A24 144Application Date: i� lU'Z`i—l�
Amount Paid: 0� 00 ��_
Receipt#:
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Tax Map: Z
Parcel #:
� Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
�200.00/�300.00 (if> 600 end) (Fee is dependent on the e of
� Mobile Home Re lacement or Buildin Addition u Yerm�c xevis�on
$150.00 (if site visit re uired) $75.00
Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charee
1) Services Re uest
Name: � �f' Phone home): '" `- r%�
. _f�Address: i (wor cell - 7— 0
S� a 3
2)Name and address of current owner (if different than applicant):
Name: � �
Address:
3) Property Description: Lot Size: %u.e�, Subdivision: ��z�'"�� Lot #:
A�d ess and/or direct' s to P operty: -- �
�
4) Proposed Use and Type of Structure:
Residential Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No
5) Water Supply:
Private Well ro ose Existing _�
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes �(please show location on site plan)
,
Note: A completed apvlicalion must a[so include:
➢ A pladsite plan of the property that shows properly dimensions and the size and location of all
proposed siructures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluaied.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid. .- rd � z� —1 a
Signatu e wn egal Representative): Date :
� v -
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
•,
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 326� ^ �
1. WELL CONTRACTOR: �I
I �a�.v�s �ain� T''�
Weli Contractor (Individual) Name
Bamette Well Drillina Inc.
Weil ConUactor Compamr Name
�11 Bamette Tinaen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code
3c 36 � 599-0015
Area code Phone number
2. WELI INFORMATION: q
WELL CONSTRUCTION PERMIT# � %�2�
OTHER ASSOCIATED PERMIT#(rfappiicabte)�A�LC I 77
SITE WELL ID #(d applicaWe)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATEDRILLED �- 31^ � (
TIME COMPIETED 301� AM ❑ PM [�/
g. WATER ZONES (depth):
Top 23 a Bottom �s Top Bottom
Top �"� Bottom ZJ'� Top Bottom
Top Bottom Top Bottom
Thicknessl
7. CASING: Depth Diam/eter Weight Material
Top O Bottom .�Ft 6�[� -2� �
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
ToP � eottom � Ft. Sand/Cemeni
Top Bottom Ft
Top ' Bottom Ft
9. SCREEN: Depth Diameter Slot Size
Method
Poured
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
4. WELL LOCATION: 10. SAND/GRAVEL PACK:
` . Depth Size Material
CITY:��jnf9 �7PMo✓i� COUNTY�iSD�) ; Top Bottom Ft.
���1'�i' (�ee �%� ( d � �,� � Top Bottom Ft.
(Street Narsle, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) . TOp BOttOm Ft.
TO�POGRAPHIC / LAND SETTING: (check apprnpriate box)
0'Stope ❑ Valley ❑ Flat ❑ Ridge ❑ Ofher
LATITUDE 36 "_ " DMS OR 3X.XXXX�UOCX DD
LONGITUDE 75 "_' " DMS OR 7X.�CXXXXXXX DD
LatitudeAongitude source: �PS �Topographic map
(IocaGon of.well musf be shown o» a USGS topo map andattached to
this form if not using GPS)
5. VYELL OVYNER
f�-i�n IQ�n,,�.er
Owner Name
Q�R �e r-�r� l d' L1� �
�5t eet Address
� r�, %l�, � . 2�sY3
City or Town State Zip Code
3c 3L � S`�3-4��1�f
Area code Phone number
6. WELL DETAILS: /�,� �('�
a TOTAL DEPTH: �"�U T`
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO.�
c. WATER LEVEL Below Top of Casing: 25 FT.
(Use "+• "rf Above Top of Casing)
d. TOP OF CASING IS � FT. Above Land SurFace'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): `7 v METHOD OF TEST BIOWfI 2OfT1
f. DISINFECTION: Type HTH /�mount _1/2 CuD
11. DRILLING LOG
Top B9ttom
�D � 7 f]_
1t2_/ `3S
�_/ � v
/
/
/
/
/
i
/
/
1
�
• 12. REMARKS:
Fortnation Description
Topso � I
��� /
1'iYiJ/df-IL
Material
� 1 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 BEEN
� PROVIDED TO THE WELL OWNER.
� �-3141
. ;n,.,r- � �.
