A24 200Application Date: � s �! p,� �_� c� -� �� i�. ��� Tax Map:
Amount Paid: 0o0 , O(� �a06. � ��� a � Parcel #:
Receipt#: _ C 4 3�-4 I 7 6d �- c.12�# I.�' I d p,/ � �
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./.��: �z�) ID'I�--1� Cred� C�, �'
Application for Services`�Sep icGSy tG s and Wells) --
Services Re uested
Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d (Fee is de endent on the ty e of s stem ermitted)
❑ Mobile Home Replacement or Buitding Addition ❑ Permit Revision
$150.00 if site visit re uired) $75.00
0 Well Permit (1�1ew/Replacement/Repair) 0 Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Service��a �ues ed4�`� -�---
Name: Q� `�-�`J� J� Phone #(home):33� yy�,��%��.�
Address: S �c.,�, � L.r- (work/cell): :33� - ✓ ��'�
r,' n,. � Ot O�
2)Name and address of current owner (if different than applicant):
.�Jor%QQ ���S�ul�n.w� �
Name: `�' � mr� -
Address:
,�
: 3) Property Description: Lot Size: Subdivision:
� Address and/or directions to Pronertv: _. _,
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 Suppt�:
Private Well � (Proposed � Existing _�
Community Well: Public Water System: .
Are there wells on the adjoining properties? No _
Lot #: —�' 31
Yes '� (please show location on site plan)
Note: A completed app[ication must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of al[
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be eva[uated.
I am submitting this application to request services from the Person County Health Departmeut. I understand that
if the information provided is incorrect or if the site is subsequentiy altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): �- �� Date • ��� `��
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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_ �� � � ����
]C���.�a���� ����.Il IL-���.11�I�
Tax Map: 2 Parcel: Z��
Subdivision S �
Phase/Section/Lot # 2 �
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: i2 S- New � Addition _
Number of: Bedrooms �/ Occupants / Emp�yees / Seats:
Proposed Wastewater System: �O "�(�Yc�� Q��rqMe �2r- e�%R-� u
Proposed Repair: (�-; p -�-�-,'_qQ '�Y.
Permit Conditions: 5�2� �� t2 St�t-o� �►
Water Supply: �� ��
�Projected Daily Flow: 3�v c� galloq�s/dpay
✓1t.l►-ril� TYPe� �. � r
Type: �_
Authorized State Agent: N^ ` v Date: - -�
(X) Owner or Legal Rep esentative: � 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 the provisions of the North Carolina `Laws
arrd Rules for Sewage Treatment and Disposa! Svstems'(15A NCAC 18A .1900). Neither 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: �0 �� L-• �� n r,,i� �un'1P (�`)Type � Design Flow 3� D gal./day
New � Repair _ Expansion _ ��— Soil LTAR: ,�?5 gal./day/ftZ
Type of Facility: ��I� �. Basement: � Yes _ No
(*) System Types IIIb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �(i � gal. Pump Tank l� 9� gal. Grease Trap '-- gal.
Drainfield: Total Area _ rJ� sq. ft. Total Length 2� ft. Max. Trench Depth � Z�
Trench Width l� s ft. Min.Soil Cover� in. Min.Trench Separation 7• �
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
�9 u) —S � p.{,�
ft.
Specifications: E�� � /i�tS� SE� � r Vp� �0 ��� Ct Co��► '� �'�
S�`� -2� .
Authorized State Agent: ,�-� ✓U`e�/ Issue Date: -�—� _
�A(�� Permit Expiration Date: �- �( Q
��
Tlie system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit. �
(X) Owner or Legal Representative: � � Date: �-�
PeYson County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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tluthaxi�ed State Agent Date
System crinrponents mjivesent appwxinurfe'eo�fbars only.' Tlra conhuctor mrrst,�lag the rystem prwr io
begraning ihe dlsfialla�r'an io i�sr+� ihde, pmpergr�de rs mainta'aed
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Sloped To Shed Water
6" Covar •
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I�let Fmm Septic Tanlc
4" SCH 40 PVC Pipe '
NEMA 4X Simplex Control Panel
4" X 4" Pressuxc Treated Post
12" Sepaxation
Electrical Con�it �
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• � Acce�s Cover � •• , ' _ ; � 1 ?
