A24 174_ �. �:
, . . . , .. .. ..
� The Districf� Healfh Dep�nrfinenf
�, Oraage, Per€on. Caswell, Chatham, Lee Couaties
�,' .
SEPT'IC 'TANK PERIv'rIT
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Name ;of owner: _l�
Name �of contractor. —
Address and Directions
Person or firm cloing insta
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Address
No. of persons to be seive� '� Bedrooms 1,_ 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washin
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machine
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Recommended• Septic tankT /
�r
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Nitrification liae: .� L_
Above recoinm'endation.based on information received and obser,ved
soil condition: Septic tank and nitrificatioa line must be iaspected•aad
approved�by a member of. the.Disir%c`�trHealth Department staff. befose
any portion of the. installation is covered.
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Date Approved: :�=� .' 0] (/�.'f1
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- 8�,.. — V�- �.
' O. David Garvin� IJL.A; M.P.H.
. ' - District Health� Officei �
-: Countersigned . " ,
_ (Over)
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Application Date: g - % y '� � ��� �� ���� ��
Amount Paid: Q , -� � .� • �
Receipt #: a�370 Z ,_,? ,-,� OU � �r � � ����
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1 �71 Ap�lication for �ervices
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 �pd)
site visit
or Building Addition
t/Repair)
Tax Map: � �"i
?Y
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, w �11
Services Re uested �---
❑ Construction Authorization
(Fee is de endent on the e of s stem ermitted)
❑ Permit Revision
$75.00
0 Repair of Existing Septic System
Application: No Charge/ CA $ I50.00 or $300.00
1) Applicant Infur �tion: � , //
Name: n (��-f�U� Phone (home): G S ���
Address: r �`y,:.-. �,% (worWcell): �
) C'� ?
2) Name and addr ss o current owner (if different than applicant):
Name: ----- ph�rte:
Address:
3)
Propprty Description: Lot S:ze: � Subdivision:
Address and/or directions to Property: '71n /�
LI yes
�s
❑ yes
❑ yes
❑ yes
I�no
� no
C� no
C� o
❑ no
Lct #:
Does the site contain any jurisdictional wetlands? ` —�
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other public agency?
,4re there a:.y easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: �
❑ Expansion of Existin� System If expansion: Current nnmbEr of bedrooms: �_ �
0 Repair t� :�4�Ifunct:oning Sysiem W iil there be a basement? �s ❑ no With plumbing fixturzs? E'J yes O no
❑Non-Residential
Type of business:
Maximum namber of employe2s:
Total Square footage of Building:
Mza:imum numbe: o: scats:
�) Water Supply: �ew well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? f�s ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other 0 Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or tf the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
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Signature (Owner/ Legal Representative*) D te
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lo[ Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Name � k`� t n � r J�►/ Ta� Ma.p #� Pa�cel #�_
Subdi � ' n _ Section/Lot#
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Autho�ized State Agent Date
System components re�resent approxisnate�contours only. The coniractor »aust. flag the syste9ra prsor to
beginning the instadla�ion to anszsre that pnnpergrrcd� as maintained
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Building Additions/ Mobile Home Replacements
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Tax Map #: �t 2� Parcel#:�_ Address: '' 7(� 0.�6U '�.f� �JP r l�cl �
Se � nr� �,_C�
Approval Requested for:
Applicant
Address:
Phone #'s:
�/ �c Home Replacement
Building Addition
Permit Located: � Yes No
Installation Date: - - Design flow: � (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �- j b-! Z (date)
(Applicant's signature if site visit is not required)
Addition/Replacement Approved
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Env' onmental Health Specialist
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Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount�net
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #� J 7C� '—�
1. WE�}- CONTRACTOR:
�fS f�NN`i e � . �u ,� �
Weil ConUactor (Individual) Na e
Bamette Well Drillina Inc.
Well Gontrector Comparry Name
611 _Sarnette Tinaen Rd
Street Address
Roxboro NC 27574
Ciry or Town State Zip Code .
