A23 201Application Date: .� S�" C} � ,�
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Amount Paid:,�"� �1Cj �G��� , , ' ,-; ���,
Receipt#: .5 3.ss' �,'.i G� ,.5 ,�<�S �?�5 I � i � �:'`�� �,c`�s- �
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-(� � r-'`'t�� Application for Services
fSentic Svstems and Wells)
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile. Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement)
$225.00/$125.00
Tax Map:
Parcel #:
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Services Re uested
Construction Authorization
ee is de endent on the e of s:
Permit Revision
$75.00
Repair of Ezisting Septic System
No Charge
Important: If the information in the application for an Improvement Permit is incnrrect, falsified, or the site is altered, then the
Imnrovement Permit and the Autliorization to Construct sliall become invalid. _
1) Services ues�ed b.�
Name: "''' Ci O �� -�� •
Address: �:: p � ' r �` n � •sY - u�
�' �� � • � �� /
Phone # (hom�:�.��' ' �� �r �� I �
f�cv'o�c/cell): J.� � s .� e.� �J�
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2)Name a�address of currents,wner (if different than applicant):
Name: � ri�"��-t.�� �5 �a �'�'. S'��
Address: `' _
3) Property Description:
4) Proposed Use �nd Type of Structure:
Residential �� Bus�iness/Type: . Other
Number of bedrooms � / Number of people served (seats/employees):
Basemerit: Yes No (with plumbing: Yes No _)
Garbage disposal: Yes No
� Water Supply:
Private Well ��(Proposed Existing _�
Community Well: Public Water Syste�}
Are there on the adjoining properties? No �/ . Yes (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying tlzat the property is ready to be evaluatec�
I am submitting this application to request services from the Person County I3ealth Department. The
information provided is accurate. I understand that if any site is altered or the intended use changes, all
permits shall become invalid.
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Signature (Owner/Legal Representative): � � `�''�—'�' � Date c =' � � � �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Type or Facili-ty: 313 �. New �C Additi�n .. ���� �a��x��y �P�(
� of Oc�upants/ir *1C # of Be�rooms Projeste D"y Flow 3� g.�,d.
Proposed Waste�atez System: � i ��t �'� G!. : - h2a�� y` Type: ��
Prop�serl Re�air. ' " ��-, d— Typ�: �a►.
Pezmit Con�itions: �� �d �.J 4 �I �%qvi ��eeS. q' K � �c-4� r► �2✓'� � t� S . � - .
_ '3�t,.P a� ,Y ;,,_� / J�i-r►zr Cu,., t' ?� . . �
�wner or Lega1 Represe
Antiiorize3 State Ageu�
Date:
Dat�:
'I7ie iq�,7a„�� of this pemrii liy the Healti� Depar�nent in does nat guar�e� the ,'.n,�a„�a of other peaniis. �f is the responsibilaiy of tlie
aPPli�aP�Y owner m in s�e ti�at aIl Pezson CauIItp P3aanin.g and Zonmg and Bu�ing Inspe�tions re� aze me#. 3'iai�
�np���ffi��# �r,r�at is saabjea:t tm �evo�a�s�m if tlae ss� pi�m; �pT��'�`• tis� iatte�de:3 �e c3�ag�,s. �3ae �rv�e�ae�t �e�nmat i� ss�t
a�te�t� i�gr a c�gs sn o�vnaer"si�� o�f t�� pragser�, i�aas pes�it vaas is�uaed � a��Dianc� ��a tbe ��o�isiea� of ih� �T�r-t� �C���, .�
`��ws aaad Ru1es f�r ,�esvac...ee ?'re�rie�a�' � .�smosal ,�'vstesras' {15�s I�i�� 1�A .19�0). I�eeifrhes� �ea�an ���,�., mm��:t?�.�.': ':
��via ��ent� �eaI#h Sg�e�i�las# avarrants t��t taae se�tic .*.� sy�sm vviil e�n��� tm fun�t3on s���aaa�aiy i� tflne fastnre�or:#���
th�wa�r supp�y w�l rr.main �Sotabie. � • �
� Aua�aoa�a�io� t� ���as�ct ��v�at� 5��i� (�,�� �a�r ��+d�g ����� �
*. Ses site plan cnsd additianal attachmen�s (_�. � . � . . -"
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Prap�sed Wasrewatar System:�`:.P �»` 44 ��i � w��t"e -�ir�,'� Ty�pe -�� 'W ast�wa.ter k 1�� �� g.p.d.
