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A24 192��, s� ��..� �� 7C�.��.-a��-,.-,Y„ ��a-��.�� I��,Il�7� ,'�pplicant: �� 1dsdre�ss/�,ocat� ry;_ .E� Q,�i Permit Valid for: Five Years Type of Facility: `3� � , Number of: Bedrooms 3 / � Proposed Wastewater System: Proposed Repair: ��, Permit Canditions: S�2 S�e'� Improvement Permit Nan-expiring __ Pdew � Addition �Emplo�es / Seats: �' , Tax Map: �a�' Par el• �� Subdivision E' �PSYa•v� Phase/Section/Lot # 1S" S �Vater Supply: w'� �I Frojected Daily Flow: o gallons/day Type: �,� Type: _7I1�_ �_ � � fil�2�P a�'l Authorized State Agent: r _ Date: lm''7�13 (X) O�vner or Legal Representative: Date: ! 0 3!' _ The issuznce of this permit b;� th� Health D�partment does not guzrantee the issuance of oth:,r required permits. It is the responsibility ef the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvemeut Perniit 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 connpliance with the provisions of the North Carolina `Laws an�1 Ru[es for SewaQe Treatment und Disnosal Svstems'(15A NCAC f8A .1900j. Neither Yerson County n�r the F.nvironmental Health Sr�ecialist warrants that thc septi� systeu► will continue to functiun satisfactorily in the future, o: that ihc water suppiy wiil rema:n Rotable. _ _ _ _ _____--- Autt�orization to Construc� VVastewater System See site p�cni and addit:onal attachments (�. x Proposed Wastewater System: ��►�+ �� (*)Type � Design Flow _�%�__ gal./day N�w � Repair _ Espanston _ Soif LTAR: ,�O gal./day/it2 Type cf Facility: ��5 . Iiasement: � Yes _ No (*) Sysrem Types Illb, Iliirg, I i�; nnd V; req�sire peric�dic system inspections by the Person County Heafth Department. - Wastev�•ater System Reyuirements Tank Size: Septic Tank �%dv gal. Pump Tank �� gal. Grease Trap '—' gal. Drain%eld: 'Cotal Area � O sq. ft. Total Length 3�� ft. Max. '1'rench Uepth ?� in. Trench Width 3 ft. iVlin.Soil Cover � in. Min.1'rench Separatiun � ft. Distribution: Distribution Box / Serial Distribution / Pressure Manifo(d iC _ Specifications: �..��Q �/"1(?�v�� wYsic��, SL.-e-e{�� j'IV rS%�H �� ('Q`R°'�''�'i ��l2two /ih)/1D�i V �:n.P �� Q S �1 da.✓K . � Authorized State Agent: The system permitted is: (:onventional /Accepted �_/ Altern ' e / Innovative . i accept the conditions and specifications of this permit. � (X) Owner or Legal Representative: Date: �a Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573% ph: 336-597-1790 (rev 5/12) ��j�� .y � � � �� icnwn�c-�:n.a.,,-,�,• ��rn.�.,�.� �"��.a►.Il�G�n. Sloped To She3 Water NEIvlA 4X Simplex Contml Panel +}" X �4" Pre�sux�e Treated Post 12" Separation Electrical Cnxtduit = 0 w 6" Covar • ' � Access Cave=• .• , ' : ;• �+ i . ; . � • - .• , .. . . � ,..�� ., . � � i � •,. , •Y � , ��, Opexciny Filled VY'ith A�:ii Siphon Hole' Iz�et Fmm Septic Tanlc Portlau�d Cement Gxaut �� Ii�� 4" SCH 40 PVC Pipe� � ' T�x M�� P�rc � # � Su�V�ci�ivision . ., Fh•�se �act�ion Lo # Duci Seal Both Ends Of The Cond�it -� 24" Minimum —� ,. ., Threaded Gate Yalre •• . . Zip Co Ties Check .f.Nylo . Valve R,ope Hig1t Water Alarm Level � (6" Separati,on) ; ; :. , High Level - Puxnp On � ( �Vapor Lock �� ,•. ;, � �L_Drm�rdrnvn �Up H311) • � IC. .�, '� � • . Law Level-Purnp Ofi . �•„'t �P ' Precast Concrete Tax�k 4" Coziczete � � � ;.; (MaterialStsength>3SOOPSI) H1ock . •`: ' '' : ? ,. •• _ _` . ' .' . 'r '• . . ' ' .� • Cozuxete Risez 6" Sepaxatian • '•� ' . � :r..��' - `_" '�^,,...�-Portland Concreie Crmut . _ . _: Ma�tu - • - : � Opening Fillad With Supply ' po:tland Caznr.nt Gzout � .. Outlet To D'utnlrutiox 2" SCH40PVC Pi�e F1oat Wizet ' � .