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�,, Opening Filled With Anti Siphon Hole� `
Portlaxid Cement Graut (Dovm Hill)
Check
Valve
� High Watex Alarm Level
' (6" Separation�
�. Iii�jt Level- Runp On -���
s e � '�Vapor Lock
' �, � � Hole _
' .; ' Drawdrnm �Up H�1)
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T�x M�� I ' P�rc�el # - `'
SlIh6iIVISI0ii1 " �
Ph���s•e Saction`Lot # �
Duct Seal Both
Ends Of The Coruc�.iit Concrete Risex '
-'� 24" Mininwm
' � �' 6" Separation
T�readed Gate Valve •
Union , , • ��. . .
. • , ..cJ:pt'
'4�--Po:t].and Concrete Gmut
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Zip Cvrd � � Opening Fillad With
T�� Supply �' portland Cement Crrout
Line ••
4utlet To Distn'bution
•�.Nvlon 2" SCH40PVC Pipe
' Precast Concrete Tank 4" Conczete
� ;.; (Material Strength y3500 PSn Block
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'e F1oat Wites . � �
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= � � �T��`Y �,� }�ese►� � 3
1E%�-�� ��¢�.11 ]Hi�.�.lt,� Owner:
Tax Map: Parcel #: � � Date: __�l�
I.ane Tap Tap (Scfl�) TaQ �'lo� Line �ength ]�oe�v / foot
# Iiiameter(ira) ( m) �:. (ft)
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10 �
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�2'� ft of line x� gal. per 100 ft =��°� Q a� ; 100 = Z fv o�
75% x��'� ga1= !�'S gai per dose '3 S gal per minute (gpm) = k'low Itate
�+'riction �ead
I.oss: • 3 S ft per 100 ft of supply line x`� �Z °� ft of supply. line =100 = S ft
�_ ft x 1.2 =�_ ft of friction head � �����. �,� a,�/�yv x•
Vr
Manifold Siae: 3 "�orce Main �ize: 3 " PVC
�otal Dynamic �ead = 3 o ft of Elevadon head + 2 ft of Pressure head +�_ft of
Friction Head = 3 �—TDH
h'aunp Requi�ement: 3 S GPM @ 3g • ft of Head«
Drawdown: l q� gal per dose ��igal per inch = 6� s inch dra.wdown per dose
30
�ea�l IHesign �ffor�a�,on
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Applicant: �b � 1Ko�— �
Location: �
e
�pe�6�.��� ����.It
System Type (From Table Va): �b
Type V& VI Expiration Date:
Tag Map �� Parce # 2� �
Subdivision -2 vv�
Phase/Section/Lot # 23
# of Bedrooms 3 Yj1�
Product (IIIg): 0 �r `'�• .
Type V& VI Renewal Date:
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and aiI �onditians �f the Improvemeut Permit and Consir�ction
Authorization.
d�.�..�. � _ ,.�,
(AutEoriz�d Agentj
�. L2t.v��
(Licensed ConYactor)
. ��`°� � `�
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.�;�e v-� �'`5�.�`'
Scale �r°�—
PCFiD, rev. 12/14/12
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(Dace)
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(Gate)
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Tax Map: � Parcel #: 20 0
SepHc �ank System Checklist (1'ype II�I� System Type: ��'/ �
Notes: �� .3�+1 '
C.C, `�R� $3�
Pump System Checklist
Cantracted Certified Operator (Type IV Systems):
P �•
_ . ���,s f ���.� ��
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'�° �rav�n�c-am�n.�rxn�sa�:�.Il ��a�am-���
WELL PERMIT
(New �, Repair_ )
Tax Map: � rcel: a0 c'�.
