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A27 240PERSON COUNTY Dear � C�.L�'�c-�-�.�C � ``oyO�GOUN(yC�4`.y� ..V . 'x ...'�� G � sc , � ` `�+Oh cou�cc+'�rc PERSON COU�ITY HEALTH DEPARTMENT ENVIRONMEti'TAL HEALTH PROGRAM 325 Souch Morgan Street Roxboro, North Carolina 27573 (33G) 597-2371 Date: � �� Re: ��l��I' 2- ( �n �ce ( �24 (� The above referenced lot has been evafuated by the Person County • Environmental Health Department. The results of the evaluation, a copy of which is