: SIGN TURE OF CERTIFIED L CONTRACTOR DATE
��'�,v�� C. %��i ✓ri.. e '{ i� �-
. PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processi�g, Form GW-1a
1617 Mail Service Center, Raleigh, NC 2T699-161, Phone ;(919) 807-6300 Rev.2/09
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SITE SS�TCH
Taz Ma.p #_1, ��.r . Patcel # 1 �i�
SCC110fl�I,Ot#
� /1- 3 - /o �
Date _
System cnmponents rrepresent appmximate�contours only: The coniractor must, flag the system prior to
begrnning the inrtalla�'ion to i�sure that propergmde is maintained �
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11�a.'IL�71.7Pam'TMn Jl.'T'n cE=.�.'���.Il �fL�SL11'(�.lt�
. W�+ �I, PERMIT (New 42epair�
�ac�h�enf
Taz Map: � Z� Parcel• ���
Subdivision: D�� K Poi rrE- Lot:
Applicant's Name: ���i „�mer _ _
Mailing Address: Z� n r'� Ln •
s� w� C� 13
Phone Numbers: - - �G) 3<0- Sa�- �83
Location of Property:
Permit Conditions:
1) Seg attached site plan for proposed well location.
2) All applicable State and County �egulations governing const�uction and setbacks apply. �
3) Permits expire S years from the date of issue.
Other Conditions/Comments: -
Qin-�i�in � �� 4P-�l,n�;��5
--.
P�rmit issued by: I)ate: // - 3'/�
C]ERT'IF�CATE 01� CO1dIPLE�ON
New Well Inspection:
EHS/Date
Location: '�t � at� I�i
Grouting: `� al�li�
Well Log: '��,a- al � l��
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner �spection:
EHS/Date
Installer:
Depth:
Grout:
Well Abanclonment:
EHS/Date
Completed:
Method/Material(s):
Well Driller: ��rr,�k�P _ License #:
Pump Installer: � License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
1)ate:
Date Results Mailed: '"
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MOI�TITORING REPORT
S-3o—I 3 �f-3- (qq 8' �o ��
tem Installation Date e ax Ma Parcel #
Date of Inspection Sys `I'yp P
a�' � .��� e tc� �,�,
Propzrty Address
Instructions: Check yes or no for appropriate items and explain inspace provided for remar�cs and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and expiain. Note that this m�nitoring form is not tutally inclusive for all systems. All main±snance
and monitoring items specifed in the permit are to be carried out.
INSPECTION RESUI,TS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface wa�er diverted 7
�eptic tank needs pur.iping ?
�Inches of solids:
Septie tank filter eleaned 7
FFFLUENT DOSING SYSTEM:
Required pumps grese. t& functional ?
High water alsrm operating properly ?
Floats, valves, etc. in �ood �andition 7
Control panel & components in good
condition ?
Effluent &ee af excess solids 7
Inches of solids(pumpi do�e tank):__�j�__
Elapsed time readin�s ?__
Counter readings ?
Drawdown rate:
YES / NO
a�
❑ � ❑ �
❑ / ❑
O i O�'I
❑ � ❑ ►`�
❑ / ❑�
DISPOSAL FIELD:
Evidence of efFuent surfacing 7 ❑
Evidence �f effluent ponding in trenches ?❑
Surface wa:er eufectively diverted 7
Dit��rsions/swales properly maint�ined ?
Vegetative cover mauiained ? �
Protected from trafiic/unauthorized uses ? �
Distribution devices in good condition 7
Field free of settled or !ow areas ? �
/
/
/
/
/
/
i
/
1:
�_�
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i
REMARKS
� SQP�,z �,� �
,��- access� 6►�.
� �aM� �� �. �t� acx,� s�� b �e
�,�1 we � /�'r�,s✓r� J� Si�
� %� �,�- ,.�,,�� 1��1•
�� U�u� �
f u � Q'� �'�"� �`�r
� P �S ��M.� � �
i'� Yu�'��'
�� ;�,�e��Q In��3 v�
l�` �
PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible 7 ❑ ❑ .,� �� ,� ��t �,q�n� ��
l l�
Pressure head properly adjusted ? ❑ � ❑ � � ��� U�p���
COMPLIANCE:
Compliant
Non-compliant
Needs Mainten�.nce
AUDiTION�I.
aCCeSS; �
�.
►/
■
■
� -{— r S
EHS
,�
I
Date: - � ' t� ' �
Owner.
Location/Directions:
PERSON COUNTY ENVIRONMENTAL HEALTH
�
�
WELL LOG
S�
$"ubdivision NZrne: "__ ,� ' S�/b� Lot ## /� br�
Drilling Contractor: ���c�
WELL CONSTRUCT`ION �
Distance from I�Iearest Properry Line lU Distance from Source of
Pollution �4U ''
Total Dept�1:__ y�, �'t. Yield: / GPM Static Water Level o?=Ft.
