A24 79� .Per�on County Health Department �
Sewage System Improvements Permit ,�.,
Date: �_ 1�'Ihis Permit Void After 5 Years
Owner:
LocaaoMDirections: _ 1� �. S e n{, ,e"
Permit # �y �
_ . SR# /`2��
Subdivision Name: �,Lh e�� ✓� p•-�e �� J� Lot #�_ �
Lot Size: •Type of Dwelling: `
Water Supply: Private• Public: Community:
Bedrooms: 3 ,� Gazbage Disposal
Basement Basement F'
INFORMA N T D BY
S8I11taI18I1: u or tep�esa�tative
REPAIIt: REEVALUATION:
Size of Septic Tank: gallons Size of Pump Tank:
Nitrification Line: ��(� � �( Z�
Depth of Stone: 12 inches S�Y �� /
Max Depth of Trenches:
Alternative System: Conv. Pump LPP Pump �
Remarks: /1 ' � .
Date Well A ved:�
BY
Date S ag S te pp�
BY
----�----------
3 Well should be 100 f� from any sewer system
. Sanitarian
,���. � u- �nTE OF COMPLETION ,.,3
Contractor. .� i m a, k c �
------------------------- �
Sewage System location, inscalladon, and protection must meet state and local �
regulations. Septic tar►k should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspecteci and approved by a member of the Person Counry
Health Department before any portion of the installation is covered and put into use. If
the site plans ar interided use ct►ange this permit is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
T� MC�(��lE ��C
,, ,
Person County Health
' Well Permit
Date:�� l3 �z This Peimit Void
Ovmer: y� �S f E
Locaaon/Direcdons:
3 Years
Department
SR# J133 �
. � . niUl�'��t,Ti�'�l���Tl.i .T..�ii • .
. , , . . '-'Ic����� ■ , � : ��
Distance from Nearest Praperty Line Distance from Source of
Pollution
Total Depth t Yield: GPM Stadc Watet Level Ft
Water Bearing Zones: Depj� Ft. Ft. �—
Casing: Depth: From V to FG Diameter �J ''Y _ Inches
T'YPE: Steel Galvanized Steel �!
If Steel, does owner approve: No '. ..
Weigh� Thiclmess: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sa�d�ement Concrete
Annular Space Width 1 L— Inches
Water in Armular Space: Yes No
Method: Pumped Pres Poured'�
��: F� _� � �
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs. '
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes !� No
4 x 4 slab Yes / No
I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN CORDANCE WTTH RF� ULATIONS SET
FORTH BY THE PERSON COUNTY H� pFiPpR�Tf�ENT. A � �
� n�-�.�
�� ��
�� ��� .
Sketch well locadon on reverse side.
�
Signature Date Issued
Sanitarians Signature Date Completed
■���ee■�����■
■������������■
The District Health Department
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PER IT No.
, Date
Owner: �' . �� C
i
Location: �
� �'/ r�� �
�
Contractor:
Water Supplp: Private —f� Public
Sewage Disposal Facilities: No. bedrooms �— Dishwasher, Disposal,
washing machine, ther auto �tic appliances
Size of tank: Nitrification line:
,
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTEI} AND AP-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
.
i
� r�Date approved: Signe` � ' '�
`/ Sanitari '
Well:
Sewage Disposal:
By:
Ceriificate of Completion
Date Approved:
Counter- .
