The URL can be used to link to this page

A24 202Sep 26 16 02:50p Barnette Well Drillinglnc �ELL CONST[tUCTI�N RECO�tD '[7tif fortn can be �aod for sioyle or multiple wctiz 336-598-9275 p.1 �� J � Ealdaaal Ure QNLY: L. Wdl Contractar [aform�tioo: � �> (� N �' � �� t'�' weu Co�a�.tor Narne o�� e+ �� I+IC WeIl CAnuaotar CerciEn�on Number Barnette Weli Dri!ling, 1nc. Compauy N,m� L N�dLConstzncrioo Yccsnit �t: Lfrloif�epp!lcablekrUcaru[r..utionperraiu(�.aCnueuy.Start Irariomce.dc) 3. VVdI IJse (eheck woU uss): ❑Agtiail�ra! LlMunitipaVE'�lic- QGtolhctsnal (ELcatinglCoolmg SnPPtY) �dmtiaLWatvSuPP�Y �5�81�) Ofndus�iallCommacia! L�Residmtial WaYcrSupply (sEeared) ❑[rriRalion Noe-Watcr SaPply WSII: � � � � !�s � / •7S fL ! �] fL i��O11iER:C�LStRPG' fo� fltD�! i0 � � r� ` �6'.�NCIEI�'CA'S1I46 k�[t. E¢on+ m - ft. R (L ft flAquifccR,cciiargc DGcoundwataRemcdiatian =�Y9 �i �MjuiferSGotageandAanv�� Silini(vBartfer L7AqtufCrTcst C1StoRD.water�Ihainage f]E�aimeatalTuhnology t]SabsidenceContmt '.'10z oGcbu,um�t (closad i�op? nitaocr ma �Geothennal(HoMgJCoolin it�in) OQthu �ainundertF2lRcmaiics i ,�./ �%[� L 4. I)�te Wel[(s) Cowpletcdz "2 �"(� R'cll IDN /f �' (" Z Sa. VYe11 iocatiun: �3c� b � e s �_ - Fet�7EqdUwncrNaaii FaiYtiiy ID� (if appli�61�) r J ��. £' f' � 2 �' e_ ,� �- � Ptysirrl Address. C'iix ar.d zip ' �3r.- �� s � a r� � � �. Co�otjr f'a�c! 1d�icaf tiooNa, (P'II� 56. Leatitude and Iun�tade ia.degrusr�uptestsecopdsor ded�aal i�ces: ��Fartd 6eld, oac IOdloag is salfieicutl . .. 3 � - S� c� � �l� N � -S� — �'�• �'� �. w 6'Isiarc�che�v.cu(sj: cnnaneut or �rempornry 7: Ls thTs a.re�atr tp au uistifng,wsU: i]Yes ot aIto lJd,h b o r�potr./�Prna-�h�n�xm11 wrwrnatoKiryforvrahonc�erdgpbin die rnrtr�rr oj'!!,e +rpairaRderE2l n�xmrtonoro+iAie.Goctof�lilaforrv. B.; Namber o� rvetls construded: � Ferambipfe tnjedioa or nrn-water ru�ly relis ONlYwerfi de srtme awri�adioe, youcvn rdssytonefars,i 9.Totzi"we�ldepthbelowlandsorfaee: �� (ft} For�eudnpleweJ/rf[tloRdeP�*fr��+��^3�� . i�Cf, iL .`QYLYiT: t 'r' :': _ �:;. •:. To H. -L L R ft Cc 2 tt i�. ia ! � � ra r sediN.fts UR�I�4FR'.E- �� E[irR 'Ii{ICQO'IFSS �� L^R z I , _ ,'mal:c6osed-1 "., [tr.a �tic[+�r�ss ia iL eR sr.o�rsras �aic� � (t . fc. ft 2 Gll GtiOG'sititl�`�idiGnaii[�b ifn"�sR� ro os�rriav �.� r,.a,m it �� it � V- � i� Ll.. u� cc 2 rc � c �� IG �jC �' R. 1" /� ic � � c�' ,q 4 � u tiL fi. re. rr. 2�.. f.�' f'icatio� .�� o�z ,u� ,� �r.�1� � �. 6 -1 �` a:��ofc�;s«�w�c�r� � n�_ B� u�gting�s farnr. F hurby avtify draa (6e xeti�;1 Kc+ (ro�erc) eons(rvaed ia aa-mdeercd widr I3A NCstC OZC.OlaO or !SA NCdC 01C .02D0 We11 C6rasrrveqoi, S�a�,�s ariarlmra � roPY�� reoonlJ�ns beta provkfcd ra die fedf owto_ Z3. �tt du�trtw oi sddl�onai rvcll dc:tails: You m8y nse thc baif of this page io provide aildifla� wdD, si[e d'eCails Cr catU edti9htrcGan dGails. You may sEso sTLaih additio�ial pages if nbiassa��. su�nricn,z, n�sruCn o�vs ?Aa. Fer dt{ '1VdC� Submit ibis foms wt'fhin 30 days of w3xeplefiol� af �t�eli oonst�uction toYhe'foFlowcmg: 10, Sfatie wster tevel bdoar top oftuing_ �`� �tl:) �O6 °�w�'��+�fortuaiioa Proorssing Uui; Ij'„vrer�eiiel.�c abo,�e c+sstn� ux +" 1617 Afaii Sctriee Ccnter, Raleigb, R''C Z7fi99-l617 ll. Borehol� disrntetcr: � {ua.