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A26 122r Application Date: 3" 13 Amount Paid: __NlG Receipt #: 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) G Mobele Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��,;,)f J!. ��1 V Tax Map: J� �-�. � �.�� Parcel#i 4 �-� T .�.�..unvna-�an.mra.�z�.d�.11 �iH[��.��.�a cation for Services Services ❑ Construction Authorizatiun �ee is depsnden: on the type of system permitted) 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: 4�j,� rncN,cl `1�j I �Gl(t� Address: 3q 58 (' hu b L11k� Rocic� Ro�b�u, �.c- 2�57� 2) Name and address of current owner (if different than applicant): Name: Q�rii,e ( 1�r1 i S�- A�dress:l0q wlin-t-rc� �,a�Q � Cboro, N. C. 275? zf Phone (home)� 33 �� 3 ZZ- � I� fl Z (work/cell):C `�`3�) Suy- 3�3 6 Phone� 33(�) 5 0`l - t-131 � 3) Property Description: Lot Size: Subdivision: Lot #: Address and/ordirections to Property: (-� �' ��,c�� m-Fo Mo��-a., P��\�L�m ��n �,. l..e-�� o +��n��.e.e lc�,c•e hr�,re. 1-�� Ci-sr1 � kc11 b�t�lainn, h��Ce A'� LIL,C�2C0.0 cR�.R-�k, ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no ls the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please pravide supporting documentation) 4) Proposed Use and �pe of Structure: �Residential ❑�iew Single Family Residence Maximum number of bedrooms: � Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential �� Type of business: _ Total Square footage of Building: � � Maximum number of employees: Maximum number of seats: ��c 4�} 5) Water Supply: ❑ New� well �1 Existing Well � Community Well ❑ Public Water ❑ Spring .�,re there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no S) If applying for `Authorization to Construct', please indicate preferred system type(s): D Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑ Any 1 cert fi tlzat the inforntation provided above is conaplete and corr�ect. l also understand that if the information provided is inaccurate, or if t��te i� subs�ently altered, or tlte intendeil t.rse changes, nll permits and apnrovals shall be invalid. Signature (Owner/ Legal Representative*) '� Supporting documentation required. �- 5-2013 Date Permits are valid for either 60 months or are n�n-expiring when accompanied 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) � �. � '� I, � +� ): t� � j �� . �� f � �; , . �� ,,d ..� I� � , . � � � `��'� y �� ''��- , �. ��,��.z.�y-�i��_rz�r.n��A��L<�.�. .i�"""��<�n. �:. �a�a�d��a� ��m��/ I��bn�� a�� 3��fl�a��a��n�5 � Tax 11�Iap #: Aa�o Parcel#: 1�3- flddress: 1O9 A►�-cw�� . Approval Requested for: Mobile Home Replacement � Building Addition ApplicantName: DAtS�� h'�v�f. % �r��1h �J��Po�-a Address: I � � A�r�-�E c,,rac�� (bwan,�w . �1.c. ah�1� Phone ,#'s: 33t�-5�8 — s�1n'1 Permii Located: i� Yes No Installation Bate: �-�t� �� Design flow: 3� v (gpd) Current Contract with Certified flpezator on file (if required}: Water Supply: � Well �ublic or Community Wastewa#er system shows no visual evidence of failure on: - - 201 , (date) (Applicant's signature if site visit is not required) Comrnents: APp�o�n �x. �'xti,�,�•z- ,�wuN lo � x 44' dr� Fxl.,,•-r a� f'��sk. • Ma�r�TPr«S A-t�. ,S�t-ar4c.c�s ��r��3��/��fl�aat ��p�-��e�i �� Q � Environmental Health Speciaiist � � i3 Date Pe:son C�un�i Env;ronme:�tai yTeaith; 3�5 S. y�orQan St., Suite C, RoYboro, NC 2 i� i 3 Fhcne: ��6-�.97-??9C/ ra;:: �� -�9�'-7�0� � �.v�:�^,��.