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A24 171Location j��u� 2 !`�� N. C. Departmcnt of Environment and Na!ural R.esources a� �'�" � �� j Divisien of Environmental Heaith INSPECTION OI' ENGIi�'EERED_,SUBSURCAC� WASTEWATER S Name of Establishment Type of Establishment g-� 1� ! Address �� 2� %�r� �� Operator J ` Adrjress Remarks Yes o i. ESTABLISHMENT: Type, size, and sewage flow in accordance wiih permit? ...................... � ❑ 2. COLLECTION SYSTEM: I�o evidence of leaks into or aut from sewer linesJmanholes? ............... ❑� Free of blockages/solids buildup in lines or manholes? ........................ .�' ❑ 3. TANKAGE (Grease TrapslLift Stations/Septic/Dosing Tanks): Tank risers accessible and surface water diverted? ................:............... ❑ Tanks and access manholes structurally sound, watertighi? .................. ❑ Sanitary tee(s) in good working condition? ........................................... ❑ Tanks pumped, cleaned out as needed? ................................................. ❑ 4. RAW SEGVAGE LIFT STATION (if pre;ent): Required �umps present, operat;ng, and cycling properly? ................... ❑ High-wate: alarm present a.r.d operating properly? ................................ ❑ Floats/pipe;valvesJdisconn�cts in good working condition? ................. ❑ Controi pan=1 enclosure�compenents in ooc:l cundi;ion? ...................... ❑ �. FFFLUENT DOSIN:; SYSTEM- � ❑ Effluent appea:s ciear, f:ce of excess solids? ......................................... YUMP SYSTEMS: Required pu�r,ns present, �rcrating, and cycling properly? ................... ❑ High-water alarm p� �s�nt and operatiug properly? ...................:............ ❑ Floatslpipe/valves/disconnects in good workinJ aondition? ........ .. ❑ .. ... .. Control panel enclosure/con:�onents in �,ocd condition? ...................... ❑ Elapsed time readings: ' --- SIPHO�1 SYSTEMS: No evidence of overflow or siphon leakage? ........... ............. ❑� Siph�n(s) appea; to be working/alternating properly? ........................... � a Bells and vents frez of debris aad in good condition? ........................... 5. GROUND ABSORE'TION FILLDS: I�o evidence of effluent surfacing/reachino surface waters? .... .............. ❑ Minimat ponding in subsur;ace trenches? ............................. ❑ ................ Surface water being effectively diverted away? ................... .. ❑ Diversions/diichesiswalesltiie drains properly maintained? .................. ❑ Line coverlvegetation adequatelmaintained as needed? ........................ ❑ Protected from vaffic, destructive uses? ................................................ ❑ Distribution devices in good condition, working properly? .................. ❑ Repair area properly reserved, maintained? ........................................... ❑ LOW-PRESSURE PIPE DRAiN FIELDS: Tumups/cteanouts/valves intact and accessible? ................................... ❑ ❑ No effluent standina in lower laterals? .................................................. ❑❑ Laterals free of excess solids, cleaned out as needed'? ........................... ❑❑ Pressure head is property adjusted? ....................................................... ❑❑ OVERALL CONDITION AND OPERATION OF SYSTEI�i: SUA�II�IARY OF IN[PROVENiENTS NEEDED: Improv,,ment DATE: `�/ j �� SIGNED: DE�R 37021Reeise� On-Site Wasccweter$ecuon(Revi:w 1'_r9R�. — over — REMARKS l�G �t No. Design Flow /�-��' '� Phone PFicne Repair �Vithin (Days) nmental Hea�th AGEI�T �Qllcatlon Date: ___ Amount Paid• Recelat *: Tax flla #: Parcei �!: /�� - ��._ � ��.