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A26 203Application Date: �- I�� I � G��_��- � L Tax Map: Amount Paid: �2bp , D (� � �G . � � � J � � Parcel #: _ Receipt#: _ � � � 3 �� --��?, � �� TC.T�� i� ��ta-iv�nu xaun.s-u-n.<c�'�catti.an.�l 1�'�rx=,.�a.�d��ia Application for Services (Septic Systems and Wells) Services Re uested � Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the ty e of system ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No CharQe 1) Services Requested 6y: Name: Address: Phone # (work/c� 2)Name and address of current owner (if different than applicant): Name: Address: � ��I� �`��-a�a� �dC.l(� 3) Property Description: Lot Size: �.(�3 Subdivision: Lot #: Address and/or directions to Property: �1�j2(��(�% ��a, ��`,Cj'f�, N� ��l'J`��7�- ' 4) Proposed Use and Type of Structure: Residential _�� Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _) Garbage disposal: Yes No _� 5) Water Supply: Private Well � (Proposed ✓ Existing � Community Well: Public Water System: Are there wells on the adjoining properti�s? No Yes (please show location on site plan) Note: A comnleted anvlication must also include: ➢ A platlsite plan of the property that shows property dimensions and the size and location of al[ proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): � �.�- Date : � �t 1� 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� S f_ ��$.�� ` _ � ' � � � �� I��u��D��.�.��.11 I�I �:�.11�1� T�x M�{� � ' F�rcel # - � Subciivi,sion Fhase Sect�ion Lot � Improvement Permit Permit Valid for Five Ye rs No Expiration ,-/ Type of Facility: �; va �e. �Si Qc�. n� P, New _ Addition _ Water Supply ►N� # of Occupants nnAx 1� # of B drooms Projected Dail Flow �( � g.p.d. Proposed Wastewat r System• r ti r S Type: Proposed Repair: ��Q� � Type: Permit Conditions: �i „-�ql Cl �� Qt'��tcf,S Owner or Legal Representativ ature: Authorized State A�ent: _ i,,,,,� Date: �� Date: 2 - 23 ' /d The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. 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 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 and Rules for SewaQe Treatment and Disposa[ Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_J. Proposed}�astewater System: FZ � Type y�� Wastewater Flow ,�1 Q_g.p.d. New t/ Repa' Ex ansi _ Soil LT � g.p.d./ ft 2 Type of Facility: i� Basement _ Yes No Tank Size: 5eptic Tank: � gal Drainfield: Total Area: rI , D sq ft Wastewater System Requirements Pump Tank: � gal Grease Trap: — —gal Total Length 21e0 ft Maximum Trench Depth � in o, �. Trench Width �_ ft Minimum Soil Cover: �_ in Minimum Trench Separation: �_ ft -i � Distribution: ' ilistribution Box ✓ Serial Distribution Pressure Manifold Specifications: f � —_ � //--j �. � / �; �� __ -- - ----- l� Authorized State Age� ^ Date: �'Z3 �D Permit Expiratio Date: - 23 - /S , The type of system permitted is Convent' nal ✓Accepted Alternative. I accept the specifications of the permit. Owner/Legal Representative: Date: � � ' � � PCHD rev. 11/10/OS .�� . . . � ~ ' �'` � � �U l�J �� ]��-o-au-�,r,,,.,..,, ��.�.11 IHC��.A� . SITE S�TC� � . . b � � �. ��. ��• �� / �'.. ��='��, � - �s■ -� ' �•� Tag Map # Aa6 � Patcel ��D 3 Section/Lot# 2'2�-/l� � Date Syste�a cum, pone�sts sr��irerent appmximc�nte �coutours o�tly: The con�mctor �saust, fiag the system prior to . beginning the i�utalla�'ion ta s�sure that pr+n�iergrade is maintai�ed , I�Cj �' . n� i �� i � � S� ��l�s Tr�,`+;a l S' s-kwt —� 3�(� Q� P, c� 1 3 � e�� J 1 — Z. Ce 0' ✓-} cce�O �e d _ _---- _ . - � — Z � ►� �,-t hC� �oi�in S � �� r � �,,�,�St _\ � ��1� . ' = �� ; � �.:. ._-., 0 ��i � �� I ��0�� L � ��.sf ��.� �� ^ � � �� IE�.�a��.,r„-„ ��.�.Il I�3I��.IL�II� Tax Map �� Parcel # a�3 Subdivision Phase/Section/Lot # # of Bedrooms �_ . Applicant: �� I�an Location: S� t� -�,� ��rook� ��.�n ��\ -� l04 a-, C� o.��9v-1 i Operation Permit System Type (From Table Va): —�o- Product (IIIg): — 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. ��h ruv +'�� (Authorized Agent) �� 1��,.�is (Licen d Contractor) �`� 1� ` ^�� 1 _ l\ �II � ly UJ � I�� /y/ �� d r� � Scale: r� � S 5��1 � to (Date) 5�a�11� (Date) Line Length � � � �-� l�o�k 3 l �� I �a��k Total 3�,oFk Tax Map: �,2,� Parcel #: �Q3 Septic Tank System Checklist (Type II-I� System Type: 1..�� Notes: Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BLTILDING INSPECTIONS: ✓Copy of OP (Revised 12/09 BH) e-mail Date: p Taz Map: _ Subdivision: ��, s� ��.� �� .na�n� am �naxn. � �rn.��.Il. .�"� s� �.11 �.�n WELL PERN.QT (New�/,Repair� Parcel: Lot: Applicant's Name: Uou G Mailing Address: 2� 2 Phone Numbers: Sq q- 54� � �( I+) 5b�( - 3�l_ Z� Location of Property: S? 1�/ � V d��; :� 1CS A �'� / 7 L6� Permit Conditions: � 1) See attached site plan for proposed weld location. 