�ersoncoun�tv.i,e� i� ` �� ' 1� � � ' . � A � {�� ; I � `� � � . I�F "' I f ' �� i � lfl/I � � • 1 I 1 .:! � � ' c �:1 i � ! Building Additions/ Mobile �ome Replacement� Tax Map #:_��C� Approval Requested for: Parcel#: � �.a Mobile Home Replacement �Building Addition � Applicant Name: _ '�� li,�� Address: " i c�� .i�-�- �.�o-�-�= L.,�.�-� � �;�� rJc, ��t S'Z3 - - Phone #' s: �„ -S� �= - S-`�l r1 `1 Permit Located: �-aC Yes No Installation Date: �- �-U3 Design flow: 3l00 (gpd) Current Contract with Certified Operator on file (if required): �}� Water Supply: � Well Public or Community Wastewatex system shows no visual evidence of failure on: S �l ,(date) (Applicant's signature if site visit is not required) 7, Addition/lZeplacem�nt Approved S- � � �l Envuonmental Health Specialist Date 11/15/OS ; �� l �, , � `�� ^� �1.� `'L....J� �� .11�.s]�A:`�'I17L"�D�.�3rIl.��.�.�A.� �c�.�ii,Jltt,.s71. I�aag�cdang Ae�da�ions/ 1@�obile �oane Replac�a�aea�t� Tax Map #: f�Zto Approval Requested for: Parcel#:1"Z 2 Mobile Home Replacement � Building Addition Applicant Name: ��„� `(V.:� t e Address: � � A;h.�, lf.c. '��.t�+ '�x z�s��f Phone #'s: �'�- 5�S - 57�� Permit Located: �/ Yes No Installation Date: �- g-�3 Design flow: 6� (gpd) Current Contract with Certified Operator on file (if required): 1� (k- Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: j- J-o�o (date) (Applicant's signature if site visit is not required) � �'� Comments: Environmental �'' 11/15/OS �, eement t�ppr�ved 25 t+- 1-- 3J- c.�(. o Date . • o �- v . �� '> � � � . � � r' O z ( , _ - Mr �• ' - � W `\\\ /� ��?, \ - -� - � ,r . co , � �- , _:, . ` 2. 79 A 1 ��_ � ,= � ;, ,T,;_ g- ��., � � :.. _ � ' o v ,. � . T S6S, _ o „� � / � �'7'� .. 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' �TJ►IQ 71� COI� OR �,1. �� SIRLCfUR�, � ATi'AiCii 3UIN�Y PiAT t�,3 �, : 6>LA,.�1 YO TNIS 11PP1.if'.A'i� I t�� td'tt� Pwr,�v�. C,aunly Hw�tlt, q�a�'u�� f�a• � c� ��dr ttw a:w� ��w� �F ltto �i�::,-d�:;i�ad pr�lyl. ! a�taq tmt tt� � 41 U'� �:--,�,��--�::xrr � tn� cs�d t�pt+��t tl� tl�aYnl�nG pi�td cn �q ��. I utd�tct N 4� aw ts �ir��d ar tha (� �� t� � the ps�n� N�d b� bN�i ih� �� 1 r�n r� ibr i�nlqjiinO ed rr��t,� �:-�;�.;�r �-�t, c�t� urial «t��p 1M �iM �o a�e�t� a�t� Par�, couri�► t�la�t, a.�mxr�rd� �c� ii�� .s:y��•..�. � e��tand tl�i, .at �.poe�l. �q y uri� � �},,.., � L.,i. � 1{ � � � � � �Q � "��ci � f14 � i iT Y J`J J�TTY� � � '�'ii""r"�"'� . ♦ � /��L • O+.E'+�w.—iW.�� , ��+�/�� ' � ' �� . � � `� � . ' . fsr ts'L - P/� 3.. 3 2 L -0�rL,", c z�`� � �,9��. ---1 �,s -r� I�5 � � t �7s'" r L �?5"`/c �.