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Improvements Permit(EstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace�
Improvements Permit (Addition)
q-��}-°�7
Date
_ Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
lace Existing Well
i�, permit requested by: . 7. Dimensions o�Proposed Structure: I
owner/prospective owner/agent: -.� Width: `� S r� �
. . . _ D._. . `.Ll__ - rl�o.,.t,• � .Z /
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Address:
ome Phone #: 23q -q 7a6 C Y��
usiness Phone #:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
Ithat this sewage disposal system is intended to serve?
. Name and address of current owner: 9. Water sup y t}pe:
---� `��, � S � private public❑ community ❑ spring❑
� Are any wells on adjoining property?Yes ❑ No p.
If so, identify location:
intion: Lot size:
Tax Map#: l�-%� " �
Parcel#: I i �
Township: � �� v�- l�` ( �
h�
��-,2 � 10. Type of structurelfacility: Proposed: Existing: Q
�3ec�►'��' Type of dwelling:
� House: ❑ Mobile Home• Business: ❑
Type of business:
Directions to property: State Road #& Road Number of Employees: .
ames,�tc. C�. , Number of bedrooms: 3 �
La- 02 � �3 eo.v e�--
. I��r� 1--6 N� s 5�-o r c p _ Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No.,i�f so, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the PeI'SOII COLtII�y Health DePartmCIIt 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 become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�in 60 DAYS after the date of the evaluation of
j the site by the Health Dept., this application shall become void and all fees p�id forfeited.
W � �
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SiQnc� Owner or Authorized Agenl
Permit Issued ❑
permit Denied ❑
Plat Observed ❑
,•
S ignature
�
Date
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B 1594
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION I1ViPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shalt be issued until Authorization for waste water system construction
has 6een issued.
Tax Map # %� � r/ Parcel # )
�
Zoning Township O ��'✓e / ���
Owner/Contractor �.' I a �,d(j � e �i� v i�- �{- Date �-1 L/ - q•7
Location/Address
Po � �}'
Subdivision Name
Sii� L,Ot�
� n r...-1 ,rrr
.R.# � � y �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 1� 5� �, c. Size of Tank D D �l•t.��j1S
SFD Mobile Home � Size of Pump Tank N��
Business # of Bedrooms�_ Nitrification Line �D Q X 3
Max Depth Trenches �. � ��
Permits may be voided if site is altere or intended use changed.
Well and Septic Layout by .�unMi�j
Comments:
Date -°I �/ Installed by `'� ��,,� ; c Approved
dVell Permit Paid WELL SYSTEM SPECIFICATIUNS
Individuat_� Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Log i/
Well Head Approved Well Tag ✓
Grouting Approved -
Comments:
- 2 �� ' �1 ' I Installed by,
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. 'Y'he environmental
health specialist is not responsible for false or misleading information
contained in the applieation. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the eavironmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permi�sam O1/95 rev.l.l
Date:�-.� -�'� '
Owner. A
Lc�cation/Directions:
Subdivision N�une:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
�
SR#
Lot #�-�_
Distance from Nearest Property Line !C� Distance from Source of
Pollution_ /C�C� '
Total.Depth:. ayC� Ft. Yield: 3 GPM Static Water Level as Ft.
Water Bearing Zones: Depth �F[.� q Ft� F� �t.
Casing: Depth: From�_to_�_Ft. Diameter: ' Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Y�s No
� Weight: � Thickness: �%�_ Height�Above Ground: 1�/ Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No .�
If "yes" gir•e reason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular- Space Width Inches
Water in Annular Space: Yes No
_ . Method: Fumped . _ Pr:ssure � Poured �' . _ . . . � :
Depth: From � to aci Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: co
ID Plates: Yes ✓' No � � �- �
� 4 x 4 slab Yes ,/ No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui1TY HEALTH DEPARTMENT.
Signa ure of Contractor Datc
::: _ �
�,
� '
�..
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:
JOSH GRINSTEAD
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://slah. ncoublichealth. com
Phone: 919-733-3937
Fax: 919-715-8610
75 SCHULLERS POINT DR.
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES052113-0095001 Date Collected: 05/20/13 Time Collected: 11:20 AM
Date Received: 05/21/13 Collected By: J. Smith
Sample Type: Raw Sampling Point: Kitchen sink Well Permit #:
Sample Source: Ground Temp. at Receipt: GPS #:
Sample Description:
Comment:
Inorganic Chemical 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 7 _, mg/L
Chloride < 5.00 250 _; mg/L
Chromium < 0.01 0.10 mg/L
Copper _ _ _ _- 0.34 _ 1.3 _ _ mg/L
Fluoride 0.21 4.00 mg/L
Iron < 0.10 0.30 ` mg/L
Lead 0.017 ; 0.015 mg/L
Magnesium 4 mg/L
Manganese < 0.03 - 0.05 _ mg/L
pH 7.1 N/A
Selenium < 0.005. 0.05 , mg/L
Silver < 0.05 0.10 ' mg/L
Sodium . 9.60 : mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 38 mg/L
Total Hardness 32 mg/L
Zinc 0.61 5.00 mg/L
Report Date: 05/30/2013
RECEYVED
JUN 0 7 2013
BY:
Page 1 of 1
Reported By: Arnold Ho//
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:
JOSH GRINSTEAD
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://sloh. ncoublichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
75 SCHULLERS POINT DR.
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES061213-0024001 Date Collected: 06/11/13 Time Collected: 4:30 PM
Date Received: 06/12/13 Collected By: J. Smith
Sample Type: Raw Sampling Point: Kitchen sink Well Permit #:
Sample Source: Ground Temp.'at Receipt: GPS #:
` - - � .�. �
.. ,
Sample Description: � � �
Comment: 1st draw '
Lead (Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Lead 0.023 0.015 mg/L
Report Date: 06/17/2013
Reported By:
:- Arno/d Ho//
JUN 2 5 2013
Page 1 of 1
n
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:
JOSH GRINSTEAD
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slah.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
75 SCHULLERS POINT DR.
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES061213-0020001 Date Collected: 06/11/13 Time Collected: 4:45 PM
Date Received: 06/12/13 Collected By: J. Smith
Sample Type: Raw Sampling Point: ' Kitchen sink Well Permit #:
Sample Source: Ground Temp. at Receipt: GPS #:
_. . __. _ ,
Sample Description:
Comment: 2nd draw ..
Lead (ProFle) � � � � v
Analyte Result Allowable Limit Unit Qualifier(s)
Lead < 0.005 0.015 mg/L
Report Date: 06/17/2013 Reported By: `��.A/'IIOId fiClll
RECEI'V �D
JUN 2 5 20i3
�t-,��.
Page 1 of 1