� �• F�oats , , ,4..R.emovable '.:' Float Tree � ' �. r � • �. �. ` � 1 • �. � . . O� � GALLUi�T FU1t�P TAl�TK i::. 'J o' u �P �� l �-3 5 � � N�,� ��H- ��`�,�� JPI��.�� --= � � � �� ,� �s� �s 1E.sa�ns�m�* �*TM* �eaa�a.�t IHL�.�.1L+ena Owner: Tax Map: A a�} Parcel #: ��1.2 Date: �— '{ I.ine �'ap Tap (Sc�) Tap �'lopv I,ine �ength �'lodv / foot # i)i eter(an) ( m) � �. (ft) 1 2 0 7- a� c� . d`� 2 Z o� Z• fmc�� o� 3 D , [Dc� � .0�7 4 5 6 7- S 9 10 7 d� ft of line x 65 al. per 100 ft=�� 5�: 100 = ��gal 75% x l Q S gai = 1�E� gal per dose � 3 gal per minute (gpm) = I+'low IZate ��'riction �ead u r I.oss: %�ft per 100 ft of supply line x'� -(�s ft of supply. line = 100 =�ft � ft x 1.2 =_� ft of friction head Manifold Size: 3 " Forc� Main �ize: Z " PVC �otal Dynamic �ead =�ft of Elevadon head + ft of Pressure head +�ft of Fricdon Head = `� _TDH � , � ,, . , 4� Puump Requirement:,� GPM �.. �• 3� = ft of Head Drawdown: �_gal per dose � 21 gal per inch =�_ inch dra.wdown per dose , _ , �, � .� � r a:� � � ,� �,� � a �� — :� a��cs , ,... ,i � . , : , . . . .'��! ■� � �� . . ■[c�»�omoo -�-�-o-�-�. o-�-o-�-e_e-o-�-e_�_a-o-�-�_�-�-r-.-�-�-�-o-o_�-..-. i► �i� i► u� ..............�..�............ ; ... :, ._ . . . .............................. _::= ,.:,._ .� :::�: 9�� . aaim� • l�ianifold Siz�! � Ta s ii�Ia�ii'old Max Na Taps off one side Siae (�duce h '/: :or ta f �oth : u» �a,.a 3/.» tans 1"' j 3» 4a+ � . . . _ � ' �`!uw er Tap � Size iLl�erial Flois GP3�1 l.c" Scl:ed 30 �•� 1; ,, SC112d 1Q %. i � , �• .�cl:ed 80 I� 1 ., . SClied ?0 I=•= :, ' North Carolina State Laboratory Public Health Environmental Sciences �'licrobiology 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: ES062514-0058001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: BOB ROSE 991 ESTATE DRIVE Collected: 06/24/2014 13:30 Received: 06/25/2014 09:10 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raieigh, NC 27611-8047 htta://slph.ncqublicheaith.com Phone: 919-733-7308 Fax: 919-715-8611 Derrick A Smith Angela Heybroek Well Permit Number: A24-192 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Denise Richardson O6/26/2014 E. coli, Colilert Report Date: 07/02/2014 Absent �C]E�'VE� JUL 0 7 2014 BY: Explanations of Coliform Analysis: Denise Richardson 06/26/2014 Reported By: Denise Richardson / � � 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. 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: ES062514-0037001 Date Collected: 06/24/14 Date Received: 06/25/14 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.3 Sample Description: Comment: Name of System: IZ�773�� 991 ESTATE DRIVE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slph. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Time Collected: 1:30 PM Collected By: Derrick A Smith Well Permit #: A24-192 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 140 mg/L Chloride 14.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.32 4.00 mg/L Iron 0.16 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 11 mg/L Manganese 0.07 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 8.3 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 29.00 mg/L Sulfate 210.00 250 mg/L Total Alkalinity 198 mg/L Total Hardness 390 mg/L Zinc 0.08 5.00 mg/L Report Date: 07/03/2014 Page 1 of 1 Reported By: Arnold Hvll IS � �. �.� . CONTOUR.DA7A- � � . •: . 71 �� F � 72 �e� s�� ' ��"" �w� s�o oae ��e +�',,9,� �S �� e1�' a`� � � � °�`�t�° 5al � sr �T � � �� .�R �.� 42a' ` ��' � CCT�ITOUR , .