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A25 157Application Date: ._� AmountPaid: ��G �VO Receipt #: I ? l 3� ( `�,;,�.J ll ��L �! Tag Map: �S �,,,1- � � �� Parcel#: i S rl r 1��caa*aa-�TM*�*�*�x.��.IL )HL�s.IE�E�. for Services Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authori�ation $200.00!$3�0.00 (if > 600 gpd) , (Fee is d�enc;ent oTt the type of system permirted j ❑ Mobile I'lome Replacen�ent or Bailding Etdditi�n � P ce arit Rer•isiun $I50.00 (if site risit requirzd) __ S75.00 __ D Weii Permit (niew/Replacement%Repair} Repair of Eaisting Septic System $300.00!$2QO.QOi$75.00 Application: No Charge/ CA $150.04 or $300.00 1) Applicant Information: Nacr�e: ..�•/•J //n�GleJ,..�S Phone(horr,e): 2SZ l�79 7S�3z Address: //�3 cr•,,lev,�,� C�f,=e .v� (work/cel(): 75� 3��Zg9S' c.�r'•t 5.�,✓is� 295 3 2) Name and addr�ss of current owner (if different than applicant): Name: Phone: Address: 3) Property Description: Lot Size: ��_ Subdivision: L�t #: Address ar,d/or directions to Property: �/�3 �,�.K„� [a,�i•;� 2o�c� � ,v�s no Does the site contain any jurisdictional wetlands? C9"ye� ❑ n Does the site contain a��y existuig wastewater systems? ❑ yes ��. ls aa�y �vastewater gcino 2o be generated on th� site other than do,nestic sewage? ❑ y;,s �0 1s the site subject to approval by any oiher public agancy? C3 yes �o Are thera any easemei�ts or right �f ways on this pru�ecty? (if `yes' is checked, please �rovide supporting documentatioa) 4�) �P 'oposed Use and Type of Structure: 5d'Residential L� Iv'ew Single Family Residence �rlaximurn number of �edrooms: Z— �pansion of Exist�ng System If exRar.cion: i,urrei�t number of bedroums: epair to MaJfunctioning System Will tt�ere be a basement? � yes G no With glumbing fixttires? CI yes C.i ne ❑Non-Residential 1'ype ofbusiness: ____ ___ Total Square footage ofBuilding: Maximum number of empiuyees: _ Maximum numoer of seats: _ 5) Water Supply: �New weli ❑ Existing Well O Community We11 0 Public Water ❑ Spring Are there any existing �vells, springs, ur existing waterlines on this properiy? ❑ yes ❑ no 6) If applying for `Autl�orization to Construct', please indicate preferred system type(s): ❑ Con��entional ❑ Accepted C] Innuvative ❑ Alternative ❑ Other ❑ Any I cert�� rhat the information provided abave is complete and cot•rect. I also ur.�erstan�� tltat f the i� forrnatiurt �rovide�l is iraccurute, or if�the site is subs�quently al�ered, or the intendzd use chai�ges, all perr.iits and approvals slurll be invalid. Signatur� (Owner/ Legal Representative*) * Supporting documentation rcquired. (o�/o�i 3 Date • Permits are valid for either GO months or are non-eapiring when accompanitid by an approved plat. � A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) Report To: North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES100113-0034001 Date Collected: 09/30/13 Date Received: 10/01/13 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.0 Sample Description: Comment: � Name of System: JOHN HODGKINS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncqublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 1163 CONCORD CEFFO RD Time Collected Collected By: Well Permit #: GPS #: 09:10 AM Derrick A Smith A25-157 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 Cadmium < 0.001 0.005 mg/L Calcium 34 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 6 mg/L Manganese 0.27 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 8.0 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.60 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 126 mg/L Total Hardness 110 mg/L Zinc 0.42 5.00 mg/L Report Date: 10/07/2013 Page 1 of 1 Reported By: Arno/d Holl �� S f ��.� �� .,r ► 1 � � �� 7 � �� a � � � � � .�. � �. Il lE-3L � �. Il � I�. WELL PERMIT (New i�Repair� Taa 1dIap: _�� ____ Parcel: _ 1�`� Svbdivision: Lot: Applicant's Name: �aN� NvnbK�r,s '.�/Iailing Address: Phone Numbers: Location of Property: I��o3 Car�c.av.s� C��a �D ; Nw�t 57 1� -> �j �.1► G�►J�ccv c� c,� ct� 7 Pno�t.