+:' � L _ .L yo-«z 4 . ; _. PLEA� Tax Map #: Zoning _ Appiican� , Locadon:_ PERSON COUNTY ENVIRONMENTAL MEALTH Parcel i / �` o` Town:hip ��1i�. I� Subdivislon: � Sadlon• , LoC _�_ Improvement Permit UT �o� � -�C � l � Repair Addition Type of Structure �� Wate� Suppiy �/'� !�� # of Occupants� #�of Bedrooms � Other easement? �I Basement F�cttues? ,�/ v Projeded Oaily Flow: 1��. g.p.d. Pertnit Vatid Proposed Wastewater System T pe: �oi'I � Pump Required? Yes No Proposed Repair : Permit Conditions: �Fo llo �.� � Owner or Legal Representative Signatur • Authorized State Agenti 0 No Expiration --o.. � ,.. � . _.. f _ , The issuance of this permit by the Health Depattment in no way guarantees the issuance of other permits. The permit holder is responsible for chedting with appropriate goveming bodies in meeting their requirements. This site is subject to re�ocation if the site plan, plat, or the intended use changes. The Improv.ement Permit shall not be affected by a change in ownership of the site. This pennit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Type of Wastewater System CO/1 ve Faality Type: � 3 � Basement? 0 Yes No Wastewater Svstem Requiremenb ,Septic Tank Size: �(� gallons Wastewater Flow: _g,p.d. Ne�epair OExpansion 0 Basement F'�xtures? Cl Yes 0 No Pump Tank Size: galtans Totaf Trench Length: � � feet Maximum Trench Depth: A� � inches Aggregate Depth:� in. m;n � /� � �MMeximum Soil Cover. vl inches Trench Separation: � Feet on Center 1 Other. T{15� bn C�O �'lTGta/�, Permit Expiration Date: /aa Authorized State Agent: Date-,��ia�- UA!`- ao„ .�r� d�� I' ' ' """` � r .}a � �nno��- The type of system pertn�tte 0 does does not differ from e type specified on the application. I accept the specifications of this permit, �Owner/Legal Representative Signatu • be �1��8'/ Date: � PCHD, rev.11118/99 �� , �_ �� _ � � �� .�� .��.¢�.]1 IE-��.71 T�x (Vl�� . . P�:rc�el :� .. ySu,,,bei'ivi�5�ion �`. - • 'P'f��se-Sec�t�io�i Lot r Applicant: � Location: `��N � r��-,.,. ��,,.,. ��. � �� ,:� � �,.,�.-� s��. - 1'—} l��- �•• �.. rZ �� o.a- � d'` Z- . ��eratio�: Per�nit . � System Type (In Accordance With Table Va): .�J1�� • THIS SYSTEM HAS BEEiV INSTALLED IN CONiPLIANCE UNITH APPLIC�►BLE NORTH � CAROLINA GEWERAL STATUTES, RULES .FOR .SEWi4GE��TREATMENT AND DISPOSAL, AND ALL CONDITIOfdS OF TkiE IMPROVENlENT ' PERMIT . AND CONSTRdJCT10N �►UTHORIZATIOPI. � � . � � . . . _... . :. . � ^� .^� . . . .. � Authoriz State Agent � � � � � : �Date � - installed By: � �-, � Date: ��g-�3 . . . . . 3Q� . � � � ' 13� �C � i Sb � 0 11;1 Vo-�e _!z� �6�, - 0 � • � �:�:...-� .�_...: .. _ � . . ... _.. .. ..... �.��vr.,s��,.;.�.� . . . ��. . .. _ ... ..I. .. f�_._. . . . �.. . .. . . . Co� � � 4'h �� i fi' 4'ja L'4'!a �'�{7p .o ' �' S'JO b�4��? 4'y�} �rc7 c-�� 6 ��A -iY--� ;,22, � L'y% � vi, �a� bo..4?