2) All applicable State and Counry regulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. Other Conditions/Comments: - Permit issued Date: 2 - 2�i -16 CERTIFICATE OF COMPLETION New Well Inspection: E S/Date Location: 27 Grouting: , Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller• � Pump Installer: Well Approved by: Date Sample Collected: ��" I D Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date• � � Date Results Mailed: f Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # � — 1. WELL CO CTOR• ubn i'�,�(�k'��1 Weli Contra or Indivi ua me � Bamette Well Drillina Inc � Weit ConVector Company Name 611 Bamette Tinaen Rd SVeet Address Roxboro NC 27574 City or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2 WELL INFORMATION: , � WELL CONSTRUCTiON PERMIT# � OTHER ASSOCIATED PERMIT#(if appticable) SITE WELL ID #('d applicable) 3. WELL USE (Check Applicable Box): Residential Water Supply ❑ DATE DRILLED J '��" � � TIME COMPLETED Z�v AM ❑ PM [� 4. VYELL OCATION: CITY: /17 COUNTY �'� o,�—�. �t d ✓-, �cQ (Street Name, Numbers, Commu�ity, ubdivision, lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: (cherJc appropriate bo� ❑Siope pValley lat ❑Ridge pOther LATITUDE 36 "_ " DMS OR 3X.XXXXXXXXX DD LONGITUDE 75 _„_ " DMS OR 7X.XXXXXXXXX DD Latitudeflongitude source: �PS �fopographic map (loca6on of.we!! must be shown on a USGS topo map andattached to this form if not using GPS) 5. WE OVYNER � � Own Name Q � 'DCb o�5 � 4� t u Fe� eet Address ^ ,7T �� ,� � �_ L �� City or Town _ State Zip Code �°�? -- SY3Y a code �hone number 6. WELL DETAILS: a TOTAL DEPTH: -Ff b. DOES WEI.I REPLACE EXISIING WELL? YES ❑ NO C9� c. WATER LEVEI Below Top of Casing: �� FT- (Use '+" ff Above Top of Casing) ' d TOP OF CASING IS � FT. Above Land SurFace' 'Top of r,asing terminated aUor beiow land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): �_ METHOD OF TEST BIOWiI 2O�T1 f. DISINFECTION: Type �"'�T�'i ____ Amount ��2 CUq g. ATER ZONES (depth): Top Bottom�Z Top Bottom Top Bottom 2? S Top Bottom Top Bottom Top Bottom Thickness/ 7. CASING: Depth Diameter Wetght Material Top�_ Bottom� Ft 6� S��Zi �� C Top Bottom Ft. Top Bottom Fk 8. GROUT: Depth Material Top�_ sottom�2_ Ft. Sand/Cemeni Top Bottom Ft. Top Bottom FL Method Poured 9. SCREEN: Depth Diameter Slot Size Materiai Top Bottom Ft. in. in. Top Bottom Ft in. in. Top Bottom Ft. in. in. 10. SAND/GRAVEL PAGK: Depth Size Mate�iai Top Bottom Ft. Top Battom Ft. Top Bottom Ft. 11. ORILLING LOG Top Bottom � / Z 2 / � ��a a i� / 1 / / / / / / 12. REMARKS: . .. �- .. . • ��T�� '��!�C�3'�!!l �. � T.T! �i�� 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 PROVIDED TO THE WELL OWNER. � � $^��-la SIG - OF ER'➢ IED WELL CONTRACTOR DATE .�..._ PRINTE NAME O R N CONSTR THE WELI Submit within 30 days of completion to: Division of Water Quality - information Processing, Form GW-1a 1617 Maii Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/09 Report To: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES070710-0117001 � �� ES Microbiology ID: 18266 GPS Number: Sample Description: Comment: Name of System: DOUG DILLAN BROOKS DAIRY RD Col lected: 07/06/2010 10:30 Received: 07/07/2010 08:40 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://s Iph. state. nc. us Phone: 919-733-7834 Fax: 919-733-8695 J. Smith Angela Heybroek Well Permit Number: A26-203 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Darneice Lyons 07/08/2010 E. coli, Colilert Absent Darneice Lyons 07/08/2010 Report Date: 07/09/2010 Explanations of Coliform Analysis: Reported By: Susan Beasley ----------. _ _ �� JUL 12 2010 BY: 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. Report To: Vorth Carolina State Laboratory of Public Healtf 3°�N W?m°�9 on St. Environmental Sciences Raleigh, Nc z�s„-ao�� htta://sl�h.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 StarLiMS ID: ES070710-0037001 Date Collected: 07/06/10 Inorganic ID: Date Received: 07/07/10 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 3.5 Sample Description: Comment: Name of System: DOUG DILLAN BROOKS DAIRY RD Time Collected: 10:30 AM Collected By: J. Smith Well Permit #: A26-203 GPS #: New Well (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Total Alkalinity Arsenic Copper Lead Manganese Zinc Barium Cadmium Chromium Silver Seleniurri I ron Mercury Fluoride Nitrate N itrite Chloride Sulfate pH Sodium Calcium Magnesium Total Hardness 37 < 0.005 < 0.05 0.011 0.08 0.83 < 0.1 < 0.001 < 0.01 < 0.05 < 0.005 < 0.10 < 0.0005 < 0.20 1.10 < 0.10 < 5.00 < 5.00 6.6 10.00 4 2 19 0.010 1.3 0.015 0.05 5.00 2.00 0.005 0.10 0.10 0.05 0.30 � 0.002 2.00 10.00 1.00 250 250 mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L N/A mg/L mg/L mg/L mg/L Report Date: 07/30/2010 I A��i 3 20�� I Reported By: �lti�(ie i�ucg age 1