New X Re�air F�panszon � .- S�� �,��8: 2� g.}�.�..! $ 2 .
Type ofFact�ity: ���IPPS, ' Basement�Yes _No .
Yl (Nu� /LIc�Q � � �D � .'�7����.���' �'�$� ���s;���� � " , .. - ..
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�� L�.�i�+i L7��.' A sGHY�4. �� 8 i�HIl� �'� 63 � .
��d: �a� �,r-� 1$[�O �a� � T��i �e�a � � . � �a �����a �e�a�a �P flaa � . . .
���cia �d�a — � �i� ��ave�: � � � �,�����na '�'r��3n ����a�i'so� 2 � u
����on: �i��'baH#ao� �o� �er_ai��iribn�fl�� ��res�e ��o��.� �G�vttK��� h�'�'
��n, ���tio�:' -��S �l� u�Ka y�1 q;�l� %1�► A�S _ ��i� � vl-0ax �' L�'jl�Y� � � � : -_ .
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�m�9a��e� �ta� Ag��. _�`�
Permit Fxpiration Date:
Date;
. T'.ae tyne oi syste:n p�it�3 is Conven�cnai A_cVti te ' A1teYnaiive. I a��s�t t.he 5qe�ifications of the
P�?• '
�rsa�-!e' ��a ���gAs��#���e: �at�: � �
��—�aUo,,-(,`r"C 5 S'�✓v� PC�rev. i'llOr��.-
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CLEARWATER S/D
P�RMIT CONDITIONS
Information for the owner:
nsuring a healthy environment
1. Before the operation permit can be released a copy of the signed certified operator
(ORC)contract must be given to the health dept. (a contract for operation �ii1d
maintenance with an American Certified ORC shall remain in effect for as long as
the system is to remain in use.) The ORC must be both a Grade II licensed
wastewater treatment facility operator and a licensed subsurface operator.
2. Grass inust be established over the drainfield area and cut when needecl.
3. Caution must be used concerning volume of water entering system and what is
put down the drain(ex. Grease, personal hygiene products, cigarette butts)
phone 336.597.1790
fa� 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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2.
3.
CLEARWATER S/D
PERMIT CONDITIONS
Information for the Installer:
nsuring a healthy environment
System shall be installed per approved engineered plans.
Contractor must be certified by the drip and pretreatment manufacturer in order io
install system.
Contractor shall have a set of approved engineer's plans on the job site throughout
installation.
4. Pre-installation meeting mandatory (Design engineer and drip/pretreat�l�ent
inanufacturer rep. inust be present).
5. Contractor must re-flag drip lines on contour after clearing and have layout
approved by health dept.
6. When clearing drainfield area disturb soil as little as possible.
7. No site work should be done under wet conditions.
8. Contractor, design engineer, drip and pretreatment manufacturer rep., and
certified operator must be present at system start-up.
9. Before operation permit can be released a registered profession�l en�ineer or
certified designer and drip/pretreatment manufacturer rep. must certify in writiiig
that the system was installed in accordance with the approved plans and
specifications.
10. All tanks must be accessible from grade.
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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W�+ LL PERIi�IIT (New�Repair�
Tas 1VIap: ��3 P rcel• Zo �
Subdivision: r��V
Applicant's Name: � /C�S�-
lddailing Address:
Lot: �
Phone Numbers: H� -4+� - q (���31�- 213- 233� �w)33(�- 5g�-5a3o
cataon f Prope
vj/�t`�uP�Q� � • —'l
I'ermit Conddtdons:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.