Subdivision: �,� ,PSFvv'� Lot: v� 3
Applicant's Name: �b yCoSsL
Mailing Address:
Phone Numbers:
Location of Property: 2i v � �.�� � C� � � �✓(e�ow�.t,a t, �� �� �� �
�sd-a, �-e VCc�. �r kL.) i �.� S/r� -� ca¢- Ue�y -2�ce(! �_�� ��
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�ew Well:
EHS ��_��
Location:
Grouting: ��'Z -l�
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
'�S 3-ro-�
Well Driller: �i '✓�I��-
Pump Installer:
Approved by:
���
Date: ���i
Certificate of Completion
OLiner:
EHS/Date
►�������
Additional Comments:
Date Sample Collected: `�'�'$' 15
EHS: �a
Person County Environmentai Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: 3-10-15
Date Results Mailed: `� "15=1-�
Phone:336-597-1790 Fax:336-597-7808
11/26/13
�/
North Carolina State Laboratory Pubiic Health
Environmental Sciences
�icrobiology
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: ESO40915-0083001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� (��� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
BOB ROSE
1345 ESTATE RD
SEMORA, NC 27343
Collected: 04/08/2015 13:34
Received: 04/09/2015 08:34
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://slqh. ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Derrick A Smith
Angela Heybroek
Well Permit Number:
A24-200
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Denise Richardson �/10/2015
E. coli, Colilert
Report Date: 04/13/2015
Absent
Explanations of Coliform Analysis:
Denise Richardson ��10/2015
Reported By: Susan Beaslev
� .�
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.
North Carolina State Laboratory of Public Health
Environmental Sciences
Report To: DERRICK A SMITH
inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
BOB ROSE
1345 ESTATE RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ESO40915-0063001 Date Collected: 04/08/15
Date Received: 04/09/15
Sample Type: Raw Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 0.0
Sample Description:
Comment:
Time Collected
Collected By:
Well Permit #:
GPS #:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
httq�//slph ncoublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
1:34 PM
Derrick A Smith
A24-200
New Well I (Profile)
Anatyte 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 440 mg/L
Chloride 7.80 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.64 4.00 mg/L
Iron 0.75 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 14 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 7.7 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 62.00 mg/L
Sulfate 1,100.00 250 mg/L
Total Alkalinity 119 mg/L
Total Hardness 1,200 mg/L
Zinc 0.41 5.00 mg/L
Report Date: 04/15/2015
Page 1 of 1
Reported By: Debbie Moncol
WELL CONSTRUCTION RECORD
This form can be �od for singk a multiple wclis
L_ We11 Contractor Informa6oa:
�����;C . ,� � r-_ _ ���` �
Wcll on�actor Namt
�..�7� -b�—
NC Wdl ContractorCcrtification Piumlxr
Barnette Well Drilling, Inc.
Co� Name
2. We(l Construction Pcrmit il: � ��'
Lisr a!I opplicab/e �wel( construuion permiu (r.0 Counry, Smte. [�oriance, etc.f
3. R'dl Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothetmal (HeatinglCooling Supply)
QIndustiiaUCommercial
Non-Wattr
❑MunicipaUPublic-
BRtgidential Water Supply (single}
❑Residentia! Watu SuPP�Y ���)
�Aquefer Recharge ❑Groundwater Remediatian
❑Aquifer Storage and Rxovery • ❑Salinity Bartier
❑Aquifer Test ❑Stormwater Drainage
❑$xperimentaLTechnology ❑SubsidenceControl
�Geqthermal (Closed L.00p) OTracer
�Geothermal (Eieating/Cooling Retum) ❑Other (e�lain undes }�2I R.emarks) 1
4. Date Well(s) Comptcted: �� `� �Ve11 IA# _� T
sa WeULocation:
,Qo ,� ���s �!'
C,
Facility(Qwnee Name Facility ID# (if applicablo)
1�� F�T S'-e � 4� e L- f� �— Z 3
P'hysical Addccss, City, and Zip
' /��' �� S ��,�c� Z c_' �
Counry Par«I (dcu4ficaaon No. (PIN)
Sb. Tafitude and Longitndc in degreeslmiuuteslseconds ur detimal degrees:
(�fweU field, one WNong is safficieqt)
3 G�30- �'�' N 7%-C� �-S�3 w
6.Is(are)thowdl(sj: �1'-eFu�anent. or �Temporary
T. is this arepair to an exisbng:weU: OYts or �iVo
Ijrhis is n repatr, frl! out brexn well consnucrion inJ'ormation 4�eduplain r1?e narure offhe
rcpairirnde� i'2I remarks secrion or pn ihe buc�F ojthls fomt
8: Number of wells consiructedc !