�� 0�7' ��a-o��e�.��.n �emn�� ot) - APPLICATtON FOR SERVICES (Mobile Hcme Rsptacemenf/Add�on) RenaidReolace ExisHrg SYstem Permft St50.00K200-0� tor Sapdc SYsta►ns- IF THE INFQRMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT tS INCORRECT. FALSIFIED. �CHANGED, OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMR AND AU7HORIZATION TO CONSTRUCT SHALL BECOME INVALiD. � i'f ) Perntlt requested by' (Owne agen rospecttva owner): N`�G ��— ��G"� "� L��• �� U� sc+�r•hi� r,,� Home Phone: . Address: '�3�1 AT�a,.r: tic avc: Business Phona: q. � � `� � � �n 5z _ (� �-c'►�-n , "l G 't�� b a a 2j Name aed address of current owner. P�g re ss E N��;y �`]�7 D A �...,.► � �,..� y R-d .68v►.0 r�. /�CG „^ M `(�s 3) Property Description: Lot size: �� Township: I�� Subdivisic Directions to the property (lncluding road names and numbers): N[�S`I � �y, �C�e�s. M, �� 2� : Le�- o n, S h u:�cc. R-d. � z1�o �.. Mc Gees M��l N s Lot #�� Fv � . ¢.� �a 4) Proposed llse d Structure Dsscription: answer each of the foilowing questions: � �� a) Proposed � Existin9 _. TYPe of Structure: �"'�S�`' 1+� 1��--�5 �dth: Depth: ��A b) Number of Bedrooms: ,� Number of occupants or people to be seroed: c) Basement: Yes_,,, No � Will there be plumbing in the basement? � d) �arbage Dispasai: Yes _, No �, 5) Water Supply Type: Private X(new � or existing_�, Public_, Community� Spring _ Are any welis on adjoining property? YesSC No � If yes, please indicate approximate iocafion on the site plan. 6) Does your properiy contain pre�iously identified jurisdictlonat wetlands? Yes � No_ PLEJ+►SE NOTE THE FOILOWING: ➢ A PLAT OF THE PROPERTY �R SITE PLAN MUST 8E SUBMITTED WITH THIS APPLICATlON. ➢ PROPERTY L1NES AND CORNER3 MUST BE CLEARLY MARKED. , ➢ TNE PROPOSED LOCATION OF ALL STRUCTURES MUSi BE STAkED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATiON BY THE HEAL7H DEPARTIIAENT STAFF. I hereby make applicatlon to the Person Caunty Health Departrnent for a site evaluatfon for the an-site sewage disposal system for the above-described property. 1 agree that the contents af this application are true and represent the maximum facifities to be pJaced on the prope�ty. I understand if the site is altered or the intended use changes, the permit shall become inva�d. � � Oumer or Legal Representative L- LL -� 4- Date PGiD, rev. OSI27102 ..... .. .... .nnv io � ion Page 1 of 1 s�:�i�: � xs http://gi s. personcounty . neticonnectgi s/Nlap/connector. aspx 6/22/2004 � _ `>�,�,� � ��., . ; S mQ �� 1'��s ;`��lj.r�. i � W�R�: / ' • . . � �� } M�� ]E.��a-�mm -� em�.Il ]E7'E��.Il� . � se.�ac\�S , � ��6 �1;�,�..��. s�:�s��x� . ,. Name t Subdivision ��'� � � �luthorized tate. Agent � Tag Map # �� Parcel # � . Section/Lot# � (� �aa-�y , Date . : sy� �„�o� „�,,,�� ,�„:��u� �ry. The co�ratto.r beginning the rnstallation to insus�t,Trat propergmde is m.rs � � --+--T= -� Scale: il�o� � �c�- �rt°r to. , l�l�. �l� �'�cr-1..� wQ.Q� �;�-e. Applicatio� Date: I b �2 q-O c� Tax Map Amount Paid: 3d0 , OU Parcel #: Receipt#: �'j �� .._.��-.,� ��- �I�IE�.�� - -� �� IG �-,-�� u� � .�_. � �.,�.. ll IL�C �- .�� ll <c:l�h Application for Services (Septic Systems and Wells) 1) Services Requested by: Name: Jfl� 1�9wpcc-L Address: �c2,�z�lc i Ec.