-c�c da O�� ►. 3 r►�.�s Pertnit Con�iitions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. . 3) Permits �xpire S yea�s from the date of issue. Oiher Conditions/Comments: � Perm3t issued 6y: o��_� ,.�.. G2_ _�, _ Da�e: lo Iq ►� CERTIFICATE OF CO_MPI.ETI�N Ne�v i��ell Inspection: EHS/Dat� Location: Grouting: Wel: Lag: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Heiaht: Concrete 51ab: Liner Insp�ction: EHS�'Date Installer: Depfli: Grout: V'��1! Abandanment: EHS/Date Completed: Method/Ivlaterial(s): _ Well Driller: ��q�o License #: Pump Installer: Li�ense#: � �'Vc11 Approved by: o�,,,�, Q. �1„7�.� Date: `j 1� �3 Date Sample Collscted: �f 3d ��3 Date Results Mailed: `0 �� v� Petson County Environmerital Health 325 S. Morgan St., Suite C� Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 8/1/08 _��.s� ��.�� r � � �� )��e�rn�n�r^��rn.�*-„-„ ��rn.-��.� ��n.�� Applicant: J �t11� Address/Location: I �. A�Pvr.�x. i M��ES � � Improvement Permit Permit Valid for: Five Years 7C Non-expiring Type of Facility: New Addition Number of: Bedrooms �/ Occupants� Employees / Seats: Proposed Wastewater System: Proposed Repair: �.�vEr1�� L. _ Tax Map: A�IS Parcel: 151 Subdivision Phase/Section/Lot # ��7 Water Supply: �-��raZT.- W� Projected Daily Flow:�,yo gallons/day Type: Type: 'TS. e, Permit Conditions: Pf�-'Y•ls��,��t,► M��-r��ta � K�pu�Ct,�.q � �q� �,�,� p�y p��S. Authorized State Agent: � (X) Owner or Legal Representative: Date: � 1g 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 applicanUproperty owner to insure that ali 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 a�rd Rules for SewaQe Treatment and Disnosa! Svstems'(15A NCAC 18A .1900). 1Veither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water suppiy will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �,av�+��ot��. (*)Type�q Design Flow 1`{O y, gal./day New Repair � Expansion Soil LTAR: 'O. �S gal./day/ft2 Type of Facility: _ a-(3�0 Rc,c� -4�Sc. Basement: _ Yes � No (*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank 1 Qaa gal. Drainfield: Total Area 9�v <% " sq. ft. Trench Width 3 ft. Pump Tank �" gal. Total Length 3�.0 ft. Min.Soil Cover to in Grease Trap '� gal. Max. Trench Depth �_ in. Min.Trench Separation � ft. Distribution: Distribution Box )C / Serial Distribution / Pressure Manifold Specifications: __�} L�►LES °� �O� i►.i L�l�6� �'�R�. -��1.�►�.��r.� M��,� t, �-��1�R�.p Authorized State Agent: Issue Date: jq 13 Permit Expiration ate Tl�e system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. � (X) Owner or Legal Representative: ��,lo'�-� Date: Person County Environmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �� ?� )� �11G�� ]Eaa�a�ro� �^�^ �a��.71� 1Htmm�ll�]la. SITE PLAN Name .��1Na �dOrcKlt,.S Tax Map #�� Parcel # i 5h Su dxvisign Secrion�'L.o # .��,,.,Y. c��- �� iv ,. Autharized State Agent Date System rompoaents tepreseat appmadmate ccnmurs only. The coatractormusttlag t3e system paar to 6�;=��=�� the Iastaliatian to incure r6atprvpergrade is maintained. �,A � `�`?°`�,`'�g 4r`� -' � ? �r��.� . "v � `�P�� t�- � �- P��.t� , Caaast� , a `3Ac� ��. �,�, sc,�J►c• -rRtiJk � P�.�..e<€ �,,�' q �� 1'O�cq F,Avwt1 -rt At�,�i.. . ..�� - � s��he.S � $� � 1�oe��ti�` _ c.3� � ��"'� a�� ` , . �«.ac� - - G�►.,�� . �k . � , i�v►s� ; �� ; : �. ; ,: -.�,�� irT , � i3 � � -� �.QQ� ��5�. � � �. .- . E; � �r �-rA� � �� R.. �-n.U\� � � 7 � ,. " � ,s ` �-.,�-i�� , . \ 5cu;�1 � ��..,.,,,�.,,, j PIPE �'� ``�-� p„�a�c, � '�+ . 1 -- i , 1 _ �; � � �� [��. �.t.rFilQ.. '!�"� y�.• _ / .� *., � �n,a•r��z.s: s� o,srtsca K;�.P si�?s�e. f�e.E��y-:s � l�,#�; s�p fr"i' �4.or�. A�. � e v; �i .. iA�9 , � �,,� . � , �b t � �q`�� i : �./ . .+��'�j t "� � �(� ` �+r.F'' ,-0.i�'.. � � � � 5 �� £ -�.�s�a� �w� �.�-��6 i�4 �R�.O -�C � j�.. . � ';Z G �T/ I � � F . � , � �� f `I {/t� A`� �� ' !' �% // � i �y�� /' _ ' t�� .a 3�. �. � �`.; ��4� ` �, j� ': i�` ,��• � N ��GC} . ` ,�.: /��' �-t80 � �. . `��'` /�I / s � � .r �- �� ?SS21Ft "��' • i :t'iD Fe�t �� .sf ��.