} 241L �or I�ieclioa��Ke!!s: En 2dditiacs to saidiag the foiia t0 tfu addiess in Z4a �/ ,� above, atto sut�aut g cop}� of thu fottd witf�ii�.30 days of camplitia� of' we11 F3. Wdl ceastruction.mclfiud: t'/ ,��, �G� �� R/ ca�ut�adtotbe fallowiri� �'�e auger, aotary.eable. di[nei pait� e�.) � liiVlS�Oa-0i�.iCtl' �i1�r �O�i[gtOPII�.�lChO¢ CORd'Oi iYOgllmr FOR'V1rA"['E3t SUPPLY R'ELiS ONL7f: 1636 i1�aB.Scntiae Ceatcr. Rate�h, NiC Z7'fi99-1636 13a.'i`idd (gpm), � 14�cthod oftest $��0 atin ?.4t �'ar�Vater So�nlv Be.I=iatiaa'R'dir. In atiditian Yn serding dx fain tu the' aedtess(�s) ebovy 91so subaiiC one copy af lhis fom� witfiin 30 daps of 13b. Di�afecfioa �ypc HTH ,�� 1�2 Cup �pt�on o�,u�n ��au�o� to ��ty t�d� � of dk �ncy .vt�ab Co�_ T'�ana GW-i Nath Caro�ina DepazLaoeot of Fnvirm,mtt ud Ttai��l Rawsaocs- Diraioa of WzterQvaliey Rcv�ood.7aa 2013 ��.sf ��.�� ,---- �- �� IE �rnwn u- ��a �cn. m aa d�m.Il IE-3C ��. ��l�a WELL PERMIT (New � Repair _ J Tax Map: � Parcel: �Z9� Z Subdivision: `�1re 1«1l�✓� Applicant's Name: r�pb j�OS�Z Mailing Address: Lot: � Phone Numbers: Location of Property: S�� ,e� Qr CS �� F�C � Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and Counry regulations governing construction and setbacks apply. 3.) Perinits 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: � p�iew Well: T � EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: o -N8-14 Hose Bib: Casing Height: Concrete Slab: Date: �— S" ( �7 Certificate of Completion OL,iner: EHS/Date Well Driller: �j��1� i�-%f —�.— i Pump Installer: n Approved by: � Additional Comments: Depth: Grout: DAbandonment: Date: _ Method/Materials: License #: 3'�?l0 - .�j License #: Date: ��g �� Date Sample Collected: Date Results Mailed: EHS: Person County Environmental Health 325 5. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 11/26/13 North Carolina State Laboratory of Public Health 3�2 Distnc�Drve Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: H. KELLY Name of System: PERSON CO ENVIRONMENTAL HEALTH AARON RUDOLF 325 S MORGAN STREET LOT 25 THE RESERVE ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES080817-0031001 Date Collected: 08/07/17 Time Collected: 3:30 PM Date Received: 08/08/17 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A24-202 Sample Source: New Well Temp. at Receipt: 2.5 GPS #: Sample Description: Comment: 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 Calcium Chloride Chromium < 0.00' 54 21.00 < 0.01 0.005 m m 250 m 0.10 m Copper < 0.05 1.3 mg/L Fluoride 023 4.00 mg/L Iron Lead Magnesium Manganese Mercury Nitrate Nitrite pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness < 0.10 < 0.005 26 < 0.03 < 0.0005 < 1.00 < 0.1 7.4 < 0.005 < 0.05 27.00 31.00 0.30 m 0.015 m m 0.05 m 0.002 m 10.00 m 1.00 m � 0.05 m 0.10 m Zinc < 0.05 5.00 mg/L Report Date:08/18/2017 Reported By: Deddie .�toncol Page 1 of 1 �� ne department of F�ealt6 and human services �� Fo� /norganic Chemical Contaminants County: Name: �% p Sample ID #: — Reviewer: TEST RESULTS AND USE RECOMMENDATIONS I.