� vn5�•*�1 �j 21- A 5 Hoec 2a-4 0 SEM� , L 2�343 Phone # (home):C�13�313'�� (work/cell): (gt�, 31D-(�2°to 2)Name and address of current owner (if different th�n applicant): Name: �c2i/�-'�l l � �yASvnst IVL 1-'l�� Address: U3 D� W��eS i�5//�¢�S � i,Q�c i,. Sus; � 5�J -r�,�n� r�� 33�a-7 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: �n» OP 5 LIdLc: Q�otlD � I►Mz�� i�Yosrat (� . 4) Proposed Use and Type of Structure: Residential Business/Type: �N,��uS i �sAz Other Number of bedrooms �l A�_ / Number of people served (seats/employees): ►DO Basement: Yes No _� (with plumbing: Yes No _� Garbage disposal: Yes No 5) Water Supply: '(�ivy�yvY»'-� v�lr�2 5✓pPc<< Private Well (Proposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No f=� C� ST 2.�z'r.�l 2�-L E�►PwVc�S oR.- �d"�5 Yes �C_ (please show �location on site plan) �To 4� I�gauo�vp�;v� � Note: A completed application must also include: ➢ A plat/site plan of tlae property t/iat s/iows property dimensions and the size and location of all proposed structures. ➢ A signed copy of tlie `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this app(ication 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. Signature (Owner/Legal Representative): • Date : �� 2`� `�$ 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � L46 L4� �� / , � �a � / v r � �I � W �� r � N r� , � � �� \`S �R o 0� l `� �6 w �v' � � � L3—'---a �`8 b C24�s_ L2.3 � �/ � ti'` d � L56 � — ��9 � ��18_ — -- _---_ ;.� �,o� 0 !.� � � / PROPOSED / � ZONING LIMITS � / O 0 0 � w Martho Royster Db. 269, Pg. 141 Plat Cab. 1, Hanger 95 L17 _ �_ ��6 L15 t �- —o �i � v� 1 � ^ � F �j H Y C 0 Corolino Power & Light C mpany Parcel "A" D.B. 98, PG. 81 _ EXIST RAI�ROAD � l / / 1 1 _ _ -_�_ —`� _ � 'n +'� / ��V / / ��SEDIM( ----sa. � STORM\ O O � �r w PROPOSED ZONING o� � LIMITS ,�5�2• �� % 60 �$ �� WELL WATER— i�gk�9 CHLORINATION BUILDING WELL SITE� 100� RADIUS� � WELL PROTECTION ��LIMITS �.�j . _,:�.% O � O � w 5 �� \ \ / r � Z�, � .A � 'o � I < s�, � \\ \\ \ �� \� ti cn X i — \ '�� '.;. . 'LAND; /� / � \ ' o 0 0 � � EMP�LOYEE/VISITC '�o . �PITRANCE WITH /26 FT MANUAL '�� . / / � GATE AND CARD � � REAGERS . / / f' fER � . I DSG l DNJi�v / \ �jOs\\ � .�' � � � � ,: C k , -\ \ L7 X C6 SS .....-.. � �_� LAKE HYCO � �,e ` � ��X � � — .� X� � 78.3 ; � � N8 7'20 — �� - � ..� � > TREATMENT PLANT � WELL �� 1�� 1 STORY I � m FRAME � TIN ROOF I ` � X � LOG � I � �N ► r �� RE R�? , � 5 R' gL�G F �' f � 60' p� �Eol. \ o �\ s, `p P , -P r.- �4�\ �j w o `� ��,� RI`�- � f -''-_ �,��" MILL FEED 12.47 kV - OVER tAD SVVITCl�GE� CONV YOR #MV1 rt__ _ — ,� RAW TERIALS MAINTENANCE �ISEDIMEt�I�,C � STORMWATE ---F� BASIN 2 �___�- GRAVEL FIRE ROAD ' �`�'r' ;:i;;`: SCRAP RECYCLE CES �FUTU / WAREH( i � � i � � , EMPLOYE' i PA i (77 � i i — _ ___ . . . . � �-, _ ` � _ � S 82, �y �� rc�Y ��NE �� ` js� � — — _ EXlS7-�N� ROA "w F, ` RAIL ENTRANCE � _ _ ` p WITH 22 FT Ex. Roilr — —`� a L MANUAL GATE �R�w unk�aw °o f��sk -� � , do f e) ^� 1l � � ^ � 2�_ -, ` � Carolina Pow re &-"Light Company r � � � arce ' �T Db. 98, Pg. 1 12 �� >- ELI I > ME � R � �l v' BU E N P L ol , � R� ES c p. /� R N� PK � o' �� , �- � � � � � � % � % % � � � �� ..,-r , , North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Certainteed Gypsum Address: 921-A Shore Rd Semora. NC Zip: 27343 County: PERSON Report To: Person Co. Health Dept. ATTN: 325 South Morgan Street Ste C (336) 597-2371 