ? circuit corresian resistant o .scauaect svitcb • � panel does nat ' � �re a dead fronL :' .,•.: ;a . l �s aauaal �iscaanee�. �z: '•:�� / ote: fl breaker does �::c:•: � constitate a � . ` , sconnect) > 1Z' ta . fiaish qrade� �a�p �npplp eircni�' '� � �lara Circuit . ?ater iight ?eal � '� HydrauliL ceaent� • 5chedale ?0 ?YC � SapQly �— -- �— ��,qcs back plug and Receptacle — �—� ( s . 4z9 pressare treated � � post ar eqniYaleat 0 - t �cuttosian tesistaat 2' ainiana &as light Coadait . �>12' to fiaisti qrade puap snpplq circait alara eoatrol Rater fiqht Seal flydranlic Ce�ent Harness &zcess Cnrds — � ; 5etiedale �0. PYC • 5npplq.. . J��'� G� SimAlex Control Panel With Built In Alarm �nte; Yhis is UUt d HIIIIIQ . diagran! Consnit an Bleciriciaa! "'� Duct Seal . � �� 0 : L/,�/ . :,�cki�q S�.a�s �_ 3araess 8zcess �_�r�� gec�ptacle anst'be mutor rated �a�-Qaltage alar� ' conaectiea Duet Sea2 0 °A�IE �idI7 aCS� �J8 30QIIC24 21 :58 t_�:�12� liviag �rea �}f the dHe'?:sq ,aat in t�e cia�i space qaraqe o: ande_ a aabile hone; :he paeel aust be aad;5le and �isi5le ta spstea :sers Lackisq straps � : ��.�� ..� �� ., � � � �� 7��.��-��.��.�.I! IlE-3C��.Il¢II� WE�L PE�I'�' P�ASE S�� A'3"�'AC�E� �'L.I�N F�R WEI.I. S�"I'E ��OU'I' ay 18) �'a�c Ndap #: �� I'aYcel # �� '�'owinship A�pplicant ��U'C � ��1�� Subdisrasion: Se�rion: �.o� % � 'I'�e of �ater Su��iv: �Individual Communitp Public Res�uire�aealts• �5 �� _ Site Approved by � � Grouting App ved bp �J. ell Lo � W Well T g S � . Air Vent i �� Za .o� Hose Bib Co P rete fl�b ""�° �' � / Well I�g�ler, rw�-1�'� � W�ll A�proved �y- I�ate: /`" Z� -o X '�See Ate�,ciiesi 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 anp building foundation. Other condit+ons: PC�ID, rev. 09/07/01 . I8� � �� '�r�� .��.,.�� /��.� �� a � p��.� `�~ ^ `L/ � �� p�9 11��9.'�a ��+'n "'^'* �7Ln.�.�J1 ��"29.��GJL1. " """'�• U � � ' . Appiicar� ��J�- �VVI�� ' � . Operation Perrnit � � � � • System Type (ln Ac,�ordanc� With Table Va): .�� Ti�I1S SYSTEiN HAS BE�AI INSTALLED IN COMPtlANCE WiTH APPLICABLE NORTH CAROLlNA GEAIERAL STATUTES, �RULES FOk� SEWAGE,TREAiMEiVT AIdD DISPOSAL, : AND� ALl: C�IdDITi�NS ,.OF THE IMPROVEMENT PERMIT AND. CONSTi�!lCT10(d �AUTHO ON. ,' � � � . . . -� . _ .. . . . . . , - . , . . -_ .. / o �- 24-0 8� '� . . Au orized State gent .• - . ' � Date ' � Instailed By. �J � �M/ t� . . , Date: � � � ��v� �-�-5 lo� I�r �� .. -.��:� : :. ....: �-. _. .---. . - � . --�. • . .::- .............. .... . ... . . �- .. .. ._ .. ..._.. _ . .. .... �: . . � . - .. . � •. .... . _. .. _ ..-. .� .�g � :'��%�� i�2 ._'.. ��: ....._ .. ... . . .... . �`��' . ;C � < � « � � � �$%�,� s�c� �� 'r � r(s�� r �5�� lc----'i rPSSc�✓'e- _C� .� i0 CJ � �6��'y �A�,� ��( ,�rsn ,76�� ' ,� ,� ,� �ly V �'2 ��z . � ��r � prZ ` (��Z �� '1� �� - J ��,�Z,, �o'g`12 � � 4 � � (�� f��r � �, ��e�� hn��aY Y ��-�� p� c� f� �� -- �-� f-1 `� Pu�, f' lr� W�� s �tn�.� '�'�,.cc � . t,�� eQs�� s�a�l� r S�3�T9C Ts4NK 91VS��TiOiV C3�E��LiS'�' (T�e 99 -!� - Ta : Map #�� Parcz! ��, � System Type (Tatile Vaj � OwnerlAQpiicant Subdivision " Address/Lflcation SeclPhase Lot # pc�d re�u. 3113t01 � :: w _ �;:`; =-. �<:, --:�. - . - - - -_:-�--.