� Your wel l water meets federal drinking water standards for inorganic cltemicals. Your water can be used for drinking, cooking, washing, cieaning, bathing, and showering based on the inoreanic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. � The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inor�anic chemical resu.lts onlv. Arsenic � � Barium � Cadmium � Chromium � Cop�er _� Fluoride � Lead � Iron Man�anese Mercurv NitrateMitrite Selenium Silver Ma�nesium Zinc oH 3. 0 a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the innr�anic c/remica[results ohlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc. 4. ❑ Re-sampling is recommended in months. 5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and IS minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. 6. ❑ The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inoreanic chemical results onlv but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. Barium Cadmium � Chromium _1 Fluoride �(ron Magnesium Man�anese Selenium Silver pH Zinc For more information regarding your wel/ wnler resu[ts, please ca!! t/ee North Carolinn Division of Public flealth at 919-707-5900. 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: ES080817-0090001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: AARON RUDOLF THE RESERVE LOT 25 SEMORA, NC Collected: 08/07/2017 15:30 Received: 08/08/2017 08:37 Sample Source: New Well Sampling Point: Outside tap P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncqublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Susan Beasley Well Permit Number: A24-202 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent o8/09/2017 E. coli, Colilert Absent O8/o9/2017 Report Date: 08/09/2017 Explanations of Coliform Analysis: 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. � !! � �•� � v�� L./ � �LJ �. V �� rn.�nsonan�ncna3�a��.� ��Il��ia Date: �� / ?�/ l 7 Name: t�'�i'/�4�t/ �UUDL� Address: . Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel: Zd Z Your well water was sampled on `� / a// 7, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: 1C No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria aze naturally found in t1:e soil. Fecal col form bacteria are associated with animnaI and/or human waste. The,presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the wate� may not be safe for use. Young childrer., the elderly, and the indiv:duals x�ith compromised immune systems are especially vulnerable and their physicians should be not�ed of the test results. A well that tests positivefor total or ecad coliform bacteria shot�ld be�ro�lv disinfected and retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, <��r� � Environmental Health Specialist Person County Health Department (rev. 4/20i 16) Person County Environmental Health; 325 S. Morgan St.: Suite C, Raxbor�; NC: 27573, Phnne: 336-579-t 790; Fax 3?6-597-78pR �.��. s� ��.� �.� �� IC �a.�n.s�n�.sn-n.�na��.Il IF-1L��.11�I�n Applicant: �� 1�� Location: , o � Tag Map f+�� arce �� Subdivision �-2 � Phase/Section/Lot # a5 # of Bedrooms 3 �uerat�on Permit p ,� System Type (From Table Va): �i `� Product {IIIg): � G'" �' P Type V& VI Expiration Date: o Type V& VI Renewal Date: �l1� 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. � � ��- � � (-�� (Authorized Agent) (Date) K. l��s la - �S-lb (Licensed Contractor� (Date) Scale T� PCFiD, rev. 12/14/12 ��M � u��v � �' ► Tax Map:% 2L , Parcel #: � Septic Tank System Checklist (Type II-I� System Type: � l�Tat��• � � Pump System Checklist '/z�� H� 43 Contracted Certified Operator (Type IV Systems): ��,,�� 'io t,y IV�tes: � �,`,�� ]�I�.IE��l' � . : � :��.