3) Permits ex,�ire � years fr�om the date of issue.
Otlier Conditions/Comments:
Permit issued b�:
I'
Date• 6 0
C�12T'i�'ICA'I'E �F COMPLETI�II�T
Neyv Well Ins�ection:
EHS/Date
Location: 75
Grouting: - 23 - ��
Well Log:
Well Tag:
Pump Tag: �
Air Vent: �
Hose Bib: ✓
Casing Height:
Concrete Slab:
✓
�
Well �riller: �Qvne�-�,
Pump Installer: � �
Well Approved by: t'v� �C �'''vP✓
Date Sample Collected: � f- ZZ'�b
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
L,iner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
Date: � '% ��
Date Results Mailed:
Phone: 33b-�97-1790 Fax: 336-�97-7808
8/1/08
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #�( 1° r—�
1. WELL CONTRAC R:
ip ,/� ` /1
n �
Well ConVactor n ividual) Name �
Bamette Well Drillina Inc
Well Contrector Company Name
611 Barnette Tinaen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code
3c 36 � 599-0015
Area code Phone number
2. WELL INFORMATION: �//
WE�L CONSTRUCTION PERMIT# �O�C /'l .--�23
OTHER ASSOCIATED PERMIT#(if applicable) �n!/t.G � '�"--=--�-�..
SITE WELL ID #{"rf applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRIL�ED � ^�Z-' � D
TIME COMPLETED ��JD AM ❑ PM 4�
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
; Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diam/eter Weight Materfai
� Top_�Bottom�Ft. � ( � sl7e-L� ,�L _
; Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Material Method
� Top_� Bottom _O Ft. Sand/Cemenl Poured
Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
_ Top Bottom Ft. in. in.
4. WELL LOCATION: 70. SAND/GRAVEL PACK:
/1 / Depth Size Material
CITY: I,UJI�l��lShA/�` COUNTY Sq�l ; Top Bottom Ft.
(_l Q�,/Wa7Li ✓ ��(. �jY"" y Top Bottom Ft.
(Street Name, {Jumbers, Community, Subdivision, Lot No., Parcel, Zip Code) . TOp BOttOm Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat pRidge ❑Other
LATITUDE 36 °_' " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 ° ' " DMS OR �X.XXXXX)(XXX OD
Latitude/longitude source: �PS pTopographic map
(IocaGon of.well must be shown on a USGS fopo map andaKached to
this form if not using GPS)
5. WELL OWNER
, .73�6 e� S�
Owner Name
l ,�PCt/•✓tt�e/ �n_L �T'_ �
Strefj t Address
4�ot�o�o li%. C- � ?� 7�
City or Town State Zip Code
c��, .�`� 7- 3 Z � `�
Area code Phone humber
6. WELL DETAIIS: ��
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: � FT.
(Use "+" ff Above Top of Casing)
d. TOP OF CASING IS � FT. Above Land Surface'
'Top of casing tertninated aVor below land surface may require
a variance in accordanoe with 15A NCAC 2C .0118.
e. YIELD (gpm): _� METHOD OF TEST BIOWCI ZOfTI
f, DISINFECTION: Type �'iT�'i anount 1/2 CuD
11. DRILLING LOG
Top Bottom
�/ 2�
?� � �( Yo
/
/
/
/
�
/
/
/
/
i
12. REMARKS:
Formation pescription
� ,l<
o �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS 6EEN
PROVIDE TO THE WELL OWNER.
� 6-�v
SI T RE OF FIED WELL CONTRACTOR DATE
a /� �'^
PRINTED NAME OF ERSON CO S RUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300
Form GW-1a
Rev. 2/09
'� I
���r. sf - ���.���
' ?�_
�, ,,,, '�.., � � � � � �
I� �n�na-��n.�•�,-�, a�aa��.Il I�3L�.s�.I1�I�n.
Operation I'ermit
Applicant: /lGy � �
Location:
� a� � n �
Tax Map �� � arcel # �� �
Subdivision C �-eA►'ul R�
Phase/Sectoin/Lot #
# of Bedrooms
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.
