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A25 212Application Date: d� 0 5l oq Tax Map: Amount Paid; G �[� C� "��'`��+ Parcel #: _ Receipt#:' 3� �, #. ��_ S� �� 77 � _ -� �c�� 7Gaa�u u-��n�aa>�4=�.11 IHC a>.t,..11 a:ll�. Application for Services (Sentic Svstems and Wells) �SI Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Services Re uested � Construction Authorization ee is de endent on the e of s: ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Char�e Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then the Improvement Permit and theAuthorization to Construct shall become invalid 1) Services Requested by: Name: Re6c�R.T li . S�T7ER�IELD Address: ��.0 2 iYl��ra�1 Pu�c i.�ru�. 2fl . �2exf31�� a7 5 �+� Phone #(home): 33l0 � 5`t 9- 7� ot (work/cell): �.'�t - 59 2 - JyyG 2)Name and address of current owner (if different than applicant): Name: Address: ..?y,�c�� r7s /!1/Cc. /2D • /3�X�at�N'� z757s/ 3) Property Description: Lot Size: 3• 5 Subdivision: I�l � Lot #: Address and/or directions to Property: (,'�,> h.r %'nrtll�cJ .1 �� a h��,,,L_o C� � . .. _ . _ . ,. , - - -- f�aSy� ��. � � 4) Propo§ed Use and Type of Structure: Residential �_ Business/Type: Other Number of bedrooms 3 / Number of people served (seats/employees): Basement: Yes �_ No (with plumbing: Yes No _� Garbage disposal: Yes No / � Water Supply: Private Well� (Proposed Existing _� Community ell: Public Water System: Are there on the adjoining properties? No Yes _� (please show location on site plan) Note: A comnleted application must also include: ➢ A pladsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. _ Signature (Owner/Lega1 Representative): ; 8/ 05 0 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� .�� _..__ _ ' �`' � � � � � � 1 I `_i 72a'tS''717i^ <CD 7Ya.7r1Y71 <L. 7L"7L �.�IL Jl 1L Jl cL d.:R. ��.� 4�tt aap Q2S �0 �� z. �� Subdivision iPh��s -�Sect�ion'Lot # Permit Valid for �� Five Ye Type of Facility: �r;�n'�e # of Occupants-�(� # of Proposed Wastewater System: Proposed Repair: CG Improvement Permit No Expiration �,r;p. New Addition Water Supply ��, s�3 � Projected Daily Flow��-- g.p.d. I ( �7 .�.%cv eP i'�a {�er ��25°7.,�L1 Type: Type: Permit Conditions: pr' ,�q Q�� S,ol'�ctC� �Owner or Legal Representati Authorized State Agent: � � The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicantlproperty owner to in sure 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 Improvement Permit 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�ad Rules for SewaQe Treatment and Disposal Svstems' _(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to funetion satisfactorily in the future or that the water supply will remain potable. Autho�i�ation to Construct Wastewater System (ltequi��ci for �uilding Permit) * See site plan and additional attachments (_�. ProposeyY�Wastewater System:��.�lv� (E_ �,w a� �a �r� Type� Wastewater Flow 3�ao g.p.d. New �� Repair Expansi n Soil I.TA • 27' g.p.d./ ft 2 Type of Facility: ��, �Qsi� e_ _ Basement Yes _ No Wastewater System Requirements "Y"ank Size: Septic Tank: /DOD gal Pump Tank: —�gal Grease Trap: --'—'�al Drainfield: 'Total Area: 990 sq ft Total Length �� ft Nla�cimum Trench Depth �� in Trench Width � ft Minimum Soil Cov r: (R in Minimum Trench Separation: 9 °gt�. �istribution: ✓ Distribution Box Y Serial Distribution _ Pressure Manifold Specifications: _� Authorized State 0 Date: � —//�—�4 Permit ExpiratioyiDate: 2_/ o— Jy�- ' [ The type of system permitted is Conventional Accepted Alternative. I accept the specifications of the permit. � �j Owner/Legal Representative: Date: �� PCHD rev. 11/10/OS 0 j� - _ . -==:�- �� "' � tl t �.