For mukiple irgection ur nort-water su�ily wtGs ONLY wirh the same eortaTiucYiort; you am
rubmit orreform. �
9. Tutst we11 dcpt8 below lind sarfacr. �� (fk)
Fo� muttipfe we/Is lutal! depths ifd�erent (amnple-3Q200' m+d Z(a�L00�
10. Static water level belovr top of casing: �✓ (ft.)
If worer leve[ is above arsinR use "+"
ll.Borehotediameter. � Co.)
12. Well wnstruckon me[hod: � 7 i��7 �/.�,� ��
(i.a auga. rotaq'. cable, dirxt pus� dc.) .
For lote�nal Use ONLY_
14. WATER ZOIVES
FROM 7'O UFSCRLPT(OlV
��S—ft / ZC7u' � . T� /
ft «
15. OUTER CASWG (or mnitit�ud �►dls OR LINER if a inble
FROM iYl DGMEZ'ER THiCfINESS MA L�L
C� n 7Cj " 6��- �R � r t�' L
16:1NNER CASInG Olt'TU[3ING eothecmal closed�vo
PROM � TO D��ME7ER 77i1CIQVES3 MATF,R(AL
ft ft ia
ft ft �
1T:SCREEN
RROM TO DUMECER � SLOT&IZE 'CRICKNFSS 11fATERUL
ft ft �
ft ft �.
18: GROUT '' ; ` .
FROM i'O MAl'ERIAL CMPIACEMF.Kf MEi7iOD Qc AMOUNT
�l.� 2 4 ga�1(� OU�
C_'j Cement
ft fc
tt ft
14.SANDlGI:AVELYACK da tieable `
FAOM TO MATERIAL EMPLACfMFNf MET�04
(c fc.
tt tt
10. AR[LLiNG [.OG aNat6 gdditional sheets if necessa ." ';
FROM TO DESGRIPITON cole� hardn �saV�vek 'a�' �et�
� fL t`.,L fk �) C%C� %� d� c.—!Z -U�
c
ft �S� ft � c1 /ti � P
�' �O r` S 2N � 1�
F o ft � o c�t f%9 �� C� i/4 � �,
ft ft
ft ft
t� rc
21. REMAftKS
22. c.erarca6ou;
,.. �
f \ (�%2. �1 . S-S-- � ��-C t � � ` 2 Z f �
SignatuceofCettified We11 C:on�r Daze,
By stgnfng this jorm. [ irereby cerrify thm 1he well(sJ war (were} constnreted in acrordanu
widr !SA NG1C 02C.0100 or !SA NCAC Q2G .6200 iPel/ Construcdon Standards aird rha! a
eopyoffhh rea�nf has beea pmviried tq (he xcl! owner.
23. Site diagr$m or additioa�l well detaiLt:
You may usc the badc o£ this paae ta proeide additional wetl. site details or well
bonstnrcEion dehils. Yon may also.attach additibnal pages if i�ssacy-
SUBMIITAL INSfUCT10PIS
24a For All Wdls: SubmiY this form within 30 days of comptetioti of x+ell
�uctioo co th+e fotlowing:
�`Divisioa of R'ater Qwility, Information Processiog Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
Z4b. For Iniection Wetts: Tn addition to sending the fortn tp the address in 24a
above, a[so subtuiE a copy of this focm within 30 days of completion of well
c�struction to the following:
Division o[ Water Quality, Undorgronnd Injection Control Pmgram,
FOR WATER SUPPLY WELLS ONL'Y: �•. 1636 Mai� Sernice Center, Rale�h, NC 27699-1636
13a. Yield (gpm) � Method of tak B�Own20 minute 24c, For iVster Supplv& Inieedon R'etls: In addition to sending the form Uo
the add��s(�) above; aLso submit one copy of this fonn witfiin 30 days of
13b. Disinfecuoo type: HTH Amount 7'2 C+up �pldion of wep wnstNction to Ehe county heatth dcpartment of thc county
whae canstriicfed �,
Fam GW-1
Nord� Carolina Depaz�cat af Firvimnmeat and NaUaal Resovrces — Divisiou of Water QuaGty
Rcviscd Jan. 2013
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