�� . . . �O os�, . . aS > . �f •� � " � �� ► �i as � fl t � ,(v � 1 . l\ � ` j G1�. , � � N� � G � �j `,� � i'� � �ti Z ('�` .'.. SEE � � _ BOUND��iRY ti . —` � ,�,� DATA `�v'o � �'t5�'� � �I S c5'i' �''�` '` p ' C�� . ,` \� '� �� 1� � � S � p % � � � � �y �tr �� 1 ` � � � I�FIE�D \� IS �� 4T i4 F� . ` �-�`°� � `, o�� o ��, �� . SE� Rt3A0 DATA CE c�� zs �;�� M .�,`�`,� �'D 0 t,.(f��' � �} ' �\JQ' �' -� c�Y-� J� � � �,� � �� IS 2i IS 2� `�� S �22 19 C74 Pt9l�PlIF�� EASER�E�1T� r—_,.' _ - --- `"-� 20 ° ---a'"' ; ; /i��2_ � S' � �'^� �4 I S � G �S j� � / \ . tiQ' ' Gro� r'o IS /' � —�__ Pt1MPL I NE E�S�.�IE�i�'�, � � � 42 � �S �� `��, f ��.� �� . . . - � � c� � gJ1�7C�Y ]��s�� .A ' IHt��.Il¢]Ea. STTE PLAN , f►�� /�; �, � � �t 1�'7!�... - .. ��, � .� .�� '1►�5�.,!ru�i��r S �.. . 3�1�13 �°�P.�.� l� �o�.. S7- [o r�c� � . �7— . .. -3pp a�c�� C��r��-� Tag Map # 1"� ��Patcel # I� Z Secrioa/ �� _ �! T . Date System rnmponeais repxseat appmavmate rontiours oaly. The coatractormust9ag rlre syatem prlot to begiaaing the iasmllatioa m _ tasunethatpmpergiadcismamta�ned _- — . l -------- � _ _� � _ _ ---�1,-� — - �_ _ � ._. �, � ( - _c;v� / _ ._ - � �(�' l 1�1'Q�+c1�1 � �ch_. 4_S .: �1ow� �.�a��'� a �� Q��a �- S�`.eks ` �C�-G� i � Q'c�Ps��s c�rrt �r� � �� 3� 5�7-1'7�'0, l << _ � � � ��, Sf ��..� �� ' C� � t�T�� I�aa�n.a-a��an.��n.��.IL �-3L��n.Il�I�n. Applicant: /7J � KaS� Location: t��eration ]Pe�m.ii � System Type (From Table Va): h Type V& VI Expiration Date: Q Taz Map �2� arcel � � Z' Subdivision �� rh�s�is��t�o�.ot � � # of Bedrooms , 3 Product (IIIg): � �� Type V& VI Renewal Date: This system has been instalIed in compliance with applicable North Carolina General Statutes, Rules for Sewage Trsatment and Disposal, and a�i eonditians of the Improvement Permit and Cansiruction Authorizatio . � �Q,�� 3—1 (Aut�o izsd Agentj � ` (Date) � � �ehb �—ZY-� � (License Con�actor) n �� } nNm� ��x e .�- (rate) x � /LA��c lA � d' � �'�t.9� h i 'f��` ��l S��' � .�, Scale �K�- PCFID, rev. 12/14/12 �' [:]sT Q Pr ��i ��PP'y ;� i�,s�`� � 1►��- �' e p � �Y �lrQ UK�7 � �-�-� � �-2 �� `� � (✓ . � JQP (!�7 , ,, C�o� �� / �l �lt � a' � � � � /5''/ �,,,' �� . �4=,v e.--� � �Q�� `i��n i�P �/�/ � ��i� Line Length ,�/yt / oo' ti !oo ' 2S o' �� ' /D Tax Map: �Parcel #: l97� SepNc �'ank System Checklist (Type II�I� System Type: `'�'_`"7_ � s; i � c�, ti..t Pamp Systeffi Checklisi Contracied Certified Operator (T'ype IV Systems): h�� WELL CONSTRUCTION RECORD This form can be uud for siogle or mulaple wclls i. Wdl Contraetor Informadou: �' �1 ��Jov i e �• PK c.� 177` Well Contractor Name �3�� -i� NC Well Couhactor Ccrtification Numbcr Barnette Well Drilling, Inc. Compa�+Name 2. Well Constracdon Permit t1: � 2' T Lfsf a!lapplicable we!! rnnstrvction permiu (i.e. Cm�nry, Smre, �ariance, erc.J 3. Wdl iJse (c6eck well use): ❑Agriculhuai ❑MunicipaUPublic � ❑Geothetmal (iieating/Cooling Suppiy) �dential Water Supply (single) QIndustriaUCommercial ❑Residenaal Water Supply (shared) Non-Water Supply Well: OAquifer Rechargt ❑Groundwater Remedia[ian ❑Aquifer Storage and Recoveay ❑SaliniN Barrier ❑Aquifa Tes[ ❑Stormwatcr Drair�e OExperimental Technology OSubsidence Control ocreothermal (clasea Loop) oTracer �Geothetmal (Heating/Cooling Retum) DOthu (expiain under tt2I Remarks) 4. bate Well(s) Completed: 2'��c Well ID# /J 2� sa wen Locatiuo: �izi� �> S e Facility/QwnerName Facility ID# (ifapplicablc) fh�2 �E' SGf�12✓� �id�c'.