�� ' � � �� I��aa-��g-a��.Il �33C�.�,Il-�I� Applicant: L�ocation: � ��eration Per.rnit System Type (From Table Va�: Type V& VI Expiration Date: C� Taz Map �I" � Parcel # l � Subdivision Phase/SecNon2ot # # of Bedrooms � Product (IIIg): �Z �� 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 all conditions af thQ Improvement Permit and C�nstru�tion Authorization. �,,,� � `7--C��3 ( ori�e3A�entj (�ate) L�C - % 1�.c,�i�� 7` �� (Licensed Contractor) (Date j � Scale Ovl� PCFiD, rev. 12(14/12 � (Q►'�ce►�� — �� C 2�( �� _r , _\ .� ` - � . � � 1 ,� IR - � Z �( � � , Y `4'� _ ,, � , � ro" � �Z„ ��o�� 13� �� I r( �i 6 ��d.� ,� ; r � N qo � — 26 � / . _. Tax Map: Parcel #: Septic Tank System Checklist {Type II-I� System Tyge: :_�� - Notes• Pump System Checklist Pum Ta�k ' InitiaUDate State ID 8e Date: Ca acity: Riser (6" min. �tE� 4X Box Tnodel: Piggy back lug Haxd wired � Alarm functioning Mounted on post Above grade {12") Conduit sealed Prassure r�ianifold � Number af taps: Size and sch: �� Contracted Certified Operator (Type IV Systems): Notes• 1. We�tractor Inf a ' i Well Co actor Name �l �,� NC W II Contractor Certification Number _�d�G�� D � Company Name 2. Well Construcfion Permit #: Lrst all applicable well construction permits (i.e. County, State, Variance, etc.) 3. Weil Use (check well use): Water Supply Well: OAgricultural ❑MunicipaUPublic ❑Geothermal (HeatingfCooling Supply) Blcesidential Water Suppiy (single) ❑IndustriaUCommercial OResidential Water Supply (shared) Non-Water Supply Well: ❑Monitoring ❑Recovery ❑Aquifer Rechazge ❑Groundwater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwaler Drainage ❑Experimenta( Technology ❑Subsidence Control ❑Geothem�al (Closed Loop) ❑Tracer ❑Geothermal (HeatinQ/Coolin� Retum) OOther (explain under #21 ] 4. Date Well(s) Completed: 7� 7��3 5. Well Location: Facility/Owner Name Facility ID# (if applicable) 1/l 3 �n_Cp� ( ,Ps1�0 !n� Physical Address, City, and Zip � so � ,'"' �,' ��ty Parcel Ide ification No. (PII� 5b. Latitude and Loogitude in degrees/minates/seconds or decimal degrees: (if well field, one laUlong is sufficient) N W 6. Is (are) the well(s): ❑Permanent or ❑Temporary 7. Is this a repair to an exis6ng well: ❑Yes or ❑No If thu is a repair, fill out Imown well construction information and explain the nature of the repair under #21 remarks section or on the back ojthis form. 8. Number of wells constructed: For multiple injection or non-warer supply wells ONLY with the same canstruction, you can submit one form. 22. Certi�ication: i ro -� 7- g- l3 Signatur f Certified Well Contractor Date By si ittg this form, I hereby cert� that the well(s) was (wereJ constructed in accordance with 1 SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Consrruction Standards and that a copy ofthrs record has been provided fo the well owner. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. 24. Submittal Instructions: 9. Total well depth below land surface• .� (v � (ft,) 24a. For All Welts: Submit this fortn within 30 days of completion of well For multrple wells list all depths ifdifferent (example- 3@200' and 2@I00') ConstruCtion to the folloWing: 10. Static water level betow top of casing: 3` I,f water level is above casing, use "+" / 11. Borehole diameter: � (io.) 12. Well construction method: _ (i.e. auger, rotary, cable, direct push, etc.) 13. FOR WATER SUPPLY WELIS ONLY: 13a. Yield (gpm) � � Method of test: �it/ 136. Disinfection type: Amount: (ft.) Division of Water Quality, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Iniection Wells: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Quality, Underground InjecBon Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Suaalv & Ceothermal Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of completion of well construction to the county health department of the county where constructed. ��- ��-13 g j�� 3 ��C� �� pow�. �� ,,�,�. -n�a� a� � fi�.b