Roxboro, NC 27573 Courier: 02-33-15 Collected By: J SMITH Date: 6/8/2009 Location of sampling point: Outside spigot Remarks: Permit # A24 - 171 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 3:10:00 PM Parameters Results Units Date Analyzed: ' Silver <0.05 mg/I 6/10/2009 Alkalinity as CaCO3 250 mg/I 6/10/2009 -: Arsenic <0.005 mg/I 6/10/2009 . Barium <0.1 mg/I 6/10/2009 T�=�-" " ��3�,� -, :��R..;- �� Calcium 83.2 mg/I 6/10/2009 , ,�� Cadmium <0.001 mg/I 6/10/2009 � a�1� Chloride IC 59 mg/I 6/10/2009 ;%� Chromium <0.01 mg/I 6/10/2009 -�;'-'�� Copper <0.05 mg/I 6/10/2009 Fluoride 0.31 mg/I 6/10/2009 Iron 0.38 � ' 'my/I 6/10/2009 Hardness as CaCO3 (Ca,Mg) 396 mg/I 6/10/2009 Mercury <0.0005 mg/I 6/10/2009 Magnesium 45.9 , mg/I 6/10/2009 Manganese <0.03 mg/I 6/10/2009 Sod i u m 25 m g/I 6/10/2009 Nitrite as N <0.10 mg/I 6/10/2009 Nitrate as N <1.0 mg/I 6/10/2009 Lead <0.005 mg/I 6/10/2009 pH 8.4 Std. units 6/10/2009 Selenium <0.005 mg/I 6/10/2009 Sulfate 55 mg/I 6/10/2009 Zi nc 0.24 m g/I 6/10/2009 � Date Received: 6/10/2009 Report Date: 7/6/2009 Reported By: � Today's Date: 7/6/2009 Ref: 8098 Login Batch �4�Q6QQ3�,� Sample Number: A690641� 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 watec 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 iirruts . Iron Lead Nlagnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg11 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.� units 5.0 mg/1 PERSON CUUNTY HEALTH DEPARTMENT 355A SOUTH MADISON SLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant ��a�� urv� Address �2�'� ��laY �^ County��P��v� .�—� Collecfed By. ,o� Date Collected (9' ��"� Time Collected �= 38' Source: ell ❑ Spring � Other Location: ❑ House Ta �Well Tap 1gUther Ne�,,� t,J��( �� -sa 1� �Charge L]Charge � ��*�x�**��*��*��,��*��*��*��**�*,�� *�*��,��*��*��*��,��*��*��*��:��*��xa�� Total Colifarm Fec�UE. Coli Present ❑ ❑� Results bsent � Reported By , h � I �� I d� bactreport . �/�"' ', WELL ABANDONMENT RECORD ��-�� Nartl1 Carolina Dcpartment of Ertvironment and Natura{ Resources- Division of Water Quality W�LL CONTR.A.CTOR CERTIFICATiON #, l. WEF.L CONTRACTOR: �t�Ni e. � � %d� � 1 f�" Well Contractor (Jndividual} Namc ��• ntc�e t�c l/ ��t il! .�c - Weli Contractar Company Namc n � STREET ADDRESS C 7% ��RI''�'�P7�7% ' n� �` ��K�1L_l�c. Z��'75� Ci�y or'i'own Statc Zip Codc 3c 36 � - _�'�,� - DOi 5` Ara codc - Phone nutnlxr 2. WELL INFORMA'f'34N: S3TE WELL ID }� (if applicablel /�%� SI'ATE W ELL PERMfI' #(if applieable) i�i�! COUN"CY WELL PERMIT tt (if appEicable) li�� DWQ or OTHER FERMIT �i (iCapplicable) WELG USE (Circle applicable usc;): l�tonitoring 'denlia Manic�pal7Public IndustrioVCommcrciAl Agricultural Recuvery lojection Irrig�lion o�herpistusc)��._, _ 3. WELL LOCATION: COUTITY �e QSO� _ QUADRATECsLE NAME ?�l�AR�ST TOWTI: f�� yC l.ns? t� �✓G i�czP•�� (StrocVRoad l�tamc, Number, Canmuaity. Snbdivision, Lo� No., Pucel, Zip Codc} TOPOGRAPHIC ! L�D.� SEiTING: Slope Vallcy [Etat- Ridge Othcr {Cincic appropriatc scuio6} May be m degets, LAT17'UDE �_ miautes, seconds, or in A LONGINDE _� � _ decimal fo�rtwt Latitu�elloagitude sourcc: CsP5 Topographic mag (Localion ojwelT must be shown on a USCS topo map and a[laclred to lhis fn»u +f rx�� eing rP.S.) 4a. FAC111TY-'iLn name of the busincss wbere the weU is located_ Camplete 4a and4b. (Ifa residential �m:ll, skip 4a; rnmptete 4b, well ownec infomu�ion ady.) FAC1LiCX 7D #(if applicable) PIpME pF FACILil'Y % f7i��G�JC - _— S'fR�ETA77DR�S5 ��7 1��31.