�PiJL'�c�7� Phys"tcal Address, City, and Zip `�P u�� lg Z Counry Parcel Identification No. (PIN) For Interoal Uu ONLY: �e weTca �nniFs, _ ft ,[r!' ft r�� rr. %� f� S�. A ( � I z�c� f� I 6��°- � So R a, ��'vc, �ar�ciN�nv��rnnrnir_i�.,.rr..'...a�.-�..�..ea....�� . . . � . . . . � {� � [�, ia R R ro- t�tt :OU' fL ft ft ND/� ft it rc ft ft tt ft ft fL f� �- ft �- � � ft CG ft R. ft i� ft h tL fk ft rr. i�! '. AL ... FMPLACEMENTM6TAOD �.. al sheeb if aece3sary} 'T10N {coAr, hardaes�, coiU'sek type, erain �ize, da) � P t�u Rc9.�iLf �_ � /. / _ Sb. T.ahtudc and Lougrtude �n degreesimiautes/seconds o� dec�mal degrees. 22. CertiTication: (ifwall ficld, one ladtong is safi'iciont) 3 6� � c� 4,i rr 7�'1' C� � C� 6 w �Q�c�u9 � �iu��+E- � Z-S' /,,�� si�ature of Ce+tiSul well Conuactor Date 6. Is (al'e) tht well(5): ��rmanent or OTemporary• By signtng.this form, ! hereby cert� that the wel!(sJ was (wemJ ovnsrructed in nccorelonce widr ISA NCAC 02C .0100 or ISA NC�C 01C .0200 iYell Cons�ruction Standards and rhar a 7. !s this a repair to an existing weU: �Xcs or ['�i'�O copyofrhts recn�d has been provlded w rhe x�e/l owner. Ijthrs is a repaf� fill ont bwwn wel! conslrtrclron informa�ion w+J ezp(m'n the nanere of the re/wir vader k11 remarks sutran or on the back ojthls jomc 23. 5ite diagram or additional well det�ils: You may use the badc of this page to provide additional well site details or well 8. l�tumber ot wells constructed: � construcfion detaiLs. You may also attach addition8l pages if necessary. For mulliple injeclion or non-waler supply wells ONLY wilh the same cottclruction, yau can .nrbmtt onefor� SUBMITTAL INSTUCI'IONS 9. Totalwdl deptfi below land sarfaee• ��v (ik) 24a. For All Wdlx Submit this form within 30 days of completion of well For muliiple we!!s lisl a/! depths rfdrJ"erent (�mnple- 3QZ00' and 1@l00� constiuctiOn to the follOwitlg: 10. Static water level bdow top of casing: Z-� (ft.) Division of R'ater Qu�li�ty, Wormation Processiug Unit, IJH+a[er leve! ts abave casing, use "+' 1617 Mail SerYice Center, Raleigh, NC 27699-1617 I1. Borehole diameter � (in.) 24b. For Iniection We1Csr Tn addition to sending the fortn to the address in 24a � above, also submit a copy of this fortn within 30 days of completion of well 12. Well construction method: /�% ��,_ i�r'� �f%itN canstruction tothe following: ��-�- 8UlS�. �azY. cablq dicecl push, dc.) Division of Water Qualitp, Undergroand Injcetion Control Program, FOR WATER SUPPLY WELLS ONLY• 1636 Mail Service Center, Raleigh, NC 27699-1636 13a Yield (gpm) Z � Method of tes� B�Own20 Ittinute 1Ac. For Water SupnW & Iniection �Yells: Tn addition to sending the form to the addfess(es) above, also submit one copy of this form within 30 days of 136. Disiafection HTH '� �2 CV completion of wdt construction to the county health dcpartmcnt of the counry type: Amount• p ��e �� Fam GW-1 North Carolina Departmrnt ofFavimament ud NaGaal Reso�uces—Division of Wa�u Quality Revised Jan. 2013 �..�� S f ��.� �� : �� c� � �� .�a��.�� WELL PERMIT (New�Repair� Tax Map: � � Parcel• � q� Subdivision: Lot: �S' Applicant's Name: �' ��- Mailing Address: Phone Numbers: of Property: U YGtitc� �< J --� 2ra� . --� Fs�a ;� 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 5 years from the date of issue. �n Other Conditions/Comments: �-�P.,p„l.i/`e�� D�'� oT b�c�, �vqrqp'�y Permit issued by: � Date: i��'7'�3 CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: � Grouting: 2'Z�") LI Well Log: Well Tag: � - Z l - �� Pump Tag: � Air Vent: ✓ Hose Bib: � Casing Height: V . Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: Grout: Well A6andonment: EHS/Date Completed: Method/Material(s): _ Well Driller: �p,�v��Q,�i'('(� Pump Installer: ` Well Approved by: �� F"l � '� � Date Sample Collected: �v a`� (`� License #: License#: Date: ' Z � — l Date Results Mailed: Person County Environmental Health 325 S. Morgan St., Suite C� Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 8/1/08 31'.e� a�o� � �! � � �., � � '1�� .� ��,. North Carolina Department of Health and Human Services Division of Public Health 1931 Mail Service Center • Raleigh, North Carolina 27699-1931 Bevezly Eaves Perdue, Govemor Albert A. Delia, Acting Secretary Onsite Water Protection Branch March 2, 2015 Todd Vore 10812 Ashland Mill Court Raleigh, NC 27617 RE: Approval No. WWM497 Existing Well Located Less than 25' to Building Perimeter —Rule 15A NCAC 2C A107(a)(2)(M) 991 Estate Road Semora, NC 27343 Laura Gerald, MD,1�iPH State Health Director On February 27, 2015, the On-Site Water Protection Branch received your request for a variance to rule 15A NCAC 2C.0301(b)(1) to allow an accessory structure to be located on your property less than 25 feet from an existing private water supply. Based upon information provided by the Person County Environmental Health Department and the property owner, it is my finding that you meet the conditions necessary for approval of a variance as specified by 15A NCAC 2C .0118 (a) (1) and (2). On that basis and provided that the foltowing conditions are met, the requested variance is approved: 1) No pesticide treatments (i.e. termiticides) for the new structure shall be applied within twenty-five feet of the well unless alternative methods are approved by the local health department. 2) The well/wellhead shall be inspected by Person County Environmental Health and shall meet all current 2C. 0100 standards, including but not limited to being properly grouted, terminated at least 12" above land surface, properly sealed, etc. 3) No potential sources of groundwater contamination shall be stored near the well-head. The approval of this variance does not affect any of the other requirements or limitations of the Well Construction Standards, including but not limited to the requirements in 15A NCAC 2C .0113(b) to repair or to abandon any well which acts as a source or channel for the migration of contamination or to your responsibility to comply with any other applicable Federal, State, or local laws or regulations. The granting of this approval is for the well location only, and in no way relieves the owner or agent from other requirements of the North Carolina Well Construction Standards, or any other applicable law, rule, or regulation that may be regulated by other agencies, nor does it imply sufficient water quality. If you have any questions regarding this variance, please contact Wilson Mize at (919) 218-5383. Sincerely, L��:� R�.� � �'Sln�; Wilson Mize R.E.H.S North Carolina P�blic Hmlth Workiny for a Feahhier and safrr Nonh Cero7ina EvcrywMerc. Everyday. Everybody. Location: 5605 Six Forks Rd. • Raleigh, N.C. 27609-3811 An Egua! Opportunity Errrployer ��c �r��A v r� �, �> � ` � / � � � \ �,�,��.�,I.�. �- , � , .., � ► --► �-. ,:� ► � � � Suilding Additions/ Mobile �Ionne Replacemeots Tax Map #:—/� Parcel#: /� � Address: %%/ �'�I'/1?'� /�r�- Approval Requested for: Mobile Home Replacement � Building Addition �.