A24B 1f Application Date: 1 � � �� �
Amount Paid:.
Receipt #•
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Parcei #:
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��aa�csoaaT-+*�+• m�aa:��.IL IE-iL�m71.iE7��
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID.
1)
2)
Permit requested by: (Owner/agentlprospective owner): C� de���� -�°l `7�''.�G�6
Home Phone: Address: � �}� �-' 7-�
Business Phone: d G � ��
Name and address of current owner: �fm��'1' �//�/'�� 7'`�
l� �.//L ��_.
3 Pro ertyDescription: Lotsize: �� Township:C.U�in-+ Subdivision: C�lU Lot#: ��� 2�
) p .
Directions to the prop��, �I�} cludin road names af d numbe s): �T �`�
JL%�/.,-.( o o �1 •// 7�7J S/JG.G2 � - �9 2�' �7" Sro.ce _ _ �.L.e- • .
4)
5)
U���., /Jfl/L(�c� -.L �t s_�' ei�•� J�7 /a T s� L eG
Proposed Use a�nd� tructure Description: answer each of the following questions:
a) Proposed _�! Existing _, Type of Structure: Width:�� Dept .t�-�
b) Number of Bedrooms: "Z Number of occupants or people to be served: _
c) Basement: Yes _, No�ll there be plumbing in the basement?
d) Garbage Disposal: Yes _, No!
Water Supply Type: Private �ew �existing �, Public , Community _, Spring _
Are any wells on adjoining property? Yes �I�o _ If yes, please indicate approximate location on the site plan.
6) Does the property contain previously identifted jurisdictional wetlands? Yes _ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I derstand if the site is altered or the intended use changes, the permit shall
become invalid. � � ? � �� /
or Lega Re ese � Date
. PCHD, rev. 10/17l01
�� i )� ���� �� _.
�.�.. �1 1 � � \LJ � � � � �
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Ta�x M�� ; — P�.rcel �
S�unhcllivi�s�ion � , , . -
Ph��•s�e Section Lot �
Improvement Permit
Permit Valid for �C Five Years No Ezpiration
Type of Facility: �o �s E New X Addition Water Supply '��- '—
# of Occupants # of Bedrooms v Projected Daily Flow � g.p.d.
Proposed Wastewater System: �' •� . Type: ,/ L�a
Proposed Repair: � Type:
Permit Conditions:
Go�t/h�l��.r
Owner or Legal Representative
Authorized State Agent: �
Date:l�"' �✓�'
Date: ii-%$'-ca �
The issuance of this permit by the Health Departme t i�do�not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County lwning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended ase changes. The Improvement Permit is not affectesi
by a change in ownership of the properfy. This permit was issued in compliance with the provisions of the North Carolina Zaws and
Rule�or Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to fwnction satisfactorily in the future or that the water supply will remain
potable.
Authoriaation to ConstaJuct �astewater System �Required for Building Permit)
* See site plan and additional attachments (��.
Proposed Wastewater System: �2�/�/F�/�j0^/� ��r;�T, Type �� Wastewater Flow � b g.p.d.
N e w ' x R e p a i r E x p a n s i o n _ S o il I. T A R: ^� o�� g. p. d./ ft 2
Type of Facility: Basement ,C Yes _ No
Wastewater System Requirements
Size: Septic Tank: ��(� gal Pump Tank: lQDO gal Grease Trap: — gal
field: Tota1 Area: �� sq ft Total Length �� ft Mazimum Trench Depth a- 3v in
�h Width � ft Minimum Soil Cover: � in Minimum Trench Separation: y ft
ibution: Distribution Box Serial Distribution X Pressure Manifold �
�Specifications:
Authorized State Agent: �
Permit Expiration Date:
The type of sv�tem nermitted is X
the permit.
Owner/Legal
Conventional
Innovative
Date: �/-/� O�
Alternative. I accept the specifications of
Date: —U `
PCHD7/30/2002
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Date .
° sy� �o�a� ��s�t �pro���contnurs only. The contrcictor mustjYag the system prior to
beginning the instadlatian to irisure thutpropergrrule is maintained'.`.
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OR Pa.RGFLS OF LANO.
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2. QEED REF.: 0.9. 424 PG. J7
3. PLAY REF.: P.9. 17 P0. 28, t0i t AN�
PLAT GlBtNET 11, NAN(�R 11—I, lOT t
4, 70TAL AREA: 0.380 ACRES
4. ADDRESS' 126 ItUNDY—OAKL£Y ROAO
CUNNINGHAM TOWNSN{P PER50N COUNTY
NORTH CAROUNA
oLl' ?, 2003 EC =1 IN 92.000 SCALE: 1" = b0•
�.�, CTRAPHTC. �C'AT.F' �
Scale• � f ��_� �
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PCHD, rev. 09/�Z/01
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Applicar�
Ta�X fv1=a��� i .., ' P�.r�cel =
S'U f) C�il'11�5�1011
F�h���e�Sec�t�iar� Lat �=
C��perat�on: Permit
System Type (!n Accordance Wifih Table Va): •
� THIS . SYSTEM HAS BEEN INS.TALLED - IN COMPLlANCE WfTH APPLlCABLE NORTH
'. ' CAROLiN�► GENEi3AL STATUTES, RULES .FOI� .SEWAG���:TREATMENT ANQ �DISPOSAL,
AND ALL CONDITIONS OF TtiE IMPROVEMENT � PERMIT . AND CONSTRUCTION
AUTHORfZi4TION... . . . . . . . ' . � .. .. . .. .