� VJ , � � � ,'Li+• � ��./ ~ �� `, � �� . . � �� IV�� SI� ��,�� Sub be -� . dIPiS:tOII .t�u o�zed s�� A — TaB .� � �� '`" � � � � " crion � #"�'=�-�.�a��j � �� e /.Lo�# � s"y.��,� �m��. �n� . . Z- � �t • D a �o�sarsss��r tl�� t� � res �.�.t�r�.xisar�r�e. �.t� �°zor fo � co��orey�. �s�sre t�p� er ��.9! �'�e �osa ncst ' .� g�'� ��r .� �'�i�at�airaet� � .��°' a�>ae s�,,r�� p�or a^� � Iy„ { c i 0 „^ � � � � ��.ss ��.�� I��a-��,.-r-� ��,.Il I�IL��.IL�I� Tax Map � Parcel # Zl •Z Subdivision Phase/Section/Lot # # of Bedrooms .3 Operation Permit � System Type (From Table Va): / Product (IIIg): �Z 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.� �, Y A �� e l� Scale: No� �} Scu�� -3-1( (Date) .�'3' � � (Date) U �— _ 5�r��,�ec� � 1� G� Sd � 'i' (�`i2 ' , gr � S � 7 d i � ,� 0� // :3 ll' Line Length �D � � � �0' Total 330' Taz Map: � Parcel #: _ �3 Septic Tank System Checklist (Type II-I� System Type: Notes • Nitr�cation Lines Trench Width: ft. Trench Depth: " Total Length: ft. Minimum s acing: ft. Rock denth/aualitv Grade (< .25" in 10' Cover (6" minimum Setbacks From wells Property lines Foundations/basements SurfaceWater Other: Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) _3 Copy of OP e-mail Date: �� a �� , � � . �. `Y � � / �� `� '�� °� I�,.a-�.��:m ��.-��.11 IHL � �..Il�� i�I�i,� ��1�I�I�' (1�� ✓ia��a�� '�� I9�ap: �'��Wfl: 2,l �i' �d��Dl�le1E��1: �a�: ��aAiea��'s i 1��: I� o�r�" Sa-�-E-�ertiv.l � �Y��1�� E�6�1��'ESS: ' �'�a�me i�7eaami�e�: Sq _ 2. s92-l��in e��on ��'�-m�e�: F� � ,�'��nit �ontdati�ns: 1) See attached site plan for pYoposed well Zocation. 2) All applicable State and Cozrnty regulations governing construction and satbacks apply. 3) �ermits expire S Jears from the date of issue. �t�er �ondation�/�'��aanen8s: ��r�aa� ��a�es� �y: � �9a��e: � /to -�A ��+ ��'�$'+��t��`� ��'+ ��1��'�'�fl� I�� `�✓`�� n�p��tno�n: EHS/Date Location: Grouting: Well Log: Well Tag: �ump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: � - (6 ,,g_�� n�a�� g��e EHS/Date Install_er: Depth: Grout: �� a��on�ae�a�: EHS/Date Completed: 1VIetl�cd/Material(s}: _ '�� a�le�o a �h .-�. Pump Installer: � �;�� p�r��d �w: - nate Samp?e Coilected: ' � P�:son Counry Environmental �?ealth 32:; S. l�lor�an St.; Suite C Roaboro, NC 275i3 �,a��a�e #: License#: ��e: 3-8�—�/ Date Results Mailed: rhone: 3�6-�97-1^90 r3s: =36-�97-7808 8/1100 North Carolina State Laborator of Public Health P'O. Box28047 Y 306 N. Wilmington St. Raleigh, NC 27611-8047 Environmental Sciences http://slph.ncpublichealth.com Phone:(919)733-7834 Microbiology Fax: (919) 733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH ALLEN SATTERFIELD 325 S MORGAN STREET MCGHEES MILL RD. ROXBORO, NC 27573 ROXBORO, NC 27574 StarLiMS Sample ID: ESO40711-0128001 Collected: 04/06/2011 01:15 J. Smith �� Received: 04/07/2011 08:38 Angela Heybroek ES Microbilogy ID: 26160 Sample Source: New Well Well Permit Number: GPS Number. Sampling Point: Well head A25-212 Sample Description: Environmental Microbiology - Colilert Profile Test on sample was not performed due to the following reason(s). Comments: Report Date: Too Old � . , Sample over 30 hrs old when received. 04/08/2011 �: . Report To: North Carolina State Laboratory of Public Health 06 N. W?m� gton St. Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncoublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis ' PERSON CO ENVIRONMENTAL HEALTH Name of System: ALLEN SATTERFIELD MCGHEES MILL RD. 