�o�oo�� o�� ,�/ �f `X 3� ' ��T�o2i.,/'r� Applicant Name: : Gf ya� I�r��lf�t� Address: Phone #'s• �� ZZ� Permit Located: � Yes No Installation Date: � Design flow, ?b (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: /✓� ) (Applicant's signature if site visit is not required) Addition/Replacerne�t Approved Envirarunen al Health ecialist /l /� /7 Date Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790! Fax: 336-597-7808 www,personcounty net AY�:i��ro� �3aie: � � � � � � Amoant Paid: Receipt #: --�� Ap� 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Bnilding Addition r------� ��y � F� Y � '�.�,�J � 1[��;�1� . - �:�� ]E��asoaa.+**�* oa�.m.Il ff�[mmIl�lla Services for Services ❑ Construction Authorization (Fee is dependent on the type 0 Permit Revision : aa Ndup: / / � / Parcel#: $150.00 if sfte visit re uired $75.00 0 Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$�75.00 Application: No Chazge/ CA $150.00 or $300.00 1) Applicant Iaf rmation: /� � 1 � � � � Name: � /.� � �l/r � Phone (home • Address: (work/cell): � 2 � �% � 2) Name and address of current owner (if different than applicant): Name: Phone: Address: � � /�s`�� #. !-� 3) Property Description: Lot Size: Subdivision: Lot . Address and/or directions to Property: ❑ yes no es the site contain any jurisdictional wetIands? ❑ yes —n/o Does the site contain any existing wastewater systems? ❑ yes ��y� s any wastewater going to be generated on the site other than domestic sewage? O yes n� o ite subject to approval by any other public agency? ❑ yes Are there any easements or right of ways on this properiy? (if `yes' is checked, please grovide supporting document ion) � � ss 4) Proposed Use and Type of Structare:, ; e�!�%f� � � OResidential O New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With ptumbing fixtures? ��X . z. ❑ yes ❑ no T r �Non-Residential �� Type of business: Total Square footage of Building: [ Maximum number of employees: Maximum number of seats: �/�l J/I_ /lfiiyT T 5) Water Supply: 0 New well Existing Well ❑ Community Well ❑ Public Water O Spring ,3 � x�� Are there any existing wells, springs, or existing waterlines on this property7 ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: �6) If applyiug for `Authorization to Construct', please indicate preferred system type(s): �/ � O Conventionai ❑ Accepted � Innovative ❑ Alternative 17 Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, th 'te is subsequentl altered, t e intended use changes, all permits and approvals shall be irrvalid. _ � � � Signature (Owner/ Legal Represent i e) Date * Supporting documentation required. Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. sz (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336�97-1790) \'4 . DUKE Et4ERCY PROGRE55 HYCO LhKE _ ----_.��,�.:� .��.�.•�,�._�.n-�._�..��,� �-��.,�g_-.,��_.=,�-�.., LEGEND ExSatlnp Iron Bar (1/2` unlees notad) 0 ErSetinp Iren plps (3/4' unlees noted) p 1/2' Iran Ptpe Set O IPS F�tlatlnq Noll � � Na71 Set p µs fbuputed Pelnt 0 420' CONTOUR� . � T7 N 6641�49'_ E„ N 8641'4^ 9��E � � S B�t541' E 1 Y � SB.93 �� 141.04 � . �c � / ' ` . �` h.yM1�O `V `" J� ' � v�i .0v �. ��O/o�', v " `�Z ;a ^ z / 1 pEyk�t,s�fr� '�? `�S' � � a g '�'�LT�. \ , U � � Dt1KE EPtERGY -� 1 d z� � % � � PROCRESS / �.i � � J � HYCO LAifE � � � / � I w PRoposED ' , % " � N�'° . ac� sum . , s � \ �\ - �,�-_ �w�' '�,,'� i �� azo' � ` '�P�°. � ♦ CONTOUR y t^ � �� s�m� % \ / ``� TFIE (2ESERVE � � k � . / � � {20' j `\` P. C. 6� P.� 93 � .; .. ACRES - � ��o�R � , _ L07 16 � \ g g3��e'29� W � '1" - � DRAIt�IECD � i �__.,_--- --"�� 6723 �� E R6ERVE � �/ � i� h/� ~\ � 7 AT HYCO IJU� o� •��! i� �� ,,�i/'`� � �,./ P.C. 77, P. 149 b, N ,y0/ ` /� '� � � : � / ` 6 � � `,\ ` h� �ry� ' \`` `- �' �� / �� LOT 14 `~� � � � DRAINFIELD � , � �, �\ M1 ' � � \ L07 ]3 x / i LOT 15 � ��\ THE RESERVE � �I ORAINFIQD � � AT HYCO LAKE �=l'o / � iV BA1 OEEP WATER � P. C. i6, P. 493 *: '-�a O�D •'� ` % '� •� OEV0.0PNENT. LLC � o' �k$' M�9 � r��ah°' 0. B. 783, P. 74 . f, 5� ' � Q�� ti CONSERVATION . . f ` / `\.