System Type: (In Accordance with Table Va): �0.
Initial: �- Repair: Expansion:
.__---- � - - - �-- - . __ . --- - - -- - - . ----- ---- ---
- - ,,� v✓`-� - .
REHS/REHSI
,�,e�-e l�%s
Licensed Conhactor
Product: Yure� '�����"�'' �
Qj'1/i�%i CA'cil r� � I 1'r i� �t"�j � vl
. . _ _ _ .-. Io. ! �� --- _.._ _ . _
Date
��?!�
Date
Scale
.�
�� f r, � � Y�� ,'.
� '
L� o� sf�S��
��
c�rT ' �/
Line Len th
Total
T
,
�
�
Tax Map: ,� Parcel #• ap �
Septic Tank System Checklist (Type II-VI)
Se tic Tank InitiaVDate
State ID & Date: �
Capacity:
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Mazker
Distribution
=D=box (levels set)_ _ . . __ ___ - __ _ . _
_ ...._
Serial
Pressure Manifold
LPP
Notes:
t
System Type: �
.,
Nitri�cation Lines InitiaUDate
Trench Width: ft.
Trench Depth: ft.
Total Length: ft. �
Minimum s acing: ft.
Rock depth/quality
Dams/stepdowns
Grade (< .25" in 10')
Cover (6" minimum)
Setbacks
From wells
- -
.
_ rope � rries ---- -- ---- - - -
Foundations/basements
SurfaceWater
Other:
Pump System Cliecklist
Pum Tank InitiaVDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (if applicable): �1�Q�7
Notes:
Tank Com onents InitiaUDate
Pum model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Ala�m float (6" separation)
Anti-siphon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Length: ft.
���.ss- ���..���
� � ����
���aa-��„-„-„ ����.Il R 33L�.�.IL�I�
Applicant:
Location:
J Operation Permit
�
System Type (From Table Va): v Product (IIIg):
Tax Map �3 Parce # �
Subdivision � a
Phase/Section/Lot #
# of Bedrooms 3
. 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.
(Autho ' ed Agent)
(Li nsed Co ctor)
C`�
. �:C;
�-�Zs
2_�20
3-)f�
�( �I �5
S-I�o
(� -�io
1,��, (;�e�a
��t �� r,
� D �
r �'
Scale: b� r��,
��,,�
_ �ecK
���' S,23-�0
� SB� Nh�
�Ai U- �
�'> 5 j' DAF -100�
PT�3(�3
C �l (-c�
(Date)
(Date)
Tax Map: Parcel #•
Septic Tank System Checklist (Type II-I�
Se tic Tank InitiaUDate
State ID & Date:
Capacity:
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box levels set)
Serial
Pressure Manifold
LPP
Notes:
�
System Type:
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Boz
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV +Systems):
Notes:
NOTIFIED BLTILDING INSPECTIONS:
(Revised 12/09 BH)
Tank Com onents InitiaUDate
Pum model:
Block (4")
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Length: ft.
Copy of OP e-mail Date:
Smoky Mountain Geology
Lynn Mann, PG
Certified American Perc-Rite Drip System Designer
131 Carriage Drive
Fairview, NC 28730
828-273-4453
Person County Environmental Health Dept.
Attn: H. Kelly and Adam Sarver
325 S. Morgan St.
Suite C
Roxboro, NC 27573
336-597-1790
Re: Lot 4 Clearwater As-Built
Adam,
The system was installed with 9171inear feet of drip tubing, which exceeds the minimum
design requirements of 9001inear feet. Please see the attached as-built schematic for the
actual run and lateral lengths. The pressures measured during the dose and flush are
adequate for system performance according to American Manufacturing guidelines. The
minimum flush rate required with 9171f is (4 Lat x 1.59)+ 4.5 gpm dose = 10.86 gpm.
The measured flush rate is 11.8gpm, so it exceeds the minimum required to maintain 2'
per second scouring of the lines during flushing.
Overall the system appears to be installed and functioning as intended.