- � . �/�p��y��y��q�p� 7l� D l � y '• 'a., rt � • L. ,.� `��%'' `:c .`•'3':: •.�' "s; ' uVw0.�1 UC! � J J. :�;: 1 �iC'.• K :� � - a��: _ V � ' . •Sl +. v _ :�_j..:,.t. =::��:�---..-.�_.--.---�..}._-�-.�=� =-` � ~�r: "` : � A . -- ��-�u«efK (ie (I I�f: �I,ny �:.;.- :��:=��.��Y=`.' . . ... _ . . _ . .. _ . :.:;.. _.. .�. :: �e��: 0� pa�I -7 - 3 n - o �ia<�-��.,��+;�-s.g�,. ¢a:�; 0 a . .. �ypIl� �: GV1U�6 � � 9 �1 C.� �i 1' I �iI'OHt � �� p3iCC� # IL1 � I.00ailOtl: � - Sli�1Vl.S1�1: Ol (1 I.Ot # • WCQ CO�C�IOII Distance Fromneare.st Pmperty Line (1V�inimu�m IO feet) ( S ��fro �Se�tic Sys�tn � fo feet) —�--- Total y �_ ft Yeld:� I D GPM - Static Wa#er LeveL- Z� ft WaterBeaziugZon� Depth g ft ZnS ft ft ft Dep�: Fmm � #o �_ ft. Diamebe�: ��_ in T`ype: Ciatvaniaed Steel �(i Weigi� iuctmess: � 21 Height above Ground: .� Z m- ; Driv+e Shoe: �7 Yes Na Any problem.s encotmtere� wb�e se�ting casing� Xes If "�►es" give reason: " (�ou� - . - _ • . No Nea� SandJCeu�t Concrete GTav.eUCem�nt - AnnuL'�r Space Width • mohe.s Water in A�mular Spac� Yes ' No Met�od of Gmu� Pnm�ed Pre�tt�e � Poumd Depih _ " to F� 11Taterials IIsed: No. Bags Portland cemeat ' Weig�t o� 1 Bag- . If m�tte (sand, gravel, �) - Ratio to ID Pla� Yes _ No 4 x 4 slab _ Yes I:mer. - .:,. I?ats Installed: Drilling Log Pounds No Grou� Insfalled by:- - Locafion Drawiug F�om 'To Rorma�oa . • O � /oc,,rJ e.� Sl�.I � - • ' . � - � � �,� . , - ; , . [ h�ereby c�tify t�t tl�e above� infa�rationt is comect and t�at this Rre11 was co�ed in acc�dance with regulatioms sct fa� by tt�e Person Caunty Hea18� Departm�t. . . 6�xtare of C.u�xcb�r �/�i'� - ID# �� Daie .�� 3 n- C� � _ _— � Pamp Instatime�t ' . e��a��: 13 c�rn�F�� l�ie�i I��;1 �,� sr�x�nx�: 3�-i � �� Z � � $ sra�� wat� ��1: $ °ttmp Make & ModeL• _(� e� S'�G/� �� Pamp Size an,d Ratm�- �� hP � P gpm I hcreby cextify ti�at i�is pump was instatled a�d ti� well head �compl� axord'mg ta ihe Persa� Co�mty Well R�ules in effe�t xi this date and fhat a oopy of this record has � p�+nvided to-t�e well owner_ . Pamp insNafler S�natare �".� � - �,�-�� D-O�P PC�D rev0U27104 North Carolina State Laboratory of Public Health Department of Health and Human Servi�es , P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Wallace, Steve Address: Plantation Dr, Oak Pt S/D Zip: County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street Ste C Roxboro, NC 27573 Courier: 02-33-15 Collected By: J WILEY Date: Location of sampling point: Outside spigot' (336) 597-2371 11 /25/2008 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 1:30:00 PM Remarks: Permit # A023 -181 � - `: Parameters Results Units Date Analyzed� Silver <0.05 mg/I 11/26/2008 Alkalinity as CaCO3 249 mg/I 11/26/2008 Arsenic <0.001 mg/I 11/26/2008 Barium 0.2 mg/I 11/26/2008 Calcium 74.0 mg/I 11/26/2008 Cadmium <0.001 mg/I 11/26/2008 Chromium <0.01 mg/I 11/26/2008 Copper 0.15 mg/I . 11/26/2008 Fluoride 0.37 mg/I ' 11/2�/2008 I ron 0.22 mg/I 11 /26/2008 Hardness as CaCO3 (Ca,Mg) 264 mg/I ., 11/26/2008 Mercury <0.0005 mg/I „ 11/26/2008 Magnesium 19.2 mg/I 11/26/2008 Manganese 0.07 mg/I : ' 11/26/2008 Sodium 16 mg/I 11/26/2008 Nitrite as N <0.10 mg/I . 