3c 36 � 599-0015
Area Code Phone number
2. WELL INFORMATION: � Z �
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(itapplicabie) �`- % % �'
SITE WELL ID #(dappiicable)
3. WELL USE (Check Applicable Box): Residential Water Supply �
DATE DRILLED l� ^I Z` I�
TIME COMPLETED S�' � C� AM ❑ PM pr
4. WELL LOCATION:
cmr: �o �lbd a2za couNnr 2S o�v
g. WATER ZONES (depth):
Top� Bottom ��A(fop Bottom
Top .��i�O Bottom S S� fop Bottom
Top Bottom Top Bottom
Thicknessl
T. CASING: Depth Diameter Weight Material
Top D Bottom %d Ft. 6 �� S z �UG
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top d sottom�Q Ft. Sand/Cement Poured
; Top Bottom Ft
: Top Bottom Ft
= 9. SCREEN: Depth Diameter Siot Size Material
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
� Top Bottom Ft.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcei, Zip Codej . Top BotlOm Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley �qFtat ❑Ridge ❑Other
LATITUDE 36 "� S� " DMS OR 3X.XXXXXXXXX DD
LONGITUDE ��"Ca3'�_" DMS OR 7X.XXXXXXXxX DD
La6lude/longitude source: �PS Qfopographic map
(IocaGon of.well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Sc�.SQ,v G � 2 v� ,2
OHmer Name
/ LZO /12o2�'oN Pc�.Ii/ctr� r� 4_
SVeet Address
-1r�o1��v2c1 f'V G. Z 7s 74�
City or Town State Zip Code
�c �6 , r4g — 34g. 6
Area code Phone number
6. WELL DETAIIS:
a. TOTAL DEPTH: % � C./I
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C9�
c. WATER IEVEL Below Top of Casing: Z.� FT.
(Use `+` if 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 accatdanoe with 15A NCAC 2C .0118.
e. YIELD (gpm): Z- • METHOD OF TEST BIOWtI ZOI'Tl
f. DISINFECTION: Ty� HTH amo�nt 1/2 Cua
11. �RILLING LOG
Top Bottom
b / �
�/ b o
�Q_/ 7 n o
/
/
/
/
i
/
/
/
/
I
12. REMARKS:
in.
in.
in.
Material
Formation Desaiption
a (�c.e���2deec.7
S�tc.4/:�e �t�c/(
G$s� c.i �4 n c�C
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE W1TH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
� ; � . �.��' �1�-- t�
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
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PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev.2/o9
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES082013-0046001 Date Collected: 08/19/13
Date Received: 08/20/13
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 3.6
Sample Description:
Comment:
Name of System:
SUSAN CARVER
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://siph. ncpublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
760 ROY CARVER RD
Time Collected: 1:50 PM
Collected By: Derrick A. Smith
Well Permit #: A24-174
GPS #:
New Well I (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 110 mg/L
Chloride 28.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.26 4.00 mg/L
Iron 0.12 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 25 mg/L
Manganese 0.19 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 8.2 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 27.00 mg/L
Sulfate 130.00 250 mg/L
Total Alkalinity 231 mg/L
Total Hardness 370 mg/L
Zinc 0.07 5.00 mg/L
��C��V��
Report Date: 08/26/2013 SEP 0 3 2013 Reported By: Arno/d Holl
BY:
Page 1 of 1
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES082013-0075001
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ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
SUSAN CARVER
760 ROY CARVER RD
Collected: 08/19/2013 13:50
Received: 08/20/2013 08:50
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://si�h. ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Derrick A. Smith
Angela Heybroek
Well Permit Number:
A24-174
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present HLBRASWELL 08/21/2013
E. coli, Colilert Absent HLBRASWELL 08/21/2013
Report Date: 08/22/2013
Explanations of Coliform Analysis:
Reported By: Susan Beasley
AU G 2 7 2013
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.
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W�LL �'ERIVIIT (New �Repair�
Taz Map: ' 2� Parcel: -$�
Subdivision•
Lot:
Applicant's Name: �J u � V
Mailing Address: 1 `L20 l '
a�o C,
PhoneNumbers: rj��-�qq��'�.�� 5q?_-32$2 iG)
%
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.�
3) Permits expire S years from the date o issue.
Other Conditions/Comments: ,��� r barn�ca�� � �}e b� ren�►e�e� -
Pe�mit issued
I)ate: g— 2� —f Z
� C]ER'I"�'ICATE OF CO1d�LE'Y'IOl�
New Well Inspection:
EHS/Date
Location: a b �a i3
Grouting:
Well Log:
Well Tag: pa 7�o c
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
L'nner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well A.bandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: �a,rl�rc� License #:
Pump Installer: i�tt.r,l�, License#:
VVell Approved by: �,,�, Q. �, I)ate: �a 1�3
Date Sample Collected: �1� 13
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date Results Mailed: � �`� �3
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
.i
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �v4�Y1 �.�r�er
Address � �� o , County C�r.��r�
Collected By -S S
�
Date Collected 3� 1 u`�ie Time Collected � d il
Source: �'Well ❑ Spring ❑ Other
Location: ❑ House Tap e'Well Tap ❑ Other
❑ No Charge r�( Charge
..............................................................................�
*********�**********�*******************************************************
Total Coliform
Fecal/E. Coli
Results
Present
❑
❑
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Report Cailed
Called To
❑ YES ❑ NO
Absent
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