�r� / F.ASE'AfENT . D . . �' . � ?i N� �,p�?j. � � \�? � m �`� � , / \� ,`?� � � � �� au o� wnr� \ � � / .'_,�\�� NORTM CAROLINA PERSON COtJNTY ��` �D.�&� 78P 3� P. 7ac � �, "� �� -'/ , / r, JOHN J. JENNfNCS _�IFy THAT 7HIS �� CONS�fiRYATION �,14 �__�__��- ',� / PLAT IS OF AN IXISTING PARCE3. (OR PARCELS) � EASEAtENT \ � f�ITHIN PERSON C6UNTY AS RECORDF� IN DEEL 800K \ r, C 5 67'�8�51' w . / / .4�4. PACE �.Z4„ AND/OR PLAT .CbE.1Z� PAGE 149 _ \ � r 2Q' P�1NPllNE F�� -``�' �� ALL PROVISIONS OF NOR7H CAROLfNA GENERAL STAME � � -----�-- {PRIY�t'f� 47-30 A5 ANEN�m RECARDINC THfS SlJRYEY HAYE BF.Ek �� 1� �—�-r--- uEr. o�tr�ss io�r�rn uru seu. ntts � aAr o� � �_ , � ESTATE fZZOAD :, �� VARIABLE WIDTN R/W � � �-� ,"�i . • \`\ � �/' ��'�� i�� _ T 15' P�IMPLME FASEMENT_ --� ��-/',/ • �rt �Ior�nL � vero - �� j • ��3�� . /' _�,_,r-__�_— .�_ -��__f U . ; o /_ y �� . ; �. / /� ' . JOHN S. JEIaltNGS ' I. CERTIFY 7HAT 7H15 ' PLAT M�AS DRAN'N IAJDER W S11PkltVl5I0N FROY . �/ AN AC7UAL SURYE7 YADE tJNDER MY SUPERYISION / (OFFJD DESCRIPTIOti RE(�R�ED IM BOOK �.4.9.. ' . PACE �.Z.'�. ETC.)(0T}�R); THA7 THE BOUNDMIES NOT SURVEYED ARE Cf.EARLT If�ICATED AS DRAWN F'RO{t INFORl/ATIDN FOUI�ID IN BDOK �,4,� PAGE 674 • 7kA7 THE RA7I0 OF PREC7SIDN AS CN..- CULATED IS 1: � N01E -.THAT THLS PLAT WAS PREPARED IN ACC9RUANCE YIITM Q S 47-30 AS AiIEiIDFD. lYI7NESS MY ORICtMAL SICNATUR� REGI57RATION M111BER AND SEAL 7NIS �_ DAY OF NOV. A. D.. 20 17 - SURVEYOR \\ `�`� � u.�.d P RECI57RATIOM � , �-3052 � � � Y � m v ndd � � o�� CSU 0 6da: UICINTTY MAP ,-=oE`.�-�� Ss��y�: : Q. 'Q L-3D52�. - `: v�s��i c . �,1, �.. ��"�',: UNE BEARIIIG DISTANCE L1 N 59' 32 W. 5p.96 L2 N 273110 W 44J4 L3 5 557A 0 W 4�.15 L4 S OG55 J6 E 15A] CURVE ARC IENGTH RADIUS DELTA ANGLE CHORD BEARINC CHORD LEHGTH Ct 8.85_ 3�5.00 1.2812 8G2445 W 8.85 C2 25.88 345.00 4.7388 �S 83�32 42 W 2Sen �C3 j5J.31 1330.00 110.2841 S 764233° WT53.?5-1 NOTE: THIS pLAT IS A COAIPOSITE PLAT ONLY. : ALL POINTS StfOWN ON THis ?LAT nr� ►u�Tsc�t, Potrrrs or�x : ftEFER TO REFERENCES FOR CORNER DESCRIPTIONS. : NC f'.E.i. SJP.�C. ifGR3C k"� pERFORMED A7 THIS DATE. . TAX 1lAP: A24-792 TNC YAFiCEL RECDRO NUMBFR 27879 j_. 0 50 9Q0 75p SCALE: ]' � 50' d L��J � �� Ir ¢ � � � u% O n � N � � �� z� m aF �� o� � � �� O �N o � �^ � � �°0 a O �o pO{� °' " )J O NM � \J � N6� Application Date: Z5 s Amount Paid: 4� O 0 Receipt #: 71�2- Cred��a+r� Ap 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/Repair) $300.00/$200.00/$75.00 ��?,) f �11G��A. � Tax Map: Z� �_ � ��,�� Parcel#: � I�sawna-o�a�sn��n�an.11 IH[ �en.11�l� tion for Services Services Re uested Construction Authorization (Fee is de endent on the e of s stem ermitted) Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $ I50.00 or $300.00 1) Applicant Infor ation: � Name: ��GIL ��oy ��G"il— Phone (home): Address: (work/cell): - S�Z- 3Z�- 2) Name and address of c rrent owner (if different than applicant): Name: O �Q Phone: Address: E S Seszc�✓ � N�- �--�J � 3) Property Description: Lot Size: Subdivision: fGLQ �._SC►'``e Lot #: �_, Address and/or directions to Property: ❑ yes ❑ no Does the site contain any jwisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes O no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this properly? (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 