11/2�/2008 Nitrate as N <1.0 mg/I 11/26/2008 � Lead 0.042 mg/I 11/26/2008 pH 7.8 Std. units 11/26/2008 Selenium <0.005 mg/I 11 /26/2008 Zinc 2.08 mg/I 11/26/2008 Date Received: 11/26/2008 Today's Date: 12/10/2008 Report Date: 12/10/2008 Ref: 16903 Login Batch: Re orted By: ►�" W Y�`�'�- P ��' J�"""' Sample Number: A682031 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria aze 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 North Carolina'State�Laboratory of Public Health Department of Health and Human Services P. O. Box 28407 - 306 N. Wilmington St. - Raleigh, N. C. 27611-8047 COLIFORM ANALYSIS - PRIVATE WATER SUPPLY Name of Owner or Tenant: Wallace, Steve County: Person Address: Plantation Dr, Oak Point S/D ZIP: Source: Well Type of Sampling Point: Outside spigot Collected By: JW Date: 11/25/2008 Time: 1:30 PM Signed By: Wiley, Jonathan B Analysis Type: Private Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27573 ' (336) 597-2371 BACTERIOLOGIC ANALYSIS . CONTAMINANTS RESULT �Fl Total Coliform (ColilertRoutine) Absent Sample No: AB14959 Date Received: 11/26/2008 Time Received: 8:15:00 AM Date Reported: 12/1/2008 Today's Date: 12/1/2008 �j (J Comments: New well permit # A023 - 181 . Person Co. Health Dept. ATTN: Wiley, Jonathan Brent ; 325 South Morgan Street � � � ,;�: %' -� Roxboro, NC 27573 = -�' -� `f ,,�� .r �. ^ , ., ,. � �.l � � � �, Courier 02-33-15 � ��" - ' ��. r'� �� 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 PERSON COUNTY HEALTH DEPARTMENT 5UBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT (� i� Dat o Inspection so �a� c 5r�y -o�} 7si8 System Installation Date Type �R. , s�roa.�► , ac. a Pronertv Address Aa3 � 8� Tax Map Pazcel # Instructions: Check yes or no for appropriate items and explain in spa:.e pr�vid�d for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and sutface water diverted ? Sepric tank needs pumping 7 Inches of solids: $,• Septic tank filter cleaned ? EFFLUEN'T DOSING SYSTEM: Require3 aumps presrnt & func*.i�nal ? High water alarm operating properly ? Floats, valves, etc. in good condition 7 Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose t c):'�.3 Elapsed time readings ? � Counter readings 7 1� Drawdown rate: ^ P YES / NO ❑ � � ❑ � � ►�� ■ � �� ■ ►� ■ � ■ !: ■ DISPOSAL FIELD: Evidence of efflue7t surfacing 7 ❑ Evidence of effluent ponding in trenches 7� Surface water effectively diverted 7 Diversions/sw.ales properly maintained ? [$( �egetative cever tn�inta�ned ? $� Protected from traffic/unauthorized uses ? '�j Distributiou uevices iii �ood condition ? [� Field free of settled or low azeas ? ffi .�-� C� ■ ■ ■ ■ PRESSUtZE DISTt'tIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessible ? � � ❑ Pressure head properiy adjusted ? 'Qj / ❑ COMPLIANCE: Compliant Non-compliant Needs Maintenance ►� ■ ■ REMARKS -� �b�ri�.. wc.tiL wP�s ��'c va u�cx.�� '�P.t��o �- •Qsu^o? '"�i��\` -'�iC �'� W��sC� � ��St'caC N.��.�5'1CL� +°�N�� +�.� 5'�. V1� 'Q4Xt�c.S • tiTlL1T1VIVHL CU1V11v1�i11 J: REt�h�p�, �5��'Y�o "�` J�Z� S� M�" "' •� _' Z�- S�P4.ESS 'R+o� �oP.Aw� �� D'�t{�lF'v�,� �ER ' Ov�,�ta��. . 5�"s�r.t� A4�J{�.'� �TO �a t� %4'Q �S1rs►p�. EHS �'•