� : � PCHD, rev. 07129/02; } : � S��YC TA�i� 6NSPECTiON �NE�9�1.ISi (Typ� i6 -� Tax Map #� a� Parce! # I a a System Type {Table Va) � Owner/Applicant Subdivision � ,��u AddresslLocation � Sec/Phase Lot # . Septic Tank n a a� atn ca#�on ines n��a ate � . State ID/date S; 3-3ay v-zz-o3� ,,�g ��-� Tnenci� Width ft, �5 7-9ro3 Capacity. ��s--� � o� . gaL � 3 Trenct�. De th fn. � �8_0 �• � Tee and F1ter ✓ �-�-�3 Trench Length U v�/ ft• -,. � a Ba#fle , -�-��3 Trench Grade �� , � � Sealartt ?-�-�3 Trenct� S acin9 c'� ��s-�3 . . Riser if ap licable . .�-8-�3 Rodc De th and Qual' �-� -,_�.�3 Tank Outlet�.Seal ,-z-�=�3 Dams/Ste downs etc. � ��-�, -,..$-�? . Permanent Marker ,/ `�-$ �; Pressure Laterals � � Pump �Tank � Hole Spacing � tate ate � � o, e �ze . � . . Capacity . gal. � � Pipe Sieeve . - - � � � -� Waterproof /Sealant Tum-u sfProtectors � � � . Riser � � �i�equi�l Se�acl�.s Water Tight From Wel1s �. � C� _g_�3 � Pump � From Property lines � � ? �-�3 Ct�eck Vatve/Gate Vaive . ._ _ Structures/Basements.:: � . . 7��3 � - t�-si hon o e .� i�c es � rainage ays � �-s--�3 � .-� � .� Floats/Switches � : : � . � . . . _ Surface` Waters - � - C-s� - ��:� . - .. _- Alarm visable and audibie) Public Water Supplies c� ?-�� Eleetricai Componerits Verticai Cuts (>2 ft. . C ��-� 3 Rate gpm Water Lines C� ?�-$-�3 Ap roved Pump Model Vehicle Traffic c -, ��-� Bloc� Under Pump � Adjacerrt�Systems � csS ��=�3 � Pum Removal Rope/Chain , Ea'sements/Ri ht of Wa C�5 ��g �3 ' Dis�ribut�on System • � . Other Serial Distribution C� �_�3 Easements Recorded . ressure an' o e e erator ontract . Low Pressure Pipe • Tri-Partate Agreement Appr. Pipe Matenal and Grade � ' � Valves � � � Coanments� . , _.. . ,.� _.. � _. Pct�d rev. 3113101 '� ��e PERSON COUNTY EiVVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SiTE LAYOUT Tax Map #: � a� P�e� �� a a r% Zo�ing Townahip ��f ✓Pi � / ApplkanC ill � . �r � ' . - - � , .,. I � i ! / Loeatloa: Subdivbb T Well Permit Tvpe of Water Suaatv: Individual Reauirements• Site Approved by Grouting Approved by Well Log Well Tag � Air Vent Hose Bib � Concrete Stab Well Driller: dT��i /eG' _' Community Public Weil Approved By: Date: � **See Attached Site Sketch'"`y' Welis must be 10 feet from �property lines. Wells must be 100 feet from septic systems. Welis must be at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29199 ��. � f � 1L-��'�.��.� �U�.� '�'� C� c0 ZC,�.I�l� `7C � �.. I.C-' �.�n�„-7�n •C�ll?L~•PtiLJIT.I(,.ti��.li. 7.C�.�•c.:n.)l�L�l:n. LJil i... :;J i.;;� ��..��i �f ; �:'�� W�a�I� �l /1 /2 _C "',C�C �l f�/rr '', li.S C�c�a DU��(lc� �, �� v � . �CJ.� �,Ob Owner: /� a- �� , � �?�,� t- '1'.L� IYIa�� 1';u�ccl f� ��— ��.__ Location: Subdivision: ,�}� �n %rt� Su- h Lot l��_ l��cil Cozxscz•uctiox� Distancc Frocn ncarc:sc 1'r�perty Linc: (ivlinimum 1 C'fec;t) �`�_._-______...,,., Aistaiicc �rom Scpcic Syste;m (Ivliniinum GO icct) � Tot�.l Dept1�: __�� ft Yield: _,��_ GI'M Slatic W:itc;r L�ve:l: _;��_, (�� Water }3carinb oncs: Dcpch �� Ic �� li ;�t [�t Casiub: Dcpth: From ,[�_ �0 3 tt. lliamcccr: � in Type: Ga�vanized Stcel '� —� Wei�ht: _1 �____ �[�llickness: ,l� Ilei�l�t abovc G��ound: __� �!