�� lEaa.r'ass�m�mao��m.0 7E�tamn� . ..�5._.,ITE-3�—. :Naal � s Tas Map #.�Paxcel # � Z �Sub � o" ` �� Sectioa/Lot# '25 . ;, � ?'�`�� Autho�ed St�te Agent Date System cdrrrp'orreirRr �epverent approarimate�c»ntoars arrly.' The contnrcibr messflag the systemprior to beg,rn�rieg flrs u�s�tallahbn ta irtsr+r� fhdspropergrrrils is nrainta�ited 1 � '� / / � `1� 1 ��' / � � �v o , , �o , \ v � p, / � i / � �\ �Qv�� _ � O�ti ,� � i \ J�y�" � � u � � Q�P � $•$�'"� W ��-1 /, � �� -�\ / titi 5 �'� - N Q �<v �v � � / � �6� 2 a, °� 2- ,��' �,�v� G � � � 'A � rtr� oJ Ov �`'� O � � `° ;� a �� . ,��,�� / � � z c,° c,� v � � 1 „� / � `- -- �o gs. N49, 5a� p0 � � �2� 3�, � � , o / � l�'�(� �� pc� �°`°` s"''�' N �`Z � �-- Ocn `sl �� Y� tf� i / o I � i � S�cJ �� ,` u� I �: �v� c� a ' Q� �� '�. o�ti� r � ' 2-° v ?° � �.o ��P `' o � I Q3,� ��v `3 w y Q�J ��' � o so' � � N� �- �. � z � � � 1 I ► ^ � , � (7 � � —..� 15� � z �/ � �� z w J °� I � � W � � � � N � N Oni �� ' � M N I I W �,; � � 0 � � I z �°�° �J�y' 45' n Z I �- � i ... _ � '( 24 W � I�� i= � l I 86. 10' 3 `�,�� w • : � cn n. � / I ._ �a' a� j w � �' � � �''�R- c~n o I``' ''" N � � I�. u °° � O J� � � � •� �., , �n o �9,,�0 � ..l � � O' � �._._-------� tQ� GO� IIji ' z/ �� O \ _ � � °- i / � / � �- � ( � � ��ti � � �� i.-. I ��\o.. � �� F. Q°� �v � I , �, � • � �• , "�� Q' c.►� Q•'E" I i I � �� `� o� 'ti ,` v � I� 1 -� '� � � ti� �O �`Z`GO Z � 9� '% r�� GT v.r� W � � � w � . � �� I' n�. i °'� \s � g� �0 I I / �� ``o I � � I O �v � WELLS MUST BE 50' MINIMUM SETBACK FROM ANY DRAINFIELD AREA OR SEPTIC PUMPLINE EASEMENT. WELLS MUST BE 10' MINIMUM SETBACK FROM PROPERTY LINES AND 25' MINIMUM SETBACK FROM THE BUIIDING FOUNDATION. CONSTRUCTION IN THE PROPOSED BUILDING AREAS MUST MEET AlL PERSON COUNTY SETBACK REQUIREMENTS. I � ti='t�f � �P��,�� ,� . 3��13��.�� o� '� � � � o�� v �� s 1nc�o�. s-� � � , �� \ � a l(9�c�� \ � � � � i �ti��°J� ° � Sv' �"„ �a►��e �ia��fe�' �v%1� � , ° ; � �, � ° � « --� i5' �y.;�� I'3 ��2�e � (�('�� I I I J�Q �� ,,I � � 50' 1 ¢ �P ��/ ` � , ' �'V'e�Q � 1.✓I (J�� O � � � � a � C'eVt, �-Y,v-� I � ,,�/,,Q �� o �' � ��-�► o�tA, � Stl � � Csl'P �`��'�t O � � � �� n�' ( c� r� s� h.� ��s��`( �� \ �► � �n v� d� �o� Cm��w�. ,�P �ti ,� . � ` � �,� �. � � � � � SC�Gen 5 �:� ,�.s.� ��.� �� ~ `�^ � � �� `�' 1��ra<o�-n�roaa�a��n.�.�.� �ae�.]j.�]�a NEMA 4X Simplex Contml Panel / T�x M�� P�rc�l # '' Suhcllivision ' - ' Ph��s�e Sect�ion Lot # h" X�" Pzessure Treated Post � �� Seal Both � Ends Of The Conanit Sloped To Shed Water 12" Separatiox 24" Miniitw:n • \ Electrical Cox�uit � I . •. ., , .. � - S" Cover •� ' � � Access Cover• � .. , e ~ ' •� , , . , • _ • � . - ; . . .-�—�. . � .� � ':: : •.� • ;~ • ; � ,• , ` • - - . . . �,. Opening Filled With � p�ti Sipkon Ho1e' Ixilet Fmm Septie Taxk PortLuid Ceme�rt Gxont �� A" SCH 40 PVC Pipe � • � Cl,eck • Valve � � , High Water Alarm Lev¢1 (6" Separation) .. ., High Level - Pump On -�._,.