signed
(Owner or his representative)
._ ,':, - - _
By:
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Wnite in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
AFplication Date: - - ' TaY ylap:
A�nount Paid: rarcel �:
Receipt�#:
��� ���._, �;��.�' f ���
____ _ _:------__ �� ��> ZL.� � �, �' -.��
7L1u�.•�-:Ls-��-z„--,-„«r:r-�,i:.�zlL IC-�t,�.-.�-�.1u��z
I����gc���on �o�' �e�'vic�s (Septic Systems and Wells�
�e�-vic�s �� uested
L Improvement �'�rmit (Site Evaluationj ❑ Constraction Authorization
�200.00/$300.00 (if> 600 j d) (Fee is dependent on the tyoe of system permitted)
❑ �Tobile �iome.�2eplacement or �uilding �ddition �J Permit Revision
$1�0.00(ifsitevisitre uired) $75.00 �
C�eil Permit (`dew/�teplacement/Il2epair) Repair of ��isiing Septic System �
$300.00/�200.00/$75.00 No Charse
� X �� �ez-vic�s R u te�l 'n /)
� Name: ����.� � - �� l' � Phone # (home) J�l?/ Z?7 '2o � Z
�� � Address: �� 3�u ,-t y�.��- �j �: (�vork/cell): 3 3 G 3 � 7'� � 7�
v �r�CrJ-jL�.9� 1-�� Z�1�0 �%Ce- �!7— �Z7�
�C' s)PT�m� a�d ad res� o z�rr�mf a a�eq- �' dif�'�r�nt than ap�l�ca�t):
� Name: ��� � - �i� G � ,,�� Sit-�c�`U�.s, o rJ
5� Address: �f.7 ��1,-� Jn S,� � 2- �-5 � —�
��� �C � /�, � v � .
� .
�) �'r�g�e�-2y �escrS��6om: Loi Size: Subdivision:
Address and/or directions to Property:
4) �roposed �Jse and 7Cype of Sta-a�ctu�-e:
R�sidential Bu �ness/Type: Other
?� Nur.iber of bedrooms �/ Number of people served (seats/employees):
Basement: Yes � No (with plumbing: Yes Na _�
Garbage disposal: Yes No
5) d'Vater Supply:
Private Well (Proposed Existing _)
Community Well: Public `Vater System:
Are there wells on the adjoining properties? TIo Yes
�ot #:
(please show location on site plan)
1'�I�ote: �i complefe� rrDt�ldcation �riusE �adso i�cclude:
�,=! �Zat/site plun of ,ths,�r�peyty �tJiczt sJtow� prc�erty di�:�en�i��s r�nc� t�ae siz� �pr� rOC:YIIObI O�f�II
�ro�osed structures. � .
5� A sagned copy af tdie `�at �T'r���sration',�'�ryr¢ ve��,�i�a� ihai Pdae vr-opeYry �� ready io be. ev�aluu�ed.
3 ar�a sacbmiiting #h�s .��pDlncatiosa to �-E�aaest 3�rvac�s �'ro� ��e �Qrson �ou��y �e:�1th �epa�-tQne�Y. � ume�rsta�ad tha�
i�'th�e infor�ation �ravide� is �neorrA�# �a� i�' #�,e ��#e : subs��ue�n��y a9�es-e�, �r �f #;�Q rntendeal u�e charg�s, a��
�er��ts a�d apprava]s shal� becarne ia�tialid. -
a'a iT P � /`' �� !�'��v .� � �%
�,?bQa�ur� {C'wncr. _.,gal Re�resentative): ��5z : � �
l 0i08 Person County ;=,nviron?nenta! �ea�Th. �?5 S. � iior?an St.; Sui�e C; R�xboro, NG '' � 57= (336-�Q7-17°0)
....... .,.- °- �_ ������
�a�n���c�nnn�rn�cn�ntC2�,.� ���c��.�.tL-�
July 6, 2009
nsuring a healthy environtnent
Re: Application for repair permit for Stephen Cobb at 485 Canvasback Rd.
Health Department file: Tax Map # A24 Parcel #79
Dear Mr. Cobb:
The Person County Health Department, En ironmental Health Division on Julv 6,
2009, evaluated the above-referenced property at t e site designated on the plat/site plan
that accompanied your repair permit application According to your application the
existing system is serving a four bedroom residenc with a design wastewater flow of 480
gallons per day. The evaluation was done in accordance with the laws and rules
governing wastewater systems in North Carolina General Statute 130A-333 including
related statutes and Title 15A, Subchapter 18A, f the North Carolina Administrative
Code, Rule. 1900 and related rules.