I have enclosed one copy of the as-built drawing for your records. If you have any
questions please don't hesitate to call.
Lynn A. Mann
; ,
� � AS-BUILT SCHEMATIC FOR
� � � � � �/� � �,,� 360 GPD AEROBIC
�/ /' � � % � _ SUBSURFACE DRIP SYSTEM
� '� � � . j�/� i '� � LOT 4
',,/
,�� ,' ,�' ' �'' " ' ,i' %� � ` ' CLEARWATER SUBDIVISION
'/ � � DF ' �OT, 3 �, � ,/ " ' � � i � ` SCALE: 1"=40' DRAWN BY: lM SHEET: 1 OF 1
N ' w "/; � % ' � � '�f � / �� ;- � DATE: 10/13/10 JOB NO.: 0805 OWG NO.: ASB-1
r '
; � ''� � ; ,, �- � • ��' � , �� (�1 4" FVC GRAVITY SEi9ER LdPiE.
� �l, � �/ � NflR�iECO SiNt�iJLAIR HTO—KII�tE'PIC bt}U
/ 'i . �
�
� , � // / � GF'D i�A�PE'6YATEF2 TFtEAT1liEN"f SYSTEM.
� ,% f ' �/ � � / � � / � ' ` / ' � F'tJ�i' �A�Ii�.
, / / '/
� , � � Pi{3fl:��Cti fi� ': TC�t F'�i,'C—
: i / � ,' �' C(iFd�2t2L P��,.t3�%5.
} , . ,�� �" , � �' ' �5 15 GPM 1fASHDOAN UNTf for '
f � �> / �' %� / American Manufacturin� PisRC—I2ITE
��� ' / DRII' SYSTSM.
' ���t ' � DF 06 1.5" Sch 40 PVC
�,I � GRAVITY BACKIPASH RETURN LINE.
, �,; ; ,<� � , f � r LOT 5 � ��r:� ������� 8���;��z.�
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r ' i ` { _ � __"� ` � 3 HDR: 36C} GPD
, i. . , r .. .� _ '� `\ i•.. �
� '`�� �. LTAR: 0.2 900 LF REQUIRED
`F — '' '�� � . `�;. . � PRIiviARY SYSTEM INSTAI.,LATION:
F9 � � � 917 LF INSiALL,ED
SYSTEM DE'SIGN: s`� �' '`t, PRIMARY
:` �,15' WASTEWATER
Smoky Mountain Geology F�i�, � ZONE 1- DRIP LATERAL
Lynn Mann, PG ='� PI�MP LINE RUN LENGTAS
Fairview, NC 1��� EA�Et�dENT � �,�� � ��g�, � ���
828-273-4453 ;-' P.C.'�1'� �iTr� � ���
l,r= PG. 632 � '�c��°��a w��
SYSTEM INSTALLATION: -�.-.. _ � „_ ���� � g��,� ;� ���
: � -�
Jimm Lewis & Sons ' ` � �
y : �' ��[�� � i.��
Retrac Lewis �€��,�, R �t�
Roxboro, NC ;,,'; LAT 3 RUN 5 110
336-598-1704 �`` SYSTEM START—UP RUN 8 110
SYSTEM SUPPLIER.: :� �: PRESSURES ZONE 1 TOTAL 220
Carolina Aerobic Systems rr `r' DOSE FLUS �T � �� 7!12
Randall Nelson � '' ` ��� � �1�
Ha esville, NC ,�' S�pply: 53 Supply: 30 TOTAI. 222
y f �` Re turn: 50 Return: 8
828-835-2332 �� TOTAL 4 LATERAIS 917
,i 4.5 GP�M 11.8 GPM
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Thursday, September 02, 2010
Mr. Haroid Kelly
Person County Environmental Heaith
325 S. Morgan Street
Roxboro, NC 27573
Caro�ina �erobic �jystems, I��.
