A26 197A�plication Date: 3��/ �� � l d�"D� Tax Map #: ��
Amount Paid�at�-oa ��S b ` J ��
Receipt #: 2-7989 � ,��y_ ��ik' ParcEl #: �
,� l.!'
(�30 �1��� .S� ���.� ��
' = � � ZCT1�T `7L" �Y
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. ' -
1) Permit requested by: (Owner/agent/prospective owner): �lir1'�'pn Sc��� oct�,+�
Home Phone:.336� 3(��l-/iiD1 Address: _335� Sa � iP_Ir� �_
Busin'ess Phone: 33�- 5°+a.- lSci(p �'�: ;w�h��1G1� aC', •;}�cj5�_
2) Name and address of current owner: (��.C(3�, i�'lot't��
�
(�b�tb�fa NC, �.�5
3) Property Description: Lot size: .t 03acrPsTownship: C��'�t�� Subdivision: Lot #
Directions to the property (Including road names and numbers):
4) P�roposed Use and Structure Description: answer each of the following questions: �_��
a) Proposed � Existing Type of Structure: 41-1C� C� o L� � Width� �� Depth:$b !o
b) Number of Bedrooms: � Number of occupants or people to be served: �
c) Basement: Yes_, No � Will there be plumbing in the basement?,�o
d) 6a�bage Disposal: Yes , No �
5) Water Supply Type: Private �, (new �or existing�, Public_, Community_, Spring _
Are any welis on adjoining property? Yes_ No � If yes, please indicate approximate location on the
�site plan.
6) Does your property cantain previously identified jurisdictional wetlands? Yes_ No�/
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED� �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED 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 understand if the site is altered or the intended use changes, the permit shall
hPrnmr� invaliri
� Q�'���7Y�, �lM.Q.�L. �Ol h�} ��
Owner or Legal Representative
_.�/—Y��----
Date
PCND, rev. 06127/02
��p��2i�o� �a�e:. , . � ,
A�o����aid: 7 0 0
������� �: q— 3��
�}-�rw.►S�eY'�� �%�— �'� �.J !a�„
Permrt
��y, f�,� i3. ..Y..LiJ�.��� � ��t �
---' --� � � ����
I��.r;.�„„,�.�c:�.lt IH[��.li�.
;YaIuation) — C� �aa5u uction Aai�or[zarsaa
pp (Fee is de endent on the ty e oisystem permittec�
o� B�t�Iding Addition G Per�i �€visian
� �75.00
ne ir - L� Rega=; af �..�s�ting 5egtis �ystem
� Applicatioa: No ChargeJ CA �150.00 or �300.00
�} E�s.����� �d'a0���4D3i:
Name: :�c�tT t,J-.,.�{ i.J � � d�� �
AddT85s' /? a'i it : t'i.at,;. r-Fr
L,� ^-, � `� ' v
�) I�ta�e a.�tc� acseire� a� �carre�t s�t�t� (i� d�fi€r��� ��� �pg�c�+#):
i�(arrte- � : �✓ G ��
. �+ c� /� __.,., ---
Addr�ss: C� C � '
xl�j�-z� �1 ?_7�?N
3) � �ape��e
t�ddr�ss
Q yes Gs �to
❑ yes ❑ no
Q yes II no
❑ yes D no
� yes � no
�m: Lof Size: �,_,,, Subdivision:
directions �o Prpp�riy: ��. �, �
the site contain an`y jurisdictional wetlands?
Phcne (homs): �'�f�,� 2'�2 � �SL.LL
(work/ceI�:_i��� �'��" Z�f,�3f
Phone• C�1 /�l � �� (� C���/
Daes tI�e sife aantain any �xis�ng tivastewater systems?
is a�yy wa�e�vater goin; to be ge�erat�d on the site other than domestic sewag�?
Is the site subject to apgroval iry any otk�er pnbiic agency?
Are ther� any easements or r't�iit of tivays on this propenY`f
('rf `yes' is chccked, please provide supporting documentation)
��) �co�fl�e� �%e a�d �'�ge t�� ��c�r�:
��esid.ential
� New 5ingle Family Residence
❑ Expansion ofE..isting System
L7 Repair to Malfunctioning System
L�
Maximum number of bedraoms: _______
If expansion: Cuir�nt number of 6edmams: _
Vi►itI ther� be a basement� CI yes Q n� With pl�mbing f�? Ct ye� 0 no
Di+Toa-i2esidentiai -
'I�+ge of businsss: Total Square footage of Bnilding.