� Nit/s6o,..a¢R �fiDRC ,�% R.,,, D r b B c�t o�3 �-� 7 5"7 5� Ciry or Towa 5cate : 2ip Code ' 4b. CONTACT PERSON/WELL OWNER: NAME — SI'REE3' ADDRESS City or Town Statc �p �______.T} - Atea code - Phone numUer 337b S. WELL DETAIIS: a. Total Dspth:�_ ft. Dinmetcr.�_in. b. Watcr Levd (Below Mcaswing Point): ft. Mcasvring point is ft. abovc land surface. 6. CA5IIVG: � Leagih Qiamctcr (� (QGSG�. •�f +�E4` a. Casing Dcpth (ifknown): !' fi. in. b. Casing Removed: � ��• �. DISINFEC'fI01�1: � =c� s � T� (Amount of 65%-75°b calcium Uypochlaritc ascd) 8. SEAL[NG MA'I'ERiAL: Neat Cemcn Cement��_ ib. Wata ✓ �,�al. ,2p�� sX��;� Bcntanite Bentoni� Ib. Type: Slurry_ Peileu_ �t�a gal. 5and Cernent Cement ►b. Waler gaL ORher �1� A� s Type material • 7`i�� GC / I�� C'Q��v+�C� � Amavnt 9. EXPI.AIN METHOD OF EMPLACEMENT UF MATLRiAL: �r•ti!/��- �� i �%-h S`o�`J � ee�•�,.�` .�a,/� �.e� � a,Q 10. WELI. DIAGY2elM: I?raw a deiailed s[cetch of the well on the back of tfiis forrn showing wtat depth, depth and diameter olscrcens (if any� remaining in i6e wcll, gravei intcrval, iatervals of casing perforstions, and depths and types of fiU materials used. 17. DATE WELL ASADIDONEU ��` �" a� - 1 DD iSFtfiSY CER77FY THAT Y1iIS WF�.L WAS ABANDOi�D I�I ACCORDANCE W!'CH i5A I3CAC 2G WFLL COt':S'[R1.IGTION STANOARDS, AND THA1' A COPY OF THIS REWRD iiAS BE£N PROViDID TO THE W�LL OWNFA GP�rnA-�-� � _ � �— lt 6 �O-�' S�7ATURE OI+CERiYF�D WELT, CONIRACTOR DATE SiG�VATUItEOFPR]VATE WELLOWI�IERASATIDQNiPIG TIiE W�+3-1- DATS ('Che Pdvate wep owner must be an iadividqal w#w ocrsonaltv abandoashisTher resida+tiak wdl in acco�dance with 15A NCAC 2C .0113.) � � rt1 / U� \ pR1NTEpN[AM£ OF PERSON ABA�I I�IINIG THS WEl.L , Snbmit a copy to thc owner and the originai to the Divis%n of Watcr Qualicy �vithin 30 days. :�ttn; lnformati�n 14[ana�emen�, 7617 Mai1 Sen�ice Ccatcr— Rsleigh, NC Z7699-i6]7, Phone No. (919) 733-7025 ext 568. ronn GW-30 Rev. 5/OG �'d �LZ6-86S-9E£ e;�auae8 •� y�ie�{ d � �: �0 80 LO ��N ��. s� ��.� �� _.. � � � ��- I�.��a��.��.¢�.Ii IHC��►,]1�1�. WELL PERMIT (New,�Repair� Taz Map: �t0 Z�-} Parcel: t� � Subdivision: _ Lot: Applicant's Name: �(�„�-�t r.j�--�,s-'� 19�V.� ► � Mailing Address: G) Z� � A 5 2t= n 5�ia.�2� r.cr. �7 3 � 3 Phone Numbers: "$�t3 -313-o4S�d'T I�'SSl3 � 3t0- lpZ�iO Location of Property: Perrriit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks appdy.� 3) Permits expire S years from the date of issue. Other Conditions/Comments: G!/fL� D,u/lf� ?�!3 -D_� - �iit��_.r/�' Permit issued by: 1. i � i : CERTIFICATE OF COMPLETION New Well Inspection: EHSlDate Location: �s (� -S� -ag Grouting: �55'� Well Log: >'S (a-�-o i Well Tag: �`(b `'`� � i �� P �� Pump Tag: �SS � -8 -lJ�1 Air Vent: Hose Bib: Casing Height: -� � I a cP �t7� Concrete Slab: ,S 5 (� -8'�Og' Liner Inspection: EHS/Date Installer: �. Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): Well Driller: �/��i �� ro5. License #: 2557 Pump Installer: License#: `�VEII Ap�roved by: � � � �ate: �e ' $�' d� Date Sample Collected: � 'g - 0� Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 �2i �,1c� Cot�s . Date Results Mailed: � te- Z�j ¢'( - g- 0�1 Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 � WELL CONSTRUCTION RECORD � q.