Water Bearing Zones: Depth �Gs Ft. Ft Ft� Ft.
Casing: Depth: From Q to �!l Ft. Diameter: � c Inches
TYPE: Steel � Galvanized Steel N
If Steel, does owner approve: Yes No
� Weight: � Thickness:,� r_ Height Above Ground:� Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes” gi�e reason:
Grout: Type: Neat Sand/Cement .� Concrete
Annular_ Space Width_�'� Inches
Water in A.nnular Space: Yes No �
_ .. Mechod: Pumped � - Pressure � Poured � .._ . . . a, . :
Depth: From_ � to �O Ft. � �
Materials Used: No. Bags Portland Cement� Weight of .1 bag �� lbs.
If mixture (sand, gravel; cuttinas) - Ratio:_� to
ID Plates: Yes �' No � � �- � .
� 4 x 4 slab Yes � No
u
Z HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 C�uiJTY HEALTH DEPAR MENT.
i
Signaturc of Contractor Date
►..
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE:_4� ��� IlViPROVEMENT PERMIT #:
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: � �t an ce ',,.�,.tin_,�
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR CONS
�
y�rn� S,
ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut # a0 3� The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
0
Person Requesting:
5�
�
'�
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!�C iiJM�I (!� �U h"-�t �
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� ` � � PERSON �'OUNTY HEALTH DEPARTMENT
WELL EiND SEWAGE SIi`!�, LOCATION IlVII'ROVEMENT PERMIT
Tax Map # � � � ' Parcel # / � �
Zoning Township a, h,'� .c � �_
A 001230
. � i _ � � �l�
Owner/Contractor
Location/Address
i � ��
� Subdivision Name
�� �
T o.,..,,f
\\ �{�, �
♦\ � �
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5�ri+.'!. � 2 f%r; r[.�C 1'�c
Lot#
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�32 z
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`" . Mtrl, i � ` <� � -
M /
.
SEWAGE SYSTEM SPECIFI A N� �%
Repair Lot Area e Size of Tank %00 • N�
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line ,� '' '
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or inten se an ed.
Well and Septic Layout by
Comments: -F' i i�ti �� ' f �I � �'' �
,•, t.! � .., �-o „ c � h � � �.� n'P�1.� . / ��l S,-F-P,,.-. �_c I �r,.- a �v r
Date� Installed by
EL
Individual Semi-Public
Public Re cemen
Site Approved
VVell Head Approved `i
S
0
�
v — — f7 •
L SYSTEM SPECIFICATIONS
Required Slab
t Air Vent �
Required Well L �
/Q � Well Tag
�e
�
0
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�'
bV VV�
�- �r�� �S .
c��a ' X3'
�r hJ�s. l� � � �
�
Date� Instal�kd by�� ,�� Apprd�ed by �
This report is based in part on information provided the homeowner or his/liar representative in the application sub ed for tlus pemut The
environmental health specialist is not responsible for false or misleading infoanation cotrtained in the application. The environmeirtal health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statemecrts provided to him in the application. Neither Peison Coucrty nor the environmental health specialist warrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will retnain potable: c:�amipro�pennitsacn O 1/95 rev.1.0
Vr'Z .
�
� Person County H�alth �Department
Sewage System Improvemer�ts -P�rmit
Date: is�Permit Void After S Years - p��
Owner. SR# ��2
Location/D'uections:
Subdivision Name:
: Lot Size: —�
� Water Supply: Pri�
$OdIOOmS: �
Basement
i' i.. L.nt #
'slac�_ Type of'Dwelling: ��
�,� `� P�blic: Community: _
Gazbage Disposal �
Basement Fixtures-
�D�Y r. -.
S�� /CitW�^'!`7 owner or repiesemauve
REPAIR: .. REEVALUATION:
Size of Septic Tank: g ons ize of Pump Tank:
Nih�if'icadon Line:
Depth of Stone: 12 inch s
Max Depth of Trenches: �
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well�Qpproved: Well should be 100 ft, from any sewer system
$� � � ,. n n , Sanitarian _ .
.TE OF COMPLETION
.
�
cu
L�
-------=—=-------- ---- '�
Sewage System location, installation, and protection must meet state and local �
regulaaons. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to creaze a public health hazard. Septic tank and'd
nitrification line must be inspected and approved by a member of the Person County �
Health Deparnnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this peimit is subject to revocadon.
(G.S.130 A-335F) �
L.ocation of sewage disposal sewage system sketched on back. �
(OVER)