Maximum number of empIayee� Maximttm number of seats:
g7 �'ici�i,e� �Yt�ag��y. Q New �veti � Existing WeII D Community WeII Q Pct6lic Water Q$prin;
Are there a�ty existitt� �vells, sPrin�, or existing ��aterlines on this properiy? � yss i1 no
6} �: ��gl�r�g fa� `AL1�10T3i�.�YDII �4 COii�f3�EICi�g BI$f3�� ZEdt�iC��� �3�'���'Y'�t� u�S�� �T�S�c
Cl Canventional D Accepted ❑ Irmavative Q Aiternarive CI �ther D�.1'
Z certrfy that the information prnvided above is complete and crnrec� I al.ro t�'tderstand Ihut ff 'Ihe irt, foPmatto�t Pt'ovlded is
utaecu�ate, or if tFie site is subs altered, or the intended zsse changes, a11 permfrs cr�d app1'ovals shall be i�valid. ,
�
o � r %'zR-J�
� re {Owa Repseseni�tive�) �s�e
Y SuFPorting dacumentation rcqnirad.
�e�mi� �s vai�d �o� ei�er 60 �ao�'� o� a�e no� ����g ����en �ccoa�pa�e� �� a� apg�v�ci pl��
A co�gie�d `�oi �repar�iion' iorm ra� accs��a�y �utp ���li�tio� �equ��� � s� evai�t3�.
.. ,... ., r�__ �...._... s..:.:�,,,.,,,�,+A� r�PQ1+1, ��; G�,r�T¢a� st_ suite � RoScboro_ NC 27573 (336-597-i794)
���.ss- ���.���
`�..� c� � �I.T���
I��.�a�-� ���: ���,ll IHI � �.Il�]�
Applican'
Location:
Ta�x fu1��� � - Parc�el � •
�.�.�.�
s��h�i����s��o�,
Fh��se SecMt�ion Lot �
� Improvement Permit
Permit Valid for ✓ Five Years _ No Ezpiration '
Type of Facility: 3BR SFD New Addition Water Supply ��,J�
# of Occupants �L # of Bedrooms 3 Projected Daily Flow 3�O g.p.d. �
Proposed Wastewater System: � ; � Type:
Proposed Repair: �,r�n , ( - Type:
�
Permit Conditions:� (l�
Owner or Legal Representative Signature: � Date:o� �3'�
Authorized State Agent. Date: ''J-9-OLf
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement PerinIt is subJect to revocatton 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 and
Rules for Sewage Treatment and Duposal Svstems' (15A NCAC 18A .1900).
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed W tewater System:.� q�o�J�inV�P,l'�,��or�o�.� Type� Wastewater Flow _���d g.p.d.
New � Repair Expansion _ Soil LTAR: • 3 g.p.d./ ft 2
Type of Facility: 3—� �,m 5� j� Basement _ Yes t�a
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: N�/� gal Grease Trap: N�1� gal
Drainfield: Total Area: ��sq ft Total Length �� ft Mazimum Trench Depth 2L7 in
Trench Width 3 ft Minimum Soil Cover: � in
Distribution: Distribution Box ✓�rial Distribution
I5pecifications:
Authorized State Agent:
Permit Exx
�' Y �
The type of system permitted is onventional Innovative
the permit. � _„._ 1
Owner/Legal Representative: ���j� ����L�
Minimum Trench Separation: � ft
Pressure Manifold
C�Date: J� ' —Q
Alternative. I accept the specifications of
o? �3-os
:���:�� �'� ► ���
�- �,o�� ��
�����»�.���.�.� ���.���
S�� 5����
Name � . � � rl � � � - �,o ('�l�t�J Tax lYtap # A 2 (O Pazcel # ! q �
Subdivision Seciion/Lot#
U���--- 3- 9� -o�
Authorized State Agent � Date .
System components re�iresent approximate�contours only. The contractor must, flag the systesn prior to
beginning the irutallatz'on to insure that�iro�iergrade is maintained
�
� T� �,��.