�p�-��, 7 North Cazolina - Deparmient of Environment and Natural Resources - Division of Water Quality - Groundwater Secrion WELL CONTRAGTOR (II�iDIVIDUAL) NAME (prSnt) �� '�� S CERTIFICATION #�� WELL CONTRACTOR COMPANY NAME ��% B TO �.i�-�Y�' PHONE # i 7� -�Z) � STATE WELL CONSTRUCIION PERMTT# AS40CIATED WQ pERMIT# (if applicable) (if applicable) 1. WELL USE (Check Applicable Box): Residential ❑ MunicipaUPublic �Industrial ❑ Agricultural O Monitoring � Recovery D Heat Pump Water Injection ❑ Other � If Other, List Use 2. WELL LOCATION: Nearest Town• �+7,r��r� Couaty �.i a � s`x�ve_ r��e' (Strxt Name, Numbas, Communiry, Subdivisioo, Lot No., Zip Code) 3. OWNER: ]�i� n,r'i"E� Address ��OI 41-G�vrfi� '�^ J� , (Strat or Route No.) �/�.+�, �, �?�(v�l� �� City Town SaOe Zip Cade uL.��- g�t – �4CZ Acea codo- Phone a�m►ber 4. DATE DRILLID '7'!�'G �' 5. TOTAL DEPTH:��4�� 6. DOES WELL REPLACE EXISTING WELL7 YES 0 NO � 7. STATIC WATER LEVEL Below Top of Casing: �@J FT. �SC ��'� lf a�bOVC TOP Of CSS1G$� 8. TOP OF CASING IS } ��Si7 • FT. Above Land Surface' � 'Top of easiaE terminated atlor 6elow land swiau reqnira a variance in acoordance wtth 15A NCAC 2C .0118. 9. YIEI.D (gpm): �_ METHO OF TF-�,ST. � o 10. WATER ZONES (depth): i i e�� 224 475 ?� � 11. DISINFECTION: Type }F'TM' Amount � 2 "f 12. CASING: Wall Thiclmess Depth Di ter or Weight/Ft Material From fil � SD To Iv2 Ft� ,� j�,_ ��'�� From To Ft From � To Ft 13. GROUT: Depth M erial Method Froa�_ To L, Z Fc a ,' f,r,� Fr�m To Ft 14. SCREEN: Depth Diameter Slot Size Material From To FL in, in. From To FL in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft From To Ft. 16. REMARKS: Topographic/I.aad setting �Ridge �Slope OValley G� c� �r� �) LatitudeJlongitude of well location (degredm,auteslseeonds) Ladtude/longitude source:�GPS�Topographic map (chcciclwz) DEPTH DRILLING LOG From To Formation Des ription —� �� T ,r f �'�� ..._ LOCATION SKEfCH Show direction and distance in miles from at least two Statc Roads or County Roads. Include the mad numbers and common road names. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE W1TH 15A NCAC 2C, WELL CONSTRUCfION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TEIE WELL OWNER SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Qaality, Groundwater Section,1636 Mail Service Center - Raleigh, NC 27699-1636 Phone Na (919) 733-3221, within 30 days. GW-1 REV. 07/2001 ��.ss ��.�� I��a��„-„-„ ��.Il IE-II��.IL�1� Applicant Location: Tax Map � Parcel # �_ Subdivision Phase/Section/Lot # # of B�rovm�� , ��a{e�, Operation Permit System Type (From Table Va): Product (IIIg): �Z 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. � ^ � � c �� 1 l � �( 2� �OYV1 �-anK � ; Stari' o� � f4ltll�'�i,lp� Scale: �P, 0 g� ��—(2 (Date) .. g-�,-�2 � � / (Date) ,i D , _) , � � , , �i3 ` �< ' 7 � ' ' r� d � �c� � �,��t� rt , .�8 � _ , �� va� v s� 5 a r�e ��" -� fo� � 5 u n d , ` � ''' _ � < ( � r " � ( ( � � c , ' � �� 4�� u�,`d �ha� ` ,' Line Length � � 3 �o` Total � � Tax Map: �Parcel #: �_ Septic Tank System Checklist (Type II-I� Notes: %�f "�i-�� r.� �pnf'a s �f�, o,,, �, ,.,.fla System Type: � Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) r� Copy of OP e-mail Date: .��;�� \��\��:� 1f�� ' `^1 ' `V 'V � Ji. � J�I��.�i�1r11 tP1YT iB��Il ��'�� Si'�. S��IE'��. Name �ERTi.� � T' -, • �l Subclivision 1� Autb.o ' d State Agent Tax IVIap #�Parcel # I�! Section/Lot# ��/i •z— Date . System compo�tents represent ap�i��cimate�contours onl,y. Tlie contructor �t, flag the system priar to beginning t,d:e installatwn to insure t.hat propergnade is maintained ��/I�'v� riaf2 `� � �'f'� Yb� C�i'��tPS• C�� .