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A23 201Application Date: .� S�" C} � ,� � � .� 7 :� Amount Paid:,�"� �1Cj �G��� , , ' ,-; ���, Receipt#: .5 3.ss' �,'.i G� ,.5 ,�<�S �?�5 I � i � �:'`�� �,c`�s- � ��� � -� � �' ���_s �" IP'I�I�:� �� ����� . �'�, - -- �C � �1���Y � ' �Ca�a^v*a.�.maa.�nna.¢��za.-�sa.�i.. ��L.c�.ta.IlQ�i.�ra. -(� � 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 #: c L;+� "13�� A ^ ���� `� lY(�j 2�JY�� �- 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� �� � �� � �� �`�� 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. _ � T �� �� "� • � I . Signature (Owner/Legal Representative): � � `�''�—'�' � Date c =' � � � � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ' ���i� ��� � �u �+��.�.9 �� i � � ��� b��� �� �'/' I •�I � `�J �.b. V � 1'L ��.-��o-,-����.�.��. ��.�.,.a� r�licant �!� �� �t�c� �23 °� c�^�l� Zo( �,o ��� �������� � �pra�e�esa�.��i� ��r�i ��li� �a�r x �`�ve �s l�% �ar�on 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 (_�. � . � . . -" � o 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����.���' �'�$� ���s;���� � " , .. - .. ��-�J f��oJa�� j-����c, �aHK � . . �� L�.�i�+i L7��.' A sGHY�4. �� 8 i�HIl� �'� 63 � . ��d: �a� �,r-� 1$[�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� � � � : -_ . _ .�, w /1 nw _ 1 i n� �. /� 1 a✓:�i � �l �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��.- � ,. .. . . � ,�-- � . e i ��.:�., .,� , z. K, � ,., ;: :. _N � � ���� 1L�la1L�n7i'�Im��ICC11��.J1 J.� �ic��l.Jlt�� 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 r a�� ":.� �.. �w,...e.,, _, ., ? Y ,.. _ ... ���� JS 1.i ��rn�a7T"�IC��ILc�ICn��.11 �c��.��� 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 � ��> � � � ,��?� �,� �'-� .\ `� `� � \ ' � \ "\, - \ \� � ��� �� � � `� � � \ �,���� '� , o � � , � `�. ` .� �� �-..: �.- .- �-��--vi-. __/ � . � . . /, �, �, / . � i � ' � i ey.:»i . �/ , � � � ; � / ,' . � � i ��., _, l"� � � . - ; / i /, / �' l I`] / o..c . / , , , i�/ �/ m�� � ^ /� ; �/.. // '� / .m / / � ,��' � � ,,U /� ,_ � � � / /� ''��/ ,'� �� • �/ t� � �/����� �'�' � ..-�� �' '�� , �� ,/ �i % � /�% . . � �.� � � U � .�,; i ; � i '' � . o . ,,-�. . 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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.� 'r' 3: � ! ' ` ;�; ! � � \,� P�T�ARY S�Y.s�I�i I� 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 , \\ f� �` f �,/ � � , : �- ., . ,.. . „ ... •� : : ....._... _. � . � , i � . �.�. _. O . ` ._.__.__._�._.. ._. . , , � ��,\u ` .. , ._. .... - 3 <�,�x, 1 � -� � : .Y �' 54,1 - .� , �, ; ;`�- _ _ _ `� � �° ' �.\ i; �g� ` ..::'� \ ��� y � . � \ �,•....,, - . t T�V�`[`. .. . . . . , 1`��.,., �_. ! ...\` \ ` ��� �� `: 1jJr O �.� � � � . . .. . . ... . ... .. . . � � � ...._ � . .. ... . . . . . 1... ` ' -_..__ _ � Q ..._.... F 2 ,�- �- �L�i� {� ._ _ _ , ._ _.__ ________ ___ . \.., � �` ; . � ' . .� _...r�. � l I \ �I' .�t;�.�l�� � ��, __ _ . .� . .. . � � �� 0 �� � ,� \ ` _ � ���� , HYCO'� �.... � LAKE �, ...,.,'° „� 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 - --, -_-- --- _ _ -- . _�_,�: .. . ._ -- ', NOV 2 9 2010 ''�',I �x :_---_---__ � 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 � : �,� � C�- ; � � / �k C�✓` (Q� 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