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ESO40711-0046001 Date Collected: 04/06/11 Time Collected: 01:15 AM Date Received: 04/07/11 Collected By: J. Smith Sample Type: Sample Source: New Well Sample Description: Comment: Sampling Point: Well head Well Permit #: A25-212 Temp. at Receipt: 5.0 GPS #: 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 11 mg/L : Chloride 7.10 250 mg/L { Chromium < 0.01 0.10 mg/L � Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 2 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L N itrate 3.30 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 6.6 N/A Selenium < 0.005 0.05 mg/L � Silver < 0.05 0.10 mg/L - Sodium 9.90 mg/L - Sulfate < 5.00 250 mg/L � Total Alkalinity 34 mg/L Total Hardness 34 mg/L Zinc 1.20 5.00 mg/L Report Date: 04/19/2011 Page 1 of 1 Reported By: �%tikc �ucq _ •';�. STATf��. ,.�P��.. ��._ ; � ' s� •'., 'Z i 1 ., '�� —� �f�r :�� :� � �—_ -.7F.�. RESIDENTIAL WELL CONSTRUCTION RECORD ' W ri ' ��g: North Carolina Department of Environment and Natural Res urces- Division of Water Quality :,��, ,��'��` 0.ix''�� WELL CONTRACTOR CERTIFICATION # J 6� 1. WELL CONTRA TO • �J� g. WATER 20NES (depth): � r/ TopT! b Bottom �(�2.. Top Bottom Well Contractor (i ividual) Name Topl q D Bottom�_ Top Bottom m W II D� �I �fl . Top Bottom Top Bottom Well ConVector Company Name . 611 Barnette Tinoen Rd Street Address Roxboro NC 7574 C�ty or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT#�oZ.S� 1'Qi�.�i� Ti�Z OTHER ASSOCIATED PERMIT#(if applicabie) SITE WELL ID #(it applicaWe) Thickness! 7. CASING: Depth D'yamQte� Weight Materiat Top�_ Bottom� Ft. �� l4 � �� Top Bottom Ft. Top Bottom Ft. 8. GROUT: �epth Material rop�^ Bottom Z� Ft. Sand/Cement Top Bottom Ft. Top Bottom Ft. ' 9. SCREEN: Depth Diameter SlotSize 3. WELL USE (Check Applicable Box): Residential Water Suppiy [� : Top Bottom Ft. in. DATE DRILLED_1� —/ �—(C7 : Top Bottom Ft. in. TIME COMPLETED L�D AM p PM [y/ Top Bottom Ft. in. 4. WELL LOCATION: CITY_�� /�p COUNTY��{tvn _ /�Jfl�/�r � � �w�s'� Zzt 2_ (Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code) TOPOGRAPHlC / LAN SE7TING (check appropriate box) ❑Stope ❑Valley lat ❑Ridge ❑Otlter LATITUDE 36 "_ " DMS OR 3X.XXXXXXXXX DD LONGITUDE 75 _' " DMS OR 7X.XXXXXXXXX DD Lakitudellongitude source: pGPS �fopographic map (location of.we!! must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OYVNER _�6�,�� S,�{�. �}�(ai owner Name �1G��_�s�t e2l �St t A dress x�m �/t/ -C.. a ?531`� C+ty or Town State Zip Code c 33� � _ 5�1?�i — ?4vL Area code Pho number 6. WELL DETAlLS: a TOTAt. DEPTH: Z Z�'�� b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO � c. WATER LEVEI Below Top of Casing: �' F7', (Use `+• if Above Top of Casing) d. TOP OF CASING IS �_ FT, Above Land Surface• '7op of casi�g terminated aUor below land su�face may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): �_ METHOD OF TEST BIOWII ZO171 r. OISINFECTION: Type_HTH .4mount 1/2 Cut� Method Poured in. in. in. 10. SANDlGRAVEL PACK: Depth Size Material Top Bottom Ft. Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Bo� m "3 / 3y �^' '�/� / 22J / / � � / � � / � 12. REMARKS: Material Formation Description l� y I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVI ED TO THE WELL OWNER. '� �Gv SI R CERTIFIED WELL CONTRACTOR DATE (T � �. n � PRINTED OF PE SON CONSTRU ING THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2io9 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant�� ZYT1 �� d Address � C lr �e5 .�� 1� I � Collected By 1 � County Or� Date Collected `{ - 27— �( Time Collected ��/ ,�� Source: �lWell 0 Spring 0 Other Location: 0 House Tap � �ew (,� �� C3�No Charge ❑ Charge C�'�Vell Tap ❑ Other ........................................................................� ****************************************************�******************* Total Coliform FecaUE. Coli Results Pr�nt Absent ❑ ❑ � Reported By , ` '� �" Date Reported �� l � � `p t � �� 1 � � ! �