�ai�l� - � � � q(�P �P�"`� t i , /DDO y. .SC�G Ti�rI1L T��-t�� DE5�9�J ��+/: /Zo c��ac/ �r-�t-a=- .33 � 90 � �-<ycc��o�-Eo) ,. . :_ _.�=:== -:� %:� :. . .. .�:: ��: �: ::: 1 `=�p' �y Qv.��io,�rs Go�+/r.t�r l��v � 5��- ��ga _��, s� �� l[�e��a��.-�.-TM-�. ��.Il. I��.Il�I� Applicant: _ f�, Address/Location: Tax Map: �Z� Parcel• /9/ Subdivision Improvement Permit Permit Valid for: Five Years ✓ Non-expiring Type of Facility: �Z�,�.Qy �,�� New � Addition _ Number of Bedrooms / Occupants / Employees ,3 / Seats: Proposed Wastewater System: ,�rs; - � �� Proposed Repair: „�� a� ,�,� 1 Permit Conditions: '�o � - Authorized State Agent: (X) Owner or Legal Re Phase/Section/Lot # �� Water Supply: M��'l.,c. Projected Daily Flow:� gallons/day Type: Type: Date: Date: The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicanbproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with t6e provisions of the North Carolina `Laws mr�l Rules for Sewase Treatment and Disposa[ Svstems'(15A NCAC 18A .1900). 1�leither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �/�� rE� (*)Type � Design Flow 1��0 gal./day New ✓ Repair _ Expansion _ Soil LTAR: . 3� gal./day/ftz Type of Facility: G�r�1� �nv.,,�,� Basement: _ Yes _,/No (*) System Types Illb, Illbg, IT�, and V, require periodic system inspections by the Person Counry Health Department. Wastewater System Requirements Tank Size: Septic Tank �DO o gal. Drainfield: Total Area �_ sq. ft. Trench Width 3 ft. Distribution:�i�stribution Box Pump Tank t��c gal. Total Length � ft. Min.Soil Cover (v in. Grease Trap �A� gal. Max. Trench Depth � in. Min.Trench Separation �_ ft. (9�Dn( \ \ ��,J / Serial Distribution ✓ / Pressure Manifold Authorized State Agent: The system permitted is: Conventional /Accepted ✓/ A rnative / Innovative . I accept the conditions and specifications of this permit. n (X) Owner or Legal Representative: Date: � / C Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �r�c��,�� — !7 ( �� _ PICDENR North Carolina Department of Environment and Natural Resources Beverly Eaves Perdue Governor GREGORY MCCOWN, PLANT MANAGER CERTAINTEED GYPSUM NC, INC 921-A SHORE ROAD SEMORA, NC 27343 Dear Sir/Madam: Division of Water Resources Thomas A. Reeder Director 04/30/2012 Re: Final Approval Final Annroval Date: 04/27/2012 CERTAINTEED GYPSUM ROXBOBO FACILITY Serial No.: I 1-00692 Water System No.: NC4073019 PERSON COUNTY Dee Freeman Secretary The Department received an engineer's certification statement and an applicant's certification statement concerning the above referenced project. The engineer's certification verifies that the construction of the referenced project has been completed in accordance with the engineering plans and specifications approved under Department Serial Number 11-00692. The applicant's certification verifies that an Operation and Maintenance Plan and Emergency Management Plan have been completed and are accessible to the operator on duty at all times and available to the Department upon request and that the system will have a certified operator as required by 15A NCAC 18C .1300. The Department has determined that the requirements specified in 15A NCAC 18C .0303(a) and (c) have been met and, therefore, issues this Final Approval in accordance with Rule .0309(a). Sincerely, �� /v J. Wayne Munden, P.E., Head Technical Services Branch Public Water Supply Section cc: Michael Douglas, P.E., REGIONAL ENGINEER PERSON COUNTY HEALTH DEPARTMENT CH2M HILL-SPARTANBURG Public Water Supply Section - Jessica C. Godreau, Chief One 1634 Mail Service Center, Raleigh, North Carolina 27699-1634 NorthCarolina Phone: 919-707-9100 \ FAX: 919-715-4374 \ Lab Form FAX: 919-715-6637 \ Internet: �latur�'LL J/ An Equal Opportunity \ Affirmative Action Employer �/ ►' v� � . , ,._. _._ .