�j` � ��: � �'
�
r\ ; t.�"' GEC�, 3
` vR ~�� � �
��'.ti�,�
Scale: �"_so, ,
��y����z �� ��
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` ' � � � � ����
I��.���� -t-n-n ��:��.11 I���.Il.�1i�
A�piicant: C� t
Location:�'�
N
�r� �1a� A � P�c�a � .1 q 7
LlL.1W�1Y V Y�..1�Oo UI�
Y tlH�ii�J�..�� � � � �
�a� o-o 00 3 �
� � , -
1�`; ` � ,� rr� , f .
��
System Type (In Accordance With Table Va): Q
TH1S SYSTEfUI y,�S �EEi� INST�4LLE� IN COfV�PL1.4AlC� �VITH APPLlCABLE NORTH
CAFtOLlR�A GEi�ERAL ST�TUTE�, �tUL�S F{3R S�IfAGE TRE.A�TIVIE�IT AIVD DISPOSAL,
AIVD /�LL COftlDITI�NS OF ` Tl-9E IIVIPROVE�IIENT PEi�1VliT AND C�NSTRUGTIQN
�4U?HOFil�AT1�N. �
. � -
Authorized ate Agerrt Date
< .
Instalied By: � Date: o � �
, . .
1
i
��
PCHD, rev. 07129/0�
�
��� � �� ��,h�� ���a��'����.� ���'�a��..��� ���� �� � ��
Tax Map ��� Parce! # Sys�e�ra Type (?a�ie Va) S�"u. �
Owner/Appiicant Subdivision
Address/Location SecfPh2se Lot �
State�ID/date S-rg-�y2
Capaci�y fT� �- �oa0
y
Tee and Fiiter
Baifle
Sealant
Riser (ifi applicable)
Tank Outiet Seal
Permanent Marker
Pum�s Tan�s
/Sealant
Riser
Water Ti ht
� � P�eva�
. Checi� VaIveJGate Valve
� �nt�au���e �i�ataca�aora �n��
;-- .� n o Trenct� Width �. 3 ft.
i. � � Trench De th 2.0 � in.
T,rencf� Length !.{/ 7 ft.
�Alarm (visable and audible)
Electrical Componer�ts
Rate (gpm)
Approved Pum� iililodel
,
BIacX Under Pum�
Pump Removal RopelC�ain
. � Distribu#��n. Sysi��a
Serial Distribution
ressur� IViani o
Lov�r Pressure Pipe
Appr. Pipe Itl9ateriai and G�de
Valrres
_ �
Trench Grade �
Tr.encn Spac�ng
Roc;c Depth and Qual"rt�
Dams/Ste�downs e#c.
Pres�ure Lateral� �
Hole Spacina �
Pipe. Sleeve
Tum-upslProtectors
� Ret�uired� Setbac"�s
From� Welis '
F�-om Propertv lines
� Surface Waters
Public 1Nater Su lies
- Vertical Cuts >2 ft.
Water Lines
. Vek�icle�Traffic �
Easements/Right.of l�
O#her
Eas��ents Recorded
i
C��men�
ll /8/0
t
�ci�d rev. 3113/01
Tax Map: ��lD
Subdivision:
���.sf �II��.���
- � � ��°��
IE�ra�na-��an�aa��rad.m.Il IE3C�.m.11 �IEn.
Parcel: �
WELL PERMIT
(New _ Repair,� )
Lot:
Applicant's Name: ti/� D��= � t— V
Mailing Address: ��.�1- 'v --� �
7�
Phone Numbers: / - - r�?1- —�lo�� �%p
a r�l
Location of Property: /%.�¢�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: �,��r� Date: _ �
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
Depth
Grout
iner: .
EHS�ate
. Q
� 7-3 �-� 5
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
���,;.��" ���.���
�--= � � � �T��rT�-
��71.'�'71�i'aO��rn �''"'n ���.�..93..1L ��.SL�L�.�
WELL PERMIT
PLEASE SEE AT7CACHED PLAN FOR WELL SITE LAYOU'I'
Tax Map #: �� Parcel # � 9� Township r1(1 �
Applica�a� � � �1�1 �P�S / vw t` ro �
Subdivision• Secrion: Lot
Location• J'r � /�% T��. �-�N �� � � 'l'�lt,. v n � ���
�r s -
Twe of Water Suvvlv: ✓ Individual Community Public
Rec�uirements•
Site Approved bp ✓ l� Z t� oS
Grouting App=oved bp ✓ l� � z I��
Well Log ,/ ln � Z 1���
Well T
Air Vent
Hose Bib
Concr�,te Slab ✓ _L_
►�u►r►P (4
Well �riller.