- in Drive Shoc: � Yc:s No �1.ny ��rob(c:ms cnc�unlcrccl whilc sc:ttia��; ca�iiis;7 _� Yc:s `No (f `�es" �ive rcasoii: � _�___ Gzout: I�teat: Sand/Cem�nt �' Coi�.cccle Gravel/Ccmc��t A.nnular Space Widt�a �_ incl�es l��alcr in .F�..aiiular Space Xes `— No Method of Grout: Pumpcd �'re:ssure ' 1'oured `� Dcp�li �� to _ i1�Saccz-�1Is vsca: No. Ba�s Por[laud ccmcnt Wc:i�;lit ot' 1 13a� ___ _ I'ou��cl� I� mixtzu'e (sand, �ravcl, ctittiiibs) - Ratio _� to ( ID pla[e�: vI'c� No �� x�� slab �'cs � No JJrilliub �.c�b �,ocatioi� 1Jrawiii�; �t. ( hezeby certify that dle abovc intomlaciot�. i5 con:ect aiad tliat tl�is wcll was conscructcd in accordance with rcgulations sct forth Uy thc Pcrsou County 1-lcslth Dcparcmez�c. Si�naturc of Cozztractor � ) !�'��_� ��:�tc _T%�% o,� , PCI�D rcv O111b102 �� 1 �� .. .� �^ �� / � � � � � �.L�,.�rn�v-:iu �cvu�n.:�-�rn�,:;rntL.�n)i 1��::.,r.a.�lil:.�-n Date: �/ 2� /� Tax Map: Parcel: � 22 —�— Name: S i c! W� � an Address: Q L . � e ��?a� ,t�%� �!� Re: Bacteriological Test Results Dear �►�, �,�f',' ( Sd � Your well water was sampled on �/� /�, and tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). The results of your water sample are noted below: � No coliform bacteria were detecied in the sarnple. Your well water is safe for normal use. _ 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. 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 was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If co[iform bacteria are present in your water sample, the water may not be safe for use. Young children, the elderly, and individuals with compromised immune systems are especially vtrinerable and their physicians should be notified of the test results. A well that tests positive or total or fecal coliform bacteria should be properlv disinfected and retested �rior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department (597-1790) to request a re-sample. For additional information, please feel free to contact Environmental Health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� Environmental Health Specialist Person County Health Department Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808 (revised 07/29/13) PERS�N COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORCI, NORTH CAROLfNA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant QS5'i Cs� �li� �S�''� 7 �p �•� �� , County Address � 1 K� �J� �� oI "✓� B Coliected y Date Collected �Z0`� Time Co{fected � ' �� yy �� ❑ Spring o Other Source. q� e ` ' Other � �1 S �� Locaiion: ❑ House Tap o Well Tap � o No Charge ''�Charge 1 s� �c�—�zz ■r��rs��sa�aa��r�r�sa��"��•*irie�r�r�iriFie�t�kir�k+�rx*�t*,t+k�k,k�tiracaR�r*atrie+rrir*itrvrir�r*#+�rir1 ie��lririr�leWiraF*ittk�le�lr9t**irir**�irir*�Aralr*Ytirie*'+1rir�ItiriR Totai Coliform Re._ suits Present U FecatlE. Coli � J Repor�ed By / �" Date Reported / ' �� Report Called ❑ YES o NO Called To Absent