�.�, .. . M _. _ _ .. , ..� . - : ��`' r,�r�� °��'�''�` . d��t c�� '� r�� ,� �r�-� �� '� � � �,� n/�� %� � / ��o � `,v� �� r �,��• �� /p DpB� • D �y�� w� !- � �G f ►D�l/ ��'� ��%`� � !� / � y�� G�� ,� Application Date: � / ��JZ AmoantPaid: �- ed� � Receipt #: 2�B1�.7 � L -29-�i 9��O�Oo Anx Improvement Permit (Site Evaluation) $20Q_00!$300.00 �if> 600 gpd) � Mobile Home Replacement or Buildtng Addttion $i50.GQ lif site visit requ'ved) _ ❑ WetI Permit (New/Replacem �3 d0.00/$200.001$75.00 `�`'1? �f �.li�ll0.�� TaxMap: �_ Z'� ,�:. �,_ Parcel#: �._ �� IE'.aava.a•caan.axae:nA.��g �i��aa.�1.�� ilication for Services Services Re aested � Coastruction (Fee is de� 0 Permit R �75.00 Authorization ent on the type of ❑ Repair of Existing Septic System Appiication: No Charge/ CA $150.00 or $3Q0.44 ,,: � 1) Applicant Inf rmat'on: Na�ns: � � r `r Address: � r �, o f /�! 7 X 2) Name and address of current owner (if different tUan applicant): Name: � _ Address. Phane(home): ��G"5!� ��1� (work/cell}: Phon�: 3) Property Descriptian: Lot Size: _ Su6divisian: T.ot #• __� ___ Address and/or directions to Property: ❑ yes �,�a Does the site contain any jurisdictional wetlands? ❑ yes �S no Does the site contain any existing wastewater systems? ❑ yes C�"no Is any wastewater going to be generated on the site other than domestic sewage? Cd"yes t3 no Is the site subject to approva] by any other public agency? � yes ❑ no Are there any easements ar right of ways on this property? (if `yes' is checked, please provicle supporting documentation) 4) Proposed Use and Type of Structurc: ❑Residential � New Single Famify Residence Maximum number of bedrooms: � �5� � ❑ Expansion of �xisting System If expansic�n: Current number af bedroams: lA� G' t�r�. `�+ ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �o �Vith plumbing fixtures? ❑ yes no ❑Non-Residential � ...��,�(" Type oi'business: �� Y��`';"'� " � otal Square footage of Building; _,�� Maximum number of employees; ��. Z��s Maximum number of seats: / N� 5) Wa#er Suppiy: �1 Netiv well ' L7 Existing Well ❑ Community �Vell t� Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines an this property? [1 yes CI no 6) If applying for `Au�l►orization to Constt'uct', please indicate preferred system type(s): ❑ Conventional L�f Accepted C} Innovative ❑ Alternative ❑ Other � AnY I cert� that the information provided above is camplete and correct. I also understcmd that f the ir formation�rovided is inaccurate, ar if thP site is subsequently altered, or the int= ed use changes, all permits and approvals shall be invalid � t � 5ignatu wner/ Legal tive*) ate '� Supporting documentation required. . Permits are valid for cithcr 60 mnntbs or are nou-expiring when accompanied by an approved plat, • A completed `Lot Preparatiot:' form must accompany any application requiring a site evaluation. {10/11) Person County Envirocunental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)