Existing System If expansion: Current number of bedroom • 0 Repair to Malfunctioning System Will there be a basement? ❑ yes o With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Squaze footage of Building: Maximum number of seats: ��X 3ZI 5) Water Supply: ❑ New well xisting Well ❑ Community Well ❑ Public Water ❑ Spring � �r� an� i�tipg wells, springs, or existing waterlines on this property? ❑ yes ❑ no ,� /�;� �/ 6) If applyin�or `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that th ' formation provided above is complete and correct. I also understand that if the information provided is inaccurate, if he site is subsequen ly alter , or the intended use changes, all permits and approvals shall be invalid. � zS � �. . -- _, T _ �__,.,..... ...v*� ate * Supporting documentation required. Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot 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) � k � -� �� . � � } �� ,j4-� �� :�� `"..��` �`" y� �� " ! �� ''�� ,��.z�-�,��.T�=��.��.,�:<�,�1 ��-�[��.�.Il�:.i� �a�a�d�� 1��#�m�a�/ IY��bnfl� ��a�� fl��a��n�5 � Tax Iv1ap #: �a`� Parc�l#: 19a- Address: 9 9 � ��'E � Approval Requeste�i for: Mobile Home F'ceplacement �— Building Addition Applicant Name: C�u� t�. ��—' L� 6,�sc.�t '�.i.�•.� Address: , Phone #'s: �3� - 59� - 3�,a� Permii Located: %� Yes r10 Installarion Bate: `1-��}-1� Design flow: 3ba (gpd) Current Contract with Certified Operator on file (if required): tJ � . Water Supply: X Well Public or Community Wastewater system shows no visual evidence of failure on: a�� 5-1� (date) (Applicant's signature if site visit is not required) Comments: /�t�o.�,��. �v0., aw�ss�.�t s�.� � ►"� f�a�s� . ._i�� tsa�,. ._ � . .fdn..n \� r. 'Rrstl��+c nQOflrwi..-� '�Y 'l'i�t'% S":�QiF ^Sl1 'a1i.\�� :N ►.��s�.,�.-- ��r��H��a�e�ar ��p�� . G. �.� Environmental Health Speciaiist ��3�is Date Person C�unri Eiiv;ronme:�tai �Teaith; 3�5 S. tiiorQan St., Suite C; Roxboro, NC 27�i3 Fhcne: ��5-�97-??9C/ ra;:: ��5-�9�-i80S ' �:�,;,��i.�;ersoncoun�tv.i,et Application Date: � S T� 06 /�_�q-j I� i�� Tax Map: Amount Paid: 000 , D 0 ��d d� ` �� a � Parcel #: Receipt#: (�-} 3 i-4 I�7 60 �- ci�`�k I� 16 p,/ � � 6� �� S ��..� �� I ��. �` � � � c� � � � � � 8��t� S�� "�1P � av.-w-n u aa aa +•-„��, .c-»rn �:.m IL IE-�t �-,.�. ll �l�n � I�/�'� �' �• � Application for Services (Septic Systems and Wells) Services �4 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/Repair) $300.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 � Repair of Existing Septic System Application: No Charge/ CA $ I50.00 or $300.00 1) Service��'i�gques ed — — � Name: a�� '4`,� Jf Phone #(home): 3-3� �/y �/.�%%�3 -�" Address: � 5 S. , .r (work/celO: :�3 �'� - � �� r" �' M � ti{ �_ 2)Name and address of current owner (if different than applicant): .A1or�((� ��S�u�.�,�.wc � Name: `�' � �� Address: � -. _ 3) Property Description: Lot Size: Subdivision: Address and/or directions to Probertv: ., _. 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 `i� 5) Water Suppl�: Private Well � (Proposed � Existing _) Community Well: Public Water System: . Are there wells on the adjoining properties? No _ Lot #: / ^� � Yes �K (please show location on site plan) Note: A comnteted application must also include: ➢ A plat/site plart of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. 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. Signature (Owner/Legal Representative): �- ��` Date • �� / 10/O8 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) _ i