Re: Certification of installation
Mr. Kelly,
PO Box 1413, 163 Highway 64 W, Ste 9, Hayesvilte, North Carolina 28904
Randall: (828) 332-7221 Michael: (828) 332-1818
Facsimile: (828) 707-9463
Pretreatment Systems � Drip Systems • Direct Discharge • Effluent Pumps • Grinder Pumps • ConUd Panels
Recircu�ating Sand Filters • Low Pressure Pipe Sewage Systems • Lift Stations
Single Femiiy • Muiti-Family • STEP Systems • Community Systems up to 1,000,000 gallons per day
American Manufacturing Perc-Rite Drip System
This letter is to certify that the waste water treatment systems installed for lots 4& 5 in the Clearwater
Subdivision, Semora, North Carolina, consisting of an aerobic drip was installed by in accordance with
both the manufacturer's and the designer's specifications by Jimmy Lewis & Sons.
All system functions have been tested and are operating within the designed parameters. For lot 4, the
dosing rate has been calculated at 4.5 gpm and each dose has been set for 720 seconds (12 minutes) for
a total of 54 gallons per dose. The system, under normal usage, should dose approximately four times
per day with a standard rest time of 360 minutes. Additionally, the flushing rate has been caiculated at
11.8 gpm for a total flush volume of 142 gallons.
For lot 5, the dosing rate has been calculated at 4.8 gpm and each dose has been set for 675 seconds (11
minutes 25 seconds) for a total of 54 gallons per dose. The system, under normal usage, should dose
approximately four times per day with a standard rest time of 360 minutes. Additionally, the flushing
rate has been calculated at 14.4 gpm for a total flush volume of 162 gallons.
As requested, attached is a copy of the service contract between Carolina Aerobic Systems and the
homeowners. Ms. Lynn Mann will submit a final "as-built" drawing within the next 10 business days.
If you do not receive the "as-built", or should you have any other questions, please feel free to call me at
your convenience. We appreciate the opportunity to serve the citizens of Person County.
Sincerely,
. �,,.� �.r
Randall G. Nelson
Vorth Carolina State Laboratory of Public Healtr 06 N. W?m�ngton St.
Environmentai Sciences Raleigh, NC 27611-8047
htto://slph. ncpublichealth.com
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH BOB ROSE
325 S MORGAN STREET CLEARWATER, LOT 4
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES112310-0063001 Date Coilected: 11/22/10
Date Received: 11/23/10
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 3.0
Sample Description:
Comment:
Time Collected: 2:45 PM
Collected By: J. Smith
Well Permit #: A23-201
GPS #:
New Well 1(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 86 mg/L
Chloride 50.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.21 2.00 mg/L
Iron 0.16 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 34 mg/L
Manganese 0.17 0.05 mglL
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 7.3 N/A
Selenium 0.020 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 34.00 mg/L
Sulfate 46.00 250 mg/L
Total Alkalinity 295 mg/L
Total Hardness 350 mg/L
Zinc 1.30 5.00 mg/L
Report Date: 12/02/2010
Page 1 of 1
Reported By: 7�� i�ucg
- --,
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_ _ -- .
_�_,�: .. . ._ -- ',
NOV 2 9 2010 ''�',I
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North Carolina State Laboratory Public Health 3 6 N. W m� gton St.
Environmental Sciences Raleigh, NC 27611-8047
http://sloh.ncaublichealth.com
M i cro b i o I o Phone: 919-733-7834
gy Fax: 919-733-8695
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
EIN:566000331 EH
StarLiMS Sample ID: ES112310-0116001
� ������� ������ ��� ����� ����� ����� ����) ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID: 22628
GPS Number:
Sample Description:
Comment:
Name of System:
BOB ROSE
CLEARWATER, LOT 4
Col lected: 11 /22/2010 14:45
Received: 11/23/2010 09:03
Sample Source: New Well
Sampling Point: Well head
J Smith
Angela Heybroek
Well Permit Number:
A23-201
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert
E. coli, Colilert
Report Date: 11/24/2010
Present
Absent
Explanations of Coliform Analysis:
� .� , .�
�
Joy Hayes
Joy Hayes
11 /24/2010
11 /24/2010
Reported By: Joy Hayes
�;- ����,�,�,'
��� �
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.