Based on the criteria set out in Title 15A, ubchapter 18A, of the North Carolina
Administrative Code, Rules .1940 through .1948, t e evaluation indicated that there is not
an on-site subsurface repair option. The rem ining soils are determined to be
UNSUITABLE for a ground absorption sewage s stem. Therefore, your request for a
repair permit is denied. The site is unsuitable based on the following:
_Unsuitable soil topography and/or la
X Unsuitable soil characteristics (strucl
X Unsuitable soil wetness condition (R
_Unsuitable soil depth (Rule .1943)
_Presence of restrictive horizon (Rule
_ Insufficient space for a re air (Rule
Unsuitable for meeting required setb;
_ Other (Rule .1946)
These severe soil or site limitations could c
the discharge of untreated sewage on the ground
ground water or inside your structure.
;ape position (Rule .1940)
or clay mineralogy) (Rule .1941)
.1942)
944)
945)
ks (Rule .1950)
premature system failure, leading to
�ce, into surface waters, directly to
The site evaluation included consideratio of possible site modifications, and
modified, innovative or alternative systems. owever, the Health Department has
determined that none of the above options will over ome the severe conditions on this site.
A possible option might be a system designed to dispose of sewage to another area of
suitable soil or off-site to additional property or a sur ace dischaxge system.
pl�one 336.597.1790
fax 336.597.7808
325 So ►th Morgan Street, Suite C, Roxboro, NC 27573
For the reasons set out above, the property is currently classified UNSUITABLE,
and no repair permit shall be issued for this site in accordance with Rule .1948(c).
However, the site classified as UNSUITABLE may be classified as
PROVISIONALLY SUITABLE if written documentation is provided that meets the
requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant
to assist you if you wish to try to develop a plan under which your site could be reclassified
as PROVISIONALLY SUITABLE.
You have a right to an informal review of this decision. You may request an
informal review by the soil scientist or environmental health supervisor at the local health
department. You may also request an informal review by the N.C. Department of
Environment and Natural Resources regional soil specialist. A request for informal review
must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal,
you must file a petition for a contested case hearing with the Office of Administrative
Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6'714. To get a copy of a petition form,
you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or
from the OAH web site at www.oah.state.nc.us/form.htm . The petition for a contested case
hearing must be filed in accordance with the provision of North Carolina General Statutes
130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General
Statute 130A-335 (g) provides that your hearing would be held in the county where your
property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form
with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS
LETTER The date of this lette� is March 20, 2007. Meeting the 30 day deadline is critical
to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere
with any informal review that you might request. Do not wait for the outcome of any
informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative
Hearings, you are required by law (N.C. General Statute 150B-23) to send a copy of your
petition to the North Carolina Department of Environment and Natural Resources. Send the
copy to: Office of General Counsel, N.C. Department of Environment and Natural
Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health department. Sending a copy of your petition to the local
health department will NOT satisfy the legal requirement in N.C. General Statute 150B-23
that you send a copy to the Office of General Counsel, NCDENR.
You may call or write the local health department if you need any additional information or
assistance.
Sincerely, �
�_ �—
Jus in B. Smith
EH Specialist
*1
RESIDENTIAL �3�rr,L coNsrRocrion REcoR�z
North Caro(ina Department of Enviroament and Natural Resources- Divi�ion of \Vate� Quality
W ELL CONTRACTOl2 CERTIFICATION # _ .J�`1p �
t. VYELL COM 70R:
R �1 1.�-= �'� "1
WeN Contractor (4id'nriduai) Nartte •
Barnette Well Drilling Inc.
Welt Contractor Company Name
STREET AODRESS 611 Bamette Tingen Rd.
Roxboro NC 27574
� cuy a T�m s�ce z� coae
c 336 �_ .599-0015
Area wde- Phone oumber
2 WEILlNFORkiAT10N:
S(TE WEII 10 A(ifapplicable) N/A
STATEWELLPERMIT#(dappr�eable} N/A
DWQ or OTHER PERMIT #("d appfipble) N/A
WELL USE (Check Applicabte Box): Residenti� W�er Supply �
DATE ORJLLED p'' �" O 9
TlNIE COMPLETEO c�J'i7 /Vy( � ppR �
3. iNELl.L TION•
ClTY: �� � ►D COUNTY_ 1 �'�'�S • '1
�I ►�.t� `�' `� 5�.�•
(Steel hame. .lumber. Canmunity, S��9sion. tct A1o.. W�el. T�P Code)
TOPOGRAPHIC / LANO SETTING:
❑ Slope ❑ Yapey ❑ Flat ❑ Rid9e � Otfier
c� a�a�� � .