�� , ;' ti fiVaparLock . ' � 'Z Drrxdrnm Hole �, . � % � �IIp H�� . •Law Level -Pump Ofi' ---��' . �•.. �� Threaded Gate Valv�e _ . - -- � Zip Co; Ties ' Precast Concrete Tanlc 4" Concrete � � � ;•; (MateaalStRx�gth>3500PSI) $lock .� • . , . ' •..:; _ � � ' �• • � - . ' : . .; ' , � . . '. : Concneie Riser �" Separatiex • • .' � %�:.d•J' - ,�,�:�-lPoztLuid Concrete Gxout _ , _: Mastic � • - • , � Opexing Filled With Supply ' : po�{� Cement Grout � .. Outlet To Distnbuti�ox 2" SCH40PVC Pipe Float Wires � � :. � i Floats ; ; �Removable '. : ' . Float Tsee � � �� ' . . \ , ° � � . .�, � l �� GALLCII�T FU1�lIl' TANI� P_�_ � � PumQ Must ge Rated ?o Deliver °3 � Gallons Pet Hinute, Agaiast � Feet OE Tota.l Dyna�aic Aead ( DN) . :; ��`�,�� I�I��.�� n �%cA' IE;aa-vaxr�� -�•M• �eaa��.11. ]HI�.m.Jt�blla Qwnei: ��C I�"C'dTr � �� Tax Map: � 2� Parcel #: 2�'Z.. Date: 2— 5-15 I.ane Tap Tap (Sc�a) Tap �'lo� Line L�ngth &'�odv 1��ot # i)aaaneter(�) ( m) ��, (ft) i Z S�5 Zo �o�S 2 � � � . 2 ' . o �( 3 � �o .S �v < <o 0 4 � �lo ?•/ �35' , s ' Yo 7<< l�o� .oy 6 7 Z n�—.v � �; 9 `` ].0 n q ft of line x 65 gal. per 100 ft=� �: lOQ =� gal � In x Eo a gal =`L Go ga1 per rlose 33 gal per minute ( g pm) = k'9ow IBate �� l� �'riction �ead , Loss: 2� c� ft per 100 ft of supply line x'" ��a ft of supply.line = 100 = 3 ft �ft x 1.2 =_�_ ft of friction head � �4►�� -�g-�-� A(��'°l� Manifolcl Saae: �_" Force Main �ize: �" PVC �otal Dynamic �$ead ==�ft of Elevation head +� ft of Pressure head +�ft of Friction Head = �_TDH � � I-�,,, Id-� Pump Requi�eaiaent: �� GPM @ 2.�_ ft of Head„ Ii�av�dow�: Z� o�al per dose � 21 gal per inch =/ Z inch drawdown per dose �r°� � � � ;r. :, �.,:� : � : , �, � �;, � � , • �� -- '=�r��t0 �_ . . � � : . : . , ,. � __ ,. ., ,.. �[(�)l�OmO� 111 II 11 I/ � o o-�-�. o-�-o-�-o-o-o-o-o-o-o-o-�-�-�-o-r-<-o-�-�-<-o-o-..-. .......,.......�..�.�........... -.. .. . .. . %��+i�*!!!��lN!!!!!�!�l��►!!r � � � � i.. :_i .,._ . a : : : y: 9��s Taeiath'mrbe. �nd/mmdoa iViaai�oid ifoid Sizs J � Taps Ma.� i�To. Taps off one side Qce bv �� :or ta»qin� �oth : I Z; � 7Z J �`lo�Y er Tap Si�e �Llcuerial Fla:t� G�Yl !:'• Sclied 80 �.� �, .. ' Sctted 10 %._ ;, " :icl:ed 80 1 � 1 =� � Sciied ?0 : " ? .., ' - ��. s� ��..� �� ?E-re �-.vn � � zraa.-sn� �n��.Il I�3L � �.11 �II�a App(icant: �'�Jb JS� �A d3� ss/Location: i �k UQ � _-� �C _� S'�P Q — �K — � _..�-� �� __�� Improvement Permit Permit Valid for: Five Years Non-expiring � Type of Facility: ��I2 !�P S New � Addition _ Number of: Bedrooms �/ Oc upants / Employees / Seats: Proposed Wastewater System: U �`� � r' � Proposed Repair: i ' Q `•> Permit Conditions: �-Pe C r-�-2 .� �� fC � Tag Map: �� Parc 1• Z� 2- Subdivision � Phase/Section/Lot # `Z� �� a V4'ater Supply: �✓`e �� Proje ted II ily Flow: 3Cv o ga[lons/ ay =2 L.Di' Type: �� Type:� Authcrized Staie Agent: �'►-� � ��"'e+� _ Date: (X) Owner or Legal Re resentative: �_� , , 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 applicandpr�perty 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 Improvemeni is noi affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the Nort6 Carolina `Luws aiid Rules for Se►va�� Treatment and Drsnnsa[ Svstems'(15A