. . . .....�_. � � � /. � �� .
� � Authoriz tat - genfi � . . . . • � � . . : � Date � - . . .
instailed By:�• ; . . .. Date: JL '4S '� 3 �. . .
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PCHD. rev. 07/29/02
S�E�i'iC T�N�C [1V����TiON ��lE��Ci.lST (Type !I - I�
Tax MaQ #��.� Parce! # / System Type (Table Va)
OwmerlAppiicant ���,2� Subdivision
AddresslLocation � SecfPhase Lot #
. Septic Tank ni a� � cation nes nit�a te ,
. St�tte ID/date � l Z. //'L-o� r��'.� Ttenct� Width 3 f�, �L ��a�
Capa ' DD p. ga(. Trencf�. Depth �a'tn. �.
Tee and F er � Trench Length � f�.
Baffle Trench Grade
� Sealac�t Trench S aci�
� Riser if ap licable Rock De th and Quaiiiy
Tank Outiet�, Sea) � - Dams/Ste downs etc. � � �
. Permanerrt Marker Pressure Laterals
� Pump Tank � Hole Spacing
. � tate ate �/-i -o ��� o e ize .. . . . - . . .
Capacity . gal. � Pipe Sieeve . � - - � � � �
Wate roof /Sealant Tum-u sfProtectors � � � � �
� � Riser - � �Required Setbac�Cs
. Water Ti ht � � From Weifs �. � i�
� � Pump- � Ftnm Property lines � � �
�heck Valve/Gate Valve . � . i z � .Strvctures/8asemerrts.::� � �. � .
_, ti-si on o e.. . es raina � e ays � .. .
� .� �ioa#s/Swiiches � � � � � � � . . . _ _ . �SurFace` Waters � - � - � � - � �
. Alarm visable and audible Public Water Supplies �
� Eiectricai Componer7ts Vertical Cuts �>2 ff. .
Rate rn Water Unes �
Ap roved Pum Model Go��� /z � Vehicle Ttaffic
Blodc Under Pum Ad]acerrt-Systems � �
Pum Removai Ro e/Chain Easemecrts/Ri � ht of Wa -
' Distribution System � O�er
Serial Distribution ' Easemerrts Recorded .
ressure an' o �y -� erator r�tr�act
Low Pressure Pipe � Tri-Partate Agreement
Appr. Pipe Material and Grade �
� �
Comments�
pcnd rev. 3113101
: �,��. �� �'�I�' .� ��
—= � � � ����-
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WEI,L PEYtMIT
PI.EASE SEE ATTACHED PI.AN FOR WELL SITE LA3�OUT
Tax Map #: �� `� Pazcel # � Townshig
Applicant
l
Subdivisiori: �✓�Ci Section: I.o�
Ty�e of Water Suvnlv: �dividual
�2ec�uirements•
Site Approved bp � -�� S ��
Grouting Approved by�.�� � -�-b'�`�
WCLL Lug 1��5 7- Z z- aZ
Well T C.CSs -� -zz-�-+-
Air Vent � / �
Hose Bib
Concrete Slab
Community Public
rr (��2�r i�'�u Sr� VI��
�� �
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E�s �� �f'`����
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o� � 3�
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Well Driller. Ev�os Wf--4 �u �� ca , I� ��.`�`-
Well Approved B. Date: J� l
ee Attached Site Sketch'�*
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building founda.tion.
Other conditions:.
PCi-ID, rev. 09/07/OY
��� ss .��.�..�'�.�
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Owner: -
Location: �
Subdivision:
Driller I D #
Com��ny Name
D t�e Drilled
�'Ycll Log
Tax Map�i�,��cel # ___�__
Lot # !
Distance From nearest 1'roperty Linc (Minimum 0 fee )��5� ctiou
Distance from Septic System (Minimum 60 feet) �
Total Depth: v � ft Yield: � a GPM Static Water Level: �_ g
Water Bearing Zones: Depth _R S �/�j'S t} _�} �
Casing:
Depth: From -�� to _�_ � Diameter: 6% in
Type: Galvanized Steel e� —'�—
Weight: % `� 'I'hi�kness: � Height above Ground:
Drive Shoe: --�yeS No q� roblems encountered while settin� in `
If "yes" givc reason: y p � �•____Z'�s No
Grout:
Neat: Sand/Cement ✓ Concretc Gravcl/Cement
Annular Space Width 3 inches Watcr in Armular Space Yes No
Method of Grout: Putnped pressure Poured c.� Depth to Ft.