May bc in degrces,
LATiTUOE 3 _ ��� �S �
LONGITUDE � �nadccimal forntat
Latit�de/longidule source: pGPS ❑Topographic map
(bcaliw+ of we0 must be shown on a USGS topo map and
a[tached to tliis form lrtW us»g GPS)
4. WFILOWNER
OWNER'S NAME _ �� � � �
STREET ADORESS W �I��
_l�,o�.�r� � . 2 ?��..�
Ctty or Town Sf�e Tip Cade
c 3 3` �- �`1 '�— R 2s'1
Area code - Pho�e number
s_ wEu. nEra�i.s:
a T07A1 DEPTti: � C� �
b. D4ES WELL REPIACE EXtST1NG WELL? YES ❑ NO �
e. WATEJ2 LEVEL BebwrTop ot Casirg: 2r'J FT.
(Use'+' � Atwve Top d Casing)
d_ TOP OF CAStNG iS �-5 Fr_,� � s�r�-
-rop ar casing te�ma�ted aflor betow lana sudace may req�rire
a rariance in accarda�ce with 15A idCAC 2C .0118_
e. Y/Fl0 (gpm): �_ M£THpp pF TEST Blow 20 min
t. DISINFECTiON: Type HTH Amount _25 CUp
g. wa-reR zoNFs �a�cn�:
Fran 'L �t� To �S F�om To
Ftom To From To
From To F�om To
6. CAS(NG: Thickness!
�P� Oiameter 1Neight Material
From�_ro�2 F�� _188 Galv
From To F�
From 7o Ft.
7. GROU7: Depth Material lutethod
Fr«n �b To Z-o �t GraveUCement Poured
From To Ft
From To Ft
& SCREEN: Depth Diameter Slot Size Material
From To Ft, i�, in,
�/AF�«�, To Ft. in. in_
F�om To FL in_ ia,
9. SANO/GRAYEI PACK:
Oepth Si2e Material
From To Ft
NIAF� �� F�
Fram To Ft
10. ORILUNG LOG
From To
`Z�i o �bo
11. REMARKS:
Fo�mation OescripCwn
�i-✓iru�tc. ,
1 DO HEREBY CERTIFY TtSAT 1HIS WELL WAS GONS7RUCTEO h ACCORDANCE WtTH
15A NC�C 2C. W ELL CONSTRUCPON STANOAR0.S. hN0 7HAT A COPv OF iMS
R�o ►ws ee�r+ �ao�o ro n+e w� ownea.
�—' `���"�7
S! T E OF CER lED WEU. CONTRACTOR OATE
\ �"'ti �'� �1 Lh iY�
PFZINTED NMAE OF PERSON CONSTRUCTIN THE W ELL
Submit the origi�al to the Divisio� of Water Quality wiLhi� 30 days_ Attn: tnformation Mgt, �� �.�a
1617 dAail Service Center — Raleigh, A1C 27699-961'7 Phone No. (919j 733 7Q15 ext 568. Rev 7ro5
08/05/2009 89:14 _3�� G�77808 PERSON CIXJNTY ENVIRO PAGE 81
� ..�.,.,..,.uu.,�� �.a�C: � .�'ax Ma
��,A,mount Paid: % p O �'' �-------,
R�ceipt#: 7,2 L Parcel #�
(�42 �� I ���`'��. �..f JC' �J.��� �.�` �
� ������
1[ + s-s.s—a sr �cs ��.a aat�.e� m��:sn.7l IE"]C wc_�+.ea 71, �G71�...