NCAC l8A .i9U0). Neither Person County nor the Environmeatal Health Sp�cialist warrants that :he septic s��stcm will c�ntiaue to fanciian satisfa�torily in the future, or ihat ti�e water supply wiil remair poiabDe. -- -------- -- - Authorization to Construct Wast��vater System See site plan and additional attachn:etits (_ j. � � � �l �� L p � (*1Typ .11�.p�t gn ��P� _ gal./day Propose�i Wastewater System: �� , l e Desi Flow New K Repair_ Expansio Soil LTf�R �'Z75 gal./day/ftz ' Type of Facilit-,�: �✓�% �QS'. Basement: 9� Yes _ No (*) System Types III6, Illbg, IY, and V, require periodic system inspections by the Ferson County Health Department. �si�.�s sa _ - Wastewater System Requirements Tank 5ize: Septic Tanl: �� gal. Pump Tank l � d�% gal. Grease Trap '~ gal. Drainfield: Total Area ��/ `, sq. ft. 'fotal Length ��70 ft. Max. Trench Depth �� _ in. Trench Width � fl. iVIin.Soil Cuver � in. Min.Trench Separation � ft. Distribuiion: Distribution Box / Serial Distribution__ / Pressure Manifoid �� ns: _ -Q si Ce i nY' rt1 tt Authoriz.,d State Agent: �?.� r ��''�`P^� Issue Date: Z-5�1$ / Permit Expiration Da�e: 2- S—Zc� �(JOf (-�;� 1'he system permitted is: Conventional �� /Accepted / Alternative / Innovative . i accept the co�iditions and specifications of this permit. • (X) Owner or Legal Representative: � Date: � � �e Person County Environmental Health, 32s S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) Appli;,atian Date: � I�i � Tax M.: '� � � f ��.�� P� �� A_fnn 1nt Paicl: l 0. � U -��, •�� — -� -- , a � parcel#: 2D 2 Receipt #: I 9 3 i� �-' � v�� IE��a-� ��¢�.Il IH[ � �.Il�ll� C�� Application for Services Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 d) (Fee is de endent on the e of s stem ermitted) Mobile Home Replacement or Building Addition ❑ Permit Revision $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 Application: No Charge/ CA $150.00 or $300.00 1) Applicant Informati n: �� v�%�'�� S Name: � S Address• l J 2) Name and ad ress of curre wn r(if different than applicant): Name: � Address: O Phone (home): (work/cell): 3�. � , � 7_ % Phone: '02 �oZ -' (�� —2-a-S� l Ll,uw l,c,� � ��-��-� - �s 3� (w� �,�,� 3) Property Description: Lot Size: Subdivision: �{�� C,1/V-e_ Lot #: o%.�j Address and/or directions to Property: � ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ 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? I l/�� ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) �Q ` 4) Proposed Use and Type of Structure: �N ��5� ❑Residential �`�� ❑ New Single Family Residence Maximuni:number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there lie a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑1�1on-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, t� site is subsequently altere,� or the intended use changes, all permits and approvals shall be invalid. �ghature�Owr{er/ Legal Representative*) * Supporting documentation required. ► a3 Date 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. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) / �. `,«.r�;lf-4.!;f i. °C �_ � �' ��(,�? �-; � � 1 q �i Scale: 1/50" = 1 ft. /) �� > � � ' J � � � \ < <t� � .\ � I � � � <- � � �.