Materials Used:
No. Bags Portland cement _�_ Weibht of 1 IIab �_ Pounds
If mixture (sand, gravcl, cuttings) - Ratio � to �_
ID plates: C�Yes _ No 4 x 4 slab YYcs No
Drilling Lo� , ---- -- -
I hereby certify that thc above information is conect and t�iat this well was constructed in accordance with regulations
set forth by the Person County Health arhnent
Signaturc of Cvntractor
, Ill # �h �� I)atc — % a-1 0 �.--
� PCHD rcv O1/16/'
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�xist�ng Sewage Spst�m� �.e�ort �or. IViobile �ome dteplac�meat
_� �ddition . Type: (�/.a P.� � �%�
I2er�nester. � . � � �iome I'hone#
� O • Z � Business #
C��� �� .�.� �� �.7s��'
�I � �l�-�p.-�,r � � � �.� �c
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OrigivalPermit i:ocatesL• � �� Water Suppl� VNti,�
Se�tic System �esignesl �or. '�Residesitial Business Other
# Bedrooms � � # Employe�s � Otiier
Spstem Type: �����`r°�. 'I'ank Size: �� 0 4 Nitri£cation Line:__�
L ' I� „
l�ate Iustalled: `� �- D� Cestifie� Opesator Requised: /V �
On-sit� wastewatez disposal system shows �o visuai signs of malfnnctioa on
g'�sion is �rante�
Com�ents:
�nv�ironmental �eaith Sper.iaiast Date: � fJ �
�
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'' C. P. & L.
HYCO LAft'F
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1( �-� 1C7L'tii%]11P ctD 7Y�.117Y1�.c� 7L71.tt.u�t-JL ,ll. Jl ��1.11 ��
Date: �- � ' � �
Tax Map: � Parcel:�
Address: �22(� 1�1i u,� n�l �I -
Re: Bacteriological Water Sample
Dear Mr�. ]�G��s
Your well water was sampled on �/�/�, and tested by the Person County Health Department for biological
cont�-ninants (tota� coliform a.�7� fecal colif:,rm bac�eria).
The results of your water sample are as follows:
No colifurm bacteria were f�un�i in your well water and the�efore y�ur water can safely be used for
drinking, cooking, washing dishes, bathing and showering.
� Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are naturally found in the soil;and fecal coliform bacteria are associated with animal and/or
human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or
repaired well has not been properly disinfected prior to being used, or that contaminated groundwater is entering
the well. The well should be properly disinfected usin� the enclosed chlorination procedure. A well contractor or
plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, the
Hsalth �epartmPn± sh�uld be notified so that the �*�ell can be re-sampled. If the well watPr continues to test
positive for coliform bacteria, then there may be a problem with the water source or with well construction. A well
contractor or the Health Department can assist you in identifying the problem and finding a solution.
If coliform bacteria are present in your water sample, then ths water may not be safe to use. Young children, the
elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should
be notified of the results. Water can be disinfected by boiling for one minute.
If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from
8:30 am to 5:00 pm.
Sincerely, ,
�-
En ironmenta ealth Specialist
Person County Health Department
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790
Revised (11/13/08)
;�
a
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �Ar� �v�S
►
Address 2, A
Collected By �S
County o
Date Collected y- 23—►2 Time Collected �� 3p
Source: LXWeII ❑ Spring ❑ Other
Location: �ouse Tap
❑ No Charge C�'Charge
❑ Well Tap ❑ Other
........................................................................�
**********************�***********************�*************************
Total Coliform
Fecal/E. Coli
Results
Present Absent
� �
❑ �
, � .
Reported By hJ
Date Reported �I � t ��
.��za ,�v
�� � �
Report To:
North Carolina State Laboratory of Public Health 06 N. W?m�ngton St.
Environmental Sciences Raleigh, NC 27611-8047
httq://slph. ncaubl ichealth. com
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
MARY MARS
226 MUNDAY OAKLEY RD.
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ESO42412-0005001 Date Collected: 04/23/12
Date Received: 04/24/12
Sample Type: Raw Sampling Point: Inside spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 09:30 AM
Collected By: J. Smith
Well Permit #:
GPS #:
Inorganic Chemical 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 71 mg/L
Chloride 39.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper 0.13 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 0.37 0.30 mg/L
Lead 0.008 0.015 mg/L
Magnesium 21 mg/L
Manganese 0.53 0.05 mg/L
pH 7.1 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 30.00 mg/L
Sulfate 23.00 250 mg/L
Total Alkalinity 251 mg/L
Total Hardness 270 mg/L
Zinc 1.80 5.00 mg/L
Report Date: 05/03/2012
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