�
Well Appmved B. Date: / 6S
'�°5ee Attaciied Site Sketch'�
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic spstems.
Wells must be at least 25 feet from any building founda.tion.
Other conditions:
PC�ID, rev. 09/07/01
����, s.�- �.��.� ��
` ������
ZE��-��-�����¢�.:DIl �HL��Il��
��� ��
�����C,S�Oh r L�`
u � po p� `-�, l� aS
Well Log
Owner. • .� �..� Tax MaP �
Loc$tion: .� Cd _ oy� a a
Subdivisio�• Lot #
- - , .�
Well Constnectioa
Distance From nearest Property Line (Minimum 10 feet) �Q�
Distance from �eptic System (Minimum 60 feet) � D..�
Tota1 Depth;1� � g Yield: �tl �' GPM Static Water Level: 3( ft
Water Bearing Zones: Depth 1�,Z ft fi ft ft
Parcei # �
Cssing: �
I�epth: From �� to � ft. Di�eeter: � in
Type: Galvanized Steel
'Weight• 'Ihiclaiess• Height above Ground: in �
Drive Shoe: . Yes iI�To , Any problems encountered while settiug c;asing? Yes ./No
Yf "yes" give reason•
Grout: �
Nrat: Sand/Cement Concrete GraveUCement
Anuular Space Width inc�es Water in Annular Space Yes _ No
Methad of Grrout: Pumpe� Pressttre Poured Depth to F�
Mxteri�ls U9ed:
No. Bags Portland cement Weight of 1 Bag _______ Pounds
If mixtiu-e (sand, gtavel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes � No
DrIDing Log Location Drawing
From To Farmation
/ o
3 � so . y � �
3o z f Su��'�-
� .� .� n
�� �� a
. �
0
� �
� ��
__. � D �
,� �
� �
—�
I hereby certify that the above informarion is correci and thai this well was constructed in accordance w�ith regulati�
set forth by +he P�rson County Health Degartmen�
Sigaature nft'ontrxctor —1 ID# 317G Date G' -Z,(fdti�_
PCHD rev Ol/16,�0�
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
BLAIR CRUMPTON
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph. ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
365 CONCORD CEFFO RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES062714-0007001 Date Collected: 06/26/14
Date Received: 06/27/14
Sample Type: Raw Sampling Point: Outside faucet
Sample Source: Well Temp. at Receipt:
Sample Description: A26-197
Comment:
Time Collected: 10:30 AM
Collected By: Derrick A Smith
Well Permit #:
GPS #:
Inorganic Chemical I (Profile)
Analyte Result Allowable Limit Unit 4ualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium < 0.1 2.00 mg/L
Cadmium < 0.001 0.005 mg/L
Calcium 29 mg/L
Chloride 5.40 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 0.28 _0.30: mg/L
Lead < 0.005 0.015 mg/L
Magnesium 7 mg/L
Manganese �_0.20 ; 0.05, mg/L
pH 7.6 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 8.60 mg/L
Sulfate 17.00 250 mg/L
Total Alkalinity 93 mg/L
Total Hardness 900_, mg/L
Zinc 0.96 5.00 mg/L
Report Date: 07/07/2014
Page 1 of 1
Reported By: Arnold Hvll
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant 13�1R. C�.+,1t'►E'�►J
Address 3b5 Cor�cuctp CF,rFO �
Collected By I�E�c�. /� . SMcr+1
County PERSON
Date Collected (a�ab� 1►} Time Collected 1�'•3p At'�
T
Source: �4 Well ❑ Spring ❑ Other
Location: ❑ House Tap
❑ No Charge � Charge
❑ Well Tap $ Other C�'S�a� ��b�� J
........................................................................�
************************************************************************
Results
Total Coliform
FecaVE. Coli
Present
❑
❑■
. �
Reported By
Date Reported �(' ( a-� 1 ( �
Report Called ❑ YES �NO
Called To:
Ab.sent
�\