�� 1 I--I <- ;� I � I � Suilding Additions/ Mobile Home Repiacements Tax Map #:� Pazcel#: �� Address: 3a , s , 7 Approval Requested for: Mobile Home Replacement � Building Addition . Applicant Name: '•� V(� . o�� Y' ro o�� Address: 02 ( �eu So . �7 a Phone #'s: �,3(� �a� 3 2zz __ P2s�l � 5'�� 2zs�/' ., �� 7s7_6�� Permit Located: Installation Date: � Yes No _ �(- ( Design IIow: 3Cv b (gpd) Current Contract with Certified Operator on file (if required); �t � Water Supply: � Well Public or Community Wastewater system shows no visual evidence of faiiure on: j 3(� �� (date) (Applicant's signature if site visit is not required) Comments: p n 4�e Q�c �fZo ` i�-�2 . (� �D�Xyn � � Addition/Replacernea�t Appr6ved ti„ � �Rv�-e� Env' nmental Health Specialist .-1— t� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.nersoncountv net Application Date: l 5 i/ � ,� �,� �� Tax Map: Amount Paid: OOd , C�� a0�. �� a ` � Pazcel #; Receipt#: 3� I 60 �— e.�°�k 15� I 6 �' C�f o-� 1 '� j2 �3�a,. `--,��.�� T e�F�-s�� -�� 1. /+ '� �v i�a.�aaan.,*�+-+,.��a.¢.rc�.�. IL�� w.11�lEn �I�/l•'� l.-�. � Applic�tio� for Se�i�es (Septic Systems and Wells) Services �lmprovement Permit (Site Ev� $200.00/$300.00 (if> 600 ❑ Mobile Home Replacement or $I50.00 (if site visit reyuirE 0 Well Permit (New/Replacemen $300.00/$200.00/$75:00 � Constructio� Authorization (Fee is dependent on the type of ❑ Permit Revision ❑ Repair of EAisting Septic System Applicatian: No Charge/ CA $150.00 or $300.00 1) Service��ues�d � �, j J,, Name: � � � ,�' Phone # (home): ��'� �/'�/ `% J��.� Address: �S ��, L��' (work/cell): :�3 � � - ✓�'�% _r'� n�. , v'�c� �+A�O�f�( �P�1�o�n.L�t�W� � 2)Name and address of current owner (if different t6an, applicant): � Name� '�'�mr� . •�- Address: • 3) Property Description: Lot Size: Subdivision: Address and/or directions to Properiv: ., _. 4) Propased Use and Type of Structure: Residential 1� Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes %� No (wi�plumbing: Yes No _____) Garbage disposal: Yes No � , Lot #: �� 31 . 5) �Vater Supply: Private WeII � (Proposed i` Existing _) Community Well: P.ublic Water System: Are there wells on the adjoining prnperties? No Yes '� (please show location on site plan) ! 11�ote: A comnleted annlicadon must afso include: � A pladsite plan of the pyoperty that shows properly dimensio�rs and the size and location of all ' proposed stractures � ➢ A signed copy of the `Lot PreparatioK' form ve��ing that the property is ready to be evaluated i am submitting this application to request services fram the Person Couaty Health Departmeni. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits �nd approvals shall become invalid, Sign�ture (Owner/Legal Representative): �-- �j` ' Date : l' .�7 , �� 10/08 Person County EnvironmentalHea(th, 325 S, Morgan St., Suite C, Roxboro, NC 27573 (336-597•1790) ��1�� -2-�-- � �; s ��.� � �y-� w�� .a �� . l� r _ . _, �/�pW �R��.-�- a�'-��- c �+;^-� , �;,,� �> ��Zl� sc�,'�b � 3�� i � Sr' �i�'� ��s ► �� ,��`� SC. � � 7 7, St � �� 3� �(z." �-� � � � �-a � f �' �� !{�� SC�. �{� �j Q�, �� 1 ( 'r ,�''i ,. ;, ? r� ;.,j r � �,�.;' � �- �m � � �� ► �e. s � � � � �V�� p`� �'^�n ��M�r� � �t C,w f.. „/�/� �0�2-1— ct� �� C�- ��G jl�� r� ��