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A24B 42-l��s � sk� r�d� �-��, , f�� ,�oss � � �. �r t�v�G��r�� ;�a� � �� l� -!- c�r�t, � � e �o� , Ca,.� �Rr C�� 1�► s� �GkSe t �ut ��-C Qp C' ],,�y� y �,�t, o�V1� • ��k l�'--- ��L�"� S�'�-,,��Gr �,CF- —�t� �! � ,.� sc��-e,,,..� p�c,c� SL1ow v�lw ��5 � �i�s� ��-[��'�� `�' s c� <-e S 4�,,,;� �.�� c� �b a��s a,,..e r�,-� ��'�s' h� s�� .��- }, � Ca�' U a � refacA..� Q�� 5�'� �YS� {�li� �t S�- � � �t rca� v, -P�', ' S �i� w�e.[ I S 7--� � n.o� c��s {( �w w� l�, � �� . ��- � a-a�-�co- �� .�.�, �..�a E�o�s �.Z ��.� :s � ��Jn�. tttic.�..� �Q �u�.kl-►:� ;y, a o�,h�.�,.. �'`�,'.,P � s �,, �,,.� ��,. c,Z. p�,.�.,.�.�a,a � -}-�1�, � �� O �,`'j� �'%/o �a�r/i�2o` �� a ,�t 1.��c�� C�l �' �.�� .�v�f.�� . � ��'� Y�a� w� �� .� e �t,loli, ,Q,,� , � � �� '� . 9 � w � � c�t �2�� ,_ �ZS .� ��w.✓�� s ,�� D� %� � �'` �-�' y��!� co,✓ �vo�,,f/� � -�,,4;�� ;�,.✓�� i�v�� . p �v� �.�� • ��-�C ��v�✓.y�✓r ?�Cv,y��✓rn�'o.�/ � Appfication Date; %-��-� ap Amount Paid: Q. Recsi t : Tax Man #• �� Parcal #: 6� "T �� l0 - " —' � � �Tl�- � �'_ ��.�a-�.��.,-,..��.�.m.a ��.m.a� APPLlCA710N FOR SERVICES � IF THE INFORMATiOfd IN THE APPLICATIOfY FOR AN .IMPR�VEMENT P�RMIT IS INCORRECT. FALSIFIED, CHANGED, OR THE SITE IS ALTIERED. THEN THE IMPROVEMENT PERMIT AiVD AUi'HORIZ,4TIOiV TO COIVSTRUCT SHALL BECOME INVALiD. • � '1) Permi# requested by: (Owmer/agent/prospective owner): • w� �� a � 6- �� Home Phone: �9�`i 2faY. E'�f4� Address: ,?DS' r��k a-►1 Business Phone: �t9 2 — 2�0 � t�.) u a w� �'_ 4�,.2) Idame and address of currept owner: i.t.)1 �� lawl ��'S� . w�.: � 3� Prope[ty Description: Lot size: ��' Township: �'v�V�� itlivisic Directions to the propetty (Inciuding road names and numbers): ,2 � � Shbr�e fl�:� 'nr � v a�l� Lot # 4) proposed Use and Structure Description: answer each of the following questions: • i a) Proposed �[,, Existing , Type of Structure: �Y27MG Width: S7 Depth: y� -- b) Number �f Bedrooms: �_ Number of occupants or people to be served: Z c) Basemen� Yes�/, No _ Wiil there be plumbing in the basement?�Lf,Z d) 6arbage Disposal: Yes . No ,� 5) Water Supply Type: Private ►�(new _ or e�tisting,�/j, �Public_,, Cammunity_, Spring _ Are any wetis on adjoining property? Yes�,[ No _ if yes, piease indicate approximate location on the 'site pian. 6) Does your property contain previousty icdentified jurisdictionai wetlands? Yes_ No f� �. � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY C�R SI'T� PLAN MUST BIE SUBMITTED WITH THIS A►PPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARi�D, •, � • ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI�D OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSiBL.E FOR AN EVALUATIOPIBY THE�HE�►L.TH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposaf system for the above-described property. I agree that the contents of this appiication are true and represent the maximum facilities to be piaced on the property. I understand ifi the siie is altered or the intended use changes, the' permit sha!! become� invalid. � 1 �/ 1 / `� �� S/ Owner or Legal Representative Dat PCNO, rev. 06127102 0 . '' l ;� � � � �� _ —� r �, - - �. � t;` < �. � � � �; � - �: - G (; -- _ [: F�._., T��ap� �� . , • r ,�� .. � � • �� U/�� l(iar►� ��'�- � � �� q�`� ��- s�Q� 70�" �-�u�,.-{�,�. � � �1�� 7�-ao.n� � l�c�r�,h �V�- � ��3,,m� PS . • Wa�s�%- iA/�� ' � � �� k �t _�� c� 0 � �� # �� . . � s� ��rav-e ( �r� s-� � a • �� x Z ` ..��a�:- ��t� z�-�o�' ' c�� ' � ��-� ��,t�� "o.� � � ,� ��, �s� g�e l�s-e . �� , olws�c�E-� vl,-Zw 3f�!'