Applicatioa for Services (Septic Systems aad Wells)
i_i l�mprovement Perrnit (Site �valnation)
5200.00/$300_00 (ifC 600�pd)
❑ 1V�ob�le Home RepiAcetnent ar Build'rng Addition
S15Q_00 ifsitc visit uircd)
O Wetl Permit (New/�t accm ep�ir)
5300.00/�200.0 /s75.00
equested
❑ Construction Authoriz
(fee is depcndent on thc
� Pcrmit Revision
a�s.00
C Rcpair af Existing Sep
Nc�„Charnc
�) Services Re cs ed bY:
Name: � e V� CO � Phone #(home):
,Flddress: /j�({ � (w4rklcell):
2)Name and address of current owner (if different than applicaqt):
Name;
Address:
3) Property Descri�►tion: Lot Size: Subdivisian:
Address and/or directions to Property: �, ����
4) Proposed Uae and Type of 5trc�ct�re; v
Residential Business/�'ype: Other
Number aFbedr oo�'ms / Nomber of people served (seats/employees): �'�
Basetnent: Yes No (with plumbing: Xes No ____�
Garbage disposat: Yes No �
#:
� Water Sapply:
Private Wetl �(Proposed Existing_____)
Commuaity Well: Public Water System:
Are there we(Is on the adjoining propertics? No Xes (please shaw location on site plan)
Note: A cnm�leted annlication mu�t also inelude �
% A plat/site plan ojthe property that shows properry dimensions and the size and location of a!d
proposed sbuciures.
A A signed copy of the 7,�t PreparatioR'form veri,�'ying th4t lhe property is ready to be evaluated
I am sobmittiag this application to reqnest service,a 1'rom the �eraon County Aealth DepArtntent � understand that
it the unforpnation provided is incorrect or if t6e site is snbsequently altcred, or ii the intendcd usc chan�es, all
permits and 9pprovst]s shal[ beeome iu�valid.
Signatare (Owner/Legal Represe�tative): bate : - � -�-6 i
10/08 Person County Environmcntal Hcalth, 325 S. Mprgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
; �..�;�. �� � 1� I�,��.� �� �
; �`,�� � ; � � �,� �. �°�
I��.���-:� -�.�� � �-�.n �.�11 IL--�C �.�.�1�I�.
��1�3�� P��.1�✓1�1�' {P��°�Y_�E'.'�Z$Ilfi•�
'�'�� i���: 2 ������• �`�
��n&�dn��sao�: %e 3�at:
r����Ilea��'s l�`1���: �yZ�'1 l_,C�ib
Ib'�ai�an� t�° da�rQss: 03 un5-e�' �',
r�ee�iS c�rc�. n!C 2?�/a$
�'9as��� �da�ffis�e�-5: 33(�- 27S—Z�G�� 33l — �» —81��5
�����io�a ����-���a-�: S7 /� 71G�1 o�on�c,�� ���`f-o �c�. �
n
=�
D Y1 l`�/ � C�$S (P, h�/c2,5G�aG�'.
�'Qr�stit �'ondi8an��:
�) See attached sire plan for�� oposed well location.
2) All czpplicable State and County regulations govei•ning construction and setbacks cr�ply.�
3� �ermits expire � years from the date of i�sue. t
��3�er ��aadz��ors�/�o�aa�saen��: Pe v� � ��� -�a ctn �� cl �o� _ _ � _ `'i�� �
��r�aa� LsSa���
�
��i�e: g 'S- d �1
����'�'��"r��'� �F ��10��� �+'�'���
P���v �✓`�I��� ��n��r���n�en:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
1�.1,1�IIfl��' 1�IlIl5���$Il�IIIl:
LHS/Date
Installer: �,-n
Depth: g ' -� �' S'o i
Grout:
��� �����a���n�a��fi:
EHS/Date
�Completed:
Method/Nlaterial(s): _
'b���l �r�fl��r: �arn��� �,i�E�a�e #:
Pump Installer:
'�'���� �p�r��e� �nw:
Date S�n�1_e CollecLed:
Pe:son C�unty Enviro:unental i�ealth
_=� �. �Iorgan St.; Suite C
Ro�:noro. NC ?7573
License#:
�at�:
Date Results Mailed:
Phone: 336-�97-1790 rax: =30-�97-7803
8/1/08