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
�--�----��-1_�___ �'a? �t o
Date of Inspection System Installation Date
522 �1-�►--�aa-e,r �� . �.��-
Property Address
�
Type
��
�3 20 �
Tax Map Parcel #
Instructions: Check yes or no for appropriate items and explain inspace provided 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: YES / NO � �S
Evidence of leaks ? ❑ � �r,��� r-
Tank risers accessible, free of �
infiltration and surface water diverted ? Q /� � s.Q I' 1�e a�K1� ��jy��
Septic tank needs pump►ng ? / 'rT ' � � ""� ``"`��
Inches of solids:_�
Septic tank filter cleaned ? � � ❑
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ? ��
Inches of solids(pump/dose tank):�
Elapsed time readings ?
Counter readings ?
Drawdown rate:
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ?
Diversions/swales properly maintained ?
Vegetative cover maintained ?
Protected from traffic/unauthorized uses ? �
Distribution devices in good condition ?
Field free of settled or low areas ?
o jlu� C.�,- ; � D 3�
❑ ��M � c � ( ���ZM %SSSeC
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iv� /t'I�c�: S2� l -�j
l � �Q✓�'i01/'e
/
i �im�S
/ ❑
/ ❑
/ ❑
/ ❑
PRESSURE DISTRIBUTION SYSTEM: _
Tumups/cleanouts/valves/taps intact &
accessible ? � ❑
Pressure head properly adjusted ?. �❑ VIQ
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
ADDITIONAL COMMENTS:
Ye
a�e
� l IR,,, �►- e�s `�
W f I ✓1 �+'�i ✓l �f � `�'t
� � ��� ��7 ��
r��,��,'-�- �vQ s-(e�� 1 er
� DAVID BRANTLEY & SONS I
WASTEWATER TREATMENT INSPECTION REPORT
SYSTEM OWNER: OPERATOR: 'Admin;Admin
Haa ; Jeff CERTIFICATION: -
ADDRESS PIN#
b245 Covin ton Bend Dr. ' ::' TAX REC:
Ralei h,NC 27613 /�2� —Zo �
/'
SYSTEM OPERATOR:
DAVID BRANTLEY & SONS
DATE OF THIS INSPECTION: 5/18/2016
DATE OF LAST INSPECTION: 11/4/2015
Y N REMARKS
FACILITY:
Type size and sewage flow in accordance with permit X
TANKAGE:
Risers accessible, surface water diverted? : X
Risers structurall sound, waterti ht? X
Sanita tee in ood condition? Effluent filters cleaned? X
Slud e de th/appearance , level acce table? 14
Grease Trap: X
EFFLUENT DOSING SYSTEM:
Slud e depth/ap earance , effluent ap ears clear? 0
Re uired um s present, operatin , and c clin ro erl ? X -
Hi h-water alarm resent and o eratin ro erl ? X
VenUfloats/pipe/valves/disconnects in good workin condition? X
Control panel/electrical com onents in ood condition? X
GROUND ABSORPTION FIELDS:
No evidence of effluent surfacin /reachin surface waters? X
Minimal ondin in subsurface trenches? ' x
Surface water diverted around fields, no depressions? 'X '
Line cover/ve etation ade uate/maintained as needed? X
Protected from traffic, destructive uses? X:
Distribution devices accessible? `X
Distribution devices in ood condition, workin ro erl ? 'X
Repair area ro erl reserved, maintained? X
Turn-ups/cleanouts/valves intact and accessible? X
No effluent standin in lower laterals? x
Laterals free of excess solids, flushed as needed? X
Diversion Ditch/Berm in qood condition? : X
COMMENTS:
MALFUNCTIONING
NEEDS MAINTENANCE
STRUCTURELY NON COMPLIANT
COMPLIANT
Flow 65424. Cycle 1265. Hours 244.41.
High 37. Peak 66. :' Flow to field 5.
Flush 7. No consistancy