�� .��tx.� ��se. ��` ✓k� � . . ��i�� . �DLi S-�� l. � �.� � � �` � s�s �e,�, � - y �4 5-� •I/L� 0 0 -� � � /� � �uw�-ei � �_ �'o � �p �`� �N� C/�'�' � j��C S[T S� O(�L1 r�� (l�s' i� ��'� n ti, '( f� � i . �i,.S'IY'�-«hZ'^ v 't— �lov�PS, r . 5 � ��{�—Od� �� 30 0 15 30 60 120 � � I I � _� ' BAR GRAPHI inch = 30 ft. 15 DRAWING FILE NAME: WILWEST.DWG DRAiNFIEL \ � � y � � J SEPTIC TANK �y�' � � ,,t � ti�' ON RETE � \ 2p � qcK ��c� �� t.v� ( ►� s �— � I� a �� rrn � �%-� � sP p�f�`� S�sa-eM . ._�.�,, , . ,,,�i�� ,� � . � ro No. oi persons to be serned ,_,. Bedrooms 1, 2, 3, Additional appliances to be used: Disposal, dishwasher, washing machine �� 'i � . R,ecommended• Septic tank +''� C � Nitrification line: Above recommendation based on information received and observed soil condition. Septic tank and nitrification li.ne musi be inspected and approved by a member of the District Heaith Deparimeat s3aif before any portion of the installation is covered. Date Approved: �y►;,��-� By: .S1gII� S8II1�T18II O. David Garvin, M.A, M.P.�i District Health Officer Caunteisigned (Over) �a�� — .��c�s��-��a� ��..� �r��';��c� ��1 �� .� � �� _ �� y y , w �\ �_ � � � � � � ��s<m��--� ��.�n.11 IHC��.]l� Applicant: �'��'1 w�� . Location: _. / , � Qy� ��rmit Valid for � �'ivv� e Type of Facility: . � # of occupants �C '% � # of Proposed Wastewater System: Proposed Re}�air: Permit Condi�ions: Owner or Legal Represe Authorized State Agent: � T�x Il1a:� I � � arc�ei � Subd!ivi.�s�ior�� ;� " �h�s�e Sectian'Lo-t � Improvement Permit " No �zpiration ,, .,,// New Addition� Water Snppiy W�( � � Projected Daily Flow '��D g.p.d. �1�s; Type: Type: ua�.c. Date: — " The issuance of this permit by the Health Departme� in does not guatantea the issuance of other permits. It is the responsibility of the applicant/property owner to in sure that aIl Person County Planning and Zoning and Building Inspections requirements are meL This �mprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the properiy. This permit was issued in compliance with the provisions of the North Carnlina `Laws and Itules i'ar Sewage Treutment and Disposal Svstems' {15A NCAC 18A .1900). Neither Person County nor the Environmental iHealth Specialist warrants that the septic tank system w�11 continue to function satisfacton7y in the future or'that the water supply will remain�potable. � Authorization to Construc� Wastewater System (Required for Building Pernut) * See site plan and additional attachments (_J. / '� �'Ft S'il 5�T T�pe� Wastewater Flow �� d . Proposed Wastewater System: � � —g•P• • New Repair Expansio Soil LTAR: g-p.� ft 2 Type of Facility: T ��1�5 • Basement Yes _ No .;Q 1 � — ��''� � BVastewater System A�es�uirements Tank Size: Septic'Tank: � gai I'ump Tank�t ��gal Grease Trap: gal �rainfield: 'Total Area: '� sq ft Total Length ,��C_ ft Ma�mum Trench Depth e� in 'Trench Width ft M'inimnm Soil Cover. in Minimnm Trencli Sepazation: ft �istribntson: Distribntion Bog Serial Distribntion Pressure Manifold Specifications: Authorized State A.g$nt: __� Permit Expiration � Date: The type of system pernutted is � Conventi Accepted Alternative. I accept the spe�ifications of the permit. Owne�//�,�gal itepresentative: Date: • PCHD rev. l l/10/OS A � � ' �� `1•. �+' y ��_ � � � � � � ��a�a-m�-�+ -��.��.�. ��.��1�. � x M a� ' r c�-e # S��. � ciliv�sio�n Ph�.s�e Se�hio�i: ot , � of edirooms A�plicant �1\�. ��- � Location: � � . . � � ::�r �f;: ' - :.� ':� F� ,, System Type (ln Accordance With Table Va): THIS SYST�IVI MAS BEE�! If�STALLE� Ils! CflMPLlANC� WiTH APPLlCABLE iVaRT}-t �� C'�iROLli�A GEiVERAL ST�'rUTES, RUL�S FOR S�1fAGE Ti�EATMENT AND DISPOSAL, AND Q+LL CDI�dDIT1OiVS OF ' THE IMPR�VE�IIE�T PEi�MiT AND CONSTRUCTION �4UTHORlZAT1�N. � . . . _-�.�v a.i,� � t� -�.�q_ � - .. Authorized State errt � Date 4 . I nstalled By: , �� 5 Date: � �. �i �-OCQ � c..��s� o`�c,l �� —� fl CGt - l� �C ��K��e� �� 'P'c 85 'P'�S"�oo° 4-14�ot� .S'T3�1y2 . �`7—�� - �� Q�� (i� Y C (� � �' T ,g� S�� 0.`S v✓f �� L �'� S a�C _ � ��. ��e, � � PCHD, rev. 07/29/Q4 m �� a��'�� 'C"��'��...�� a �� @ - �� Tax Niap #'�?ya Parcfll #�! Sys�esr� Type (?a�le Va) � Owner/A�plicanf Subdivision Address/Location Ser,lPt�as� Lot # State � 1 D/dat�-r3- � �a Capacifij�-�o�. Tee and F�iter Baffie Sealant Riser (ifi applicabie) Tank Outie� Seal Permanent Niarker Ptarnp Tank . . .. . . ��/ J � � Wate roofi ISealant Riser Water Ti ht ' � Pump . Checic Valve/Gate Valve and audible ooner�ts � Rate m A �roved Pum �Aode! Bloc#c Under Pum Pum Removal Ro elChain . � Dos#aibu#ao�_ S��ra � Seriai Distnbution ressur� an o Low Press�re Pi e � � A r. Pi e ItAater�al and .Grade Val�es , , Trenct� Widih � � ft. . � Trencl� De th � in. Trencl� Len ft. Trench G�ade � � Tcenct� S acin Rock De th and� Quai' Dams/Ste downs e#c. Pressure Laterals � Sieeve � Res�ui�esi' Setbac� From� VUells �� From Propertv iines � � � SurFace Waters Pubiic Water Su lies ' - Verticai Cuts >2 ft. Water Lines � . VeF�icle�Traffic � � 0 I - C�mmenis �/Righf. of �#her � pcf�d re��. 3/1�/01 ��..� �� . _. � ,,. . _ _:: , �:� �� +x��rn�-o�nirara.��.�:� 'g��.��.� . WELL PERIVIIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map�o2�{� � Parcel # � Township: Applicant: � ��t a � �� , 5ubdivision: C k Lot # T nratinn• Type of Water Supply: � Individual _ Community Public Requirements: Site Approved By: �. C.S �--�q--oc� Grouting Approved By: CS �• zst-�� Well Log: CS l -2� -�. Pump Tag: Well Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner: Installed by: Depth set: _ Grouted: Date: Water Sample: Well Driller: ��r� W� � �` � Well Approved by: � ti' V v Date: "�D ****See Attached Site Sketch**** .� � In Wells must be 10 feet from property lines. � � `� � � v m Wells must be 100 feet from septic systems. � � Wells must be at least 25 feet from any building foundation. ; " � . Other conditions: � �� W-e � ( �L�r S-� �,�; �,;- � � � q,��A� �c�c� PCHD rev O1/27/04 �-�P� � 57s�� `'�� .� �� D� fl� � 2 u � °� � a , � �,,�.f-k w`I� Ari�l,� _ ' � � �.7�T��.- �, 9 II� aa�na-oara�� .��.Il:: IE��.Il�.�%n . IXsJlSI� 1JUUUU��I°J 6�%-r' 06 Owner: f l 1 Location: Subdivision: G � Grout Log Tax Map l�' 2 YQ Parcel #� l.,svt /�t.✓+S 1ir -�T �'rt w..o�n y �e.�E/r /t�./ Lot # . � Well Constrnction Distance From nearest Property Line (Minimum 10 feet) ( n t Distance from Septic System (Minimum 60 feet) 1 vro Total Depth: 0 u ft Yield: 2 GPM � Static Water Level: 2� ft Water Bearing Zones: Depth 3y n ft 3 K 2 ft ft ft Casing: . Depth: From . 0 to �� ft. Diameter: in Type: Galvanized Steel ✓ Weigh� Thiclrness: �(�i_l Height above Ground: l. Z. in Drive Shoe: ✓ Yes No Any problems encountered while setting casing� 1�Yes _No If "yes" give reason: Grau� Neat: Sand/Cement Annular Space Width � Method of Grou� Pumped _ ✓ Concrete GraveUCement inches Water in Annular Space Yes �� No Pressure Poured �' Depth t) to �_ Ft Materials Used: - No. Bags Portland cement � Weight of 1 Bag47 Pounds If mixture (sand, gravel, cuttings) — Ratio to ID plates: �Yes _ No 4 x 4 slab �Yes _ No Liner: -. ,,, Depth: Date Installed: Grou� Installed by: Drilling Log Location Drawing From To Formation V �ncr K,rd c., 2. tt v � d +� D t�� . VYG%" � ; ' �,51,,�os +'v lt 1� w I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health De�,utm�cant. _ , � _ Sigriature of Contractor Pump Installation Contractor: Pump Depth: Pump Make & Model: i ID # � Date . .(�i L Pump Installment Registration Number: `�,� � 6 , ft Size and Rating: �hp l Q gpm I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect on this date and that a copy of this record has been provided to the well owner. �- .�. Pump Installer Signature Date: �`-�6 PCHD rev O1/27/04 � `� �� ... � . `�-� � �� L�arn�'ittr•�s�ir��r7m�Tu7itLxa.�. ��,Ln.�iL��it Da�e: !o � �!� '� "Tat �fap: �� Parcel: � �iame: � �Z,�.� 1�usaGf .=lddress: i�� (u:1� f]i4��1 �. '�Grar�pt�, �.�1 7�7�3 i Rz: Bacteriologi�al Test Results Uear �¢ . �,�s}��_: �'1�Ur u�!! �<<ater was sampled on �O /�/►3 , and tested by the Person County Health Department for FioloJicaE �ontaminants (totai �oliform and fecal cotiform bacteria). -f l�e results of your water sample are noted below: _�/ eVo colijorm bacteria tivere detected in tlte sa�nple. Your well water is safe for normal use. TotaI coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. i��ru1 culifornt bacteria are naturally found in the soil. Fecal coliform baeteria are assoeiated with animal an�'or human ��aste. T'he Qresence of either total or fecal coliform bacteria in well water may indicate tha# , ne«� or repaired well «-as not properly disinfected prior to use, or that contaminated groundwater may be �nt�ring the «�ell. lf coliforn: bacteria are present irr your water sample, the water may nat be safe for r�se. ��'o:er�g children, the elderly, and individuals with compromised immune systems are especially ;•>>z'n�rable and lheir physicians shozrlcl be notified of the test results. . d ti��ell that tes�s positive fof• total or fecal colifurm bacteria should be properlv disin%eted and retested ��r�ar to 1•esumin� norrnal use. The welI may be disinfected using the enclosed disinfection procedure. A u-ell �,ontractor or plumber can assist you if needed. �nce the chlorinated water has been thoroughiy ; tlushed out of the system, please contact the Health Department (597-1790} to request a re-sample. I�or additional information, please feel free ta contact Environmental Health at 336-597-1790. Our o�ce i�ours are 8:30 to �:00, Vtonday through Friday. � �II1�C1'C�1', � � E:n� ironmental Health Specialist Pzr�o►� County Health Department f'e�;o:� Co�ni• Em�ironmental Health, 32� S. ��lorean St., Suite C, Roxbora, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808 � �� ;�d 07:39' i � ) PERS0�1 COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS \ame of O«•ner or Tenant �+� �t��l��' Address l�?� N�.Lt�►�.��/ DA�1�� . Collected By .L.� � 1�Lv—� County PERSON Date Collected D Time Collected 7� Cj Z� Source: �ell - Spring � Other Location: �hIouse Ta J Well Tap � Other _ \o Charge arge ■��a�s��r�a��rs��ai��a�s��r�� *fi##�kM��*�k#��k�k��k�k**#****#�k�k*�k�k�k**�k�k�k#*#�k�k�k#�k�k�k�k�k%k*�k#�k*#�k****#*�k#��k�k**�k Total Coliform FecaVE. Coli Resirlts Present Ab�t ,. _ � Reported By � %� Date Re�orted E�1 � � 1 � � Rcport Called Called To: � YES �'t�.0 / `-��rv�7 � North Carolina State Laboratory Public Health 3012 D�stnct Drve Environmental Sciences Raleigh, NC 27611-8047 htta://slqh. ncaublicheaith.com � I C i0 b 1 O � O Phone: 919-733-7308 g y Fax: 919-715-8611 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: ES100113-0056001 � �� (�� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JOHN HODGKINS 1163 CONCORD CEFFO RD Collected: 09/30/2013 09:10 Received: 10/01/2013 08:50 Sample Source: New Well Sampling Point: Well head Derrick A Smith Angela Heybroek Well Permit Number: A25-157 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 10/02/2013 E. coli, Colilert Absent Susan Beasley 10/02/2013 Report Date: 10/10/2013 Explanations of Coliform Analysis: Reported By: Susan Beasley � ,.T.f�' � 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. WELL ABANDONMENT RECORD North Carolina DepaRment of Environment and Natural Resources- Division of VVater Quality WELL CONTRACTOR CERTIF[CAT[ON # � �� / WELL C�O / � •1 R: � '[ % ` +4�/(f K We ontractor ([ndivid al Name �-h,v � ?�r �,�� G/ �� Well Contractor Company Name � � STREETADD SS N�: �p�1/ 27s� ty or Town State Zip Code � - _,�� 5- �d /S Area code - Phone number 2. WELL INFORMATION: SITE WELL ID # (if applicable) STATE WELL PERbIIT # (if applicablel COUNTY WELL PER11fIT # (if applicable) DWQ or OTHER PERMIT #(if applicable) WELL USE (Circle applicable use): Monitoring Residential MunicipaUPublic IndustriaUCommercial Agricultural Recovery Injection Irrigation Other (list use) 3. WELL LO TiON• COUNTY ��sa� QUAD NGLENAME NEAREST T WN: ` L% �� -V � !� (Street/Road Name, Number, Commu ity, Subdivision, Lot No., Parcel, Zip Co e) TOPOGRAPHIC / LAND SETTING: Slope Valley Flat Ridge Other (Circle appcopriate setting) LATITUDE May be in degrees, — — minutes,seconds,orin a LONGITUDE decimal formaz Latitude/longitude source: GPS Topographic map (Locatron ojwell must be shown on a USGS topo map and attached to this form ijnot using GPS.) 4a. FACILITY-T1ie name of flie business where the well is located. Complete 4a and4b. (If a residential well, skip 4a; comptete 4b, well owner infomtation only.) FACILITY ID #(ifapplicable) NAME OF FACILITY STREET ADDRESS City or Town State Zip Code 4b. CONTACT E N/WELL OWN NAME 1L ST ET DDR�SS � 7 S% City or Tow State Zip Code U- Area code - Phone number 5. WELL DETAILS: � �/ a. Total Depth:��-�� fL Diamcter:��+ � / in. b. Water Level (Below Measuring Point)`. ` v ft. -�— Measuring point is �_ ft. above land surface. 6. CASING: Length Diameter a. Casing Depth (if known): _� ft. in. b. Casing Removed= d_ ft_ in. 7. DtSINFECTION: �� 1 LI� (Amount of 65%-75% calcium hypochlorite used) 8. SEALING NTATERIAL: Neat Cement Sand Cement Cement lb. Cement��lb. Water gal. Water� gal. Bentonite Bentonite 16. Type: S(urty_ Pellets_ Water gal. Other Type material Amount 9. EXPL�i jN DIETHOD OF EMPLACEMEN OF MATERIAL: �li �/�.1 � ! �� h 10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this form showing total depth, depth and diameter of saeens (if any) remaining in the well, gravel interval, intervals of casing perforations, and depths and types of fill materials useA. 11. DATE WELL ABANDONED � � d� I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE WI'CH ISA NCAC 2C, WELL CONSTRUGTION STANDARDS, AND TI IAT A COPY OF THIS RECO HA EEN P VIDED TO THE WELL OWNER. � N TU OF CERTIFIED WELL CONTRACTOR DATE SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE (The private well owner must be an individual who cersonallv abandoos his/her residential well in accordancf� th ISA NCAC 2C .01 I K � j �� 1�A /!/ �t •—�.`"� PRINTE N Dt�OF PERSON ABANDONING THE WELL Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30 Attn: Information Management, 1617 Mail Service Center - Raleigh, NC 27699-1617, Phone No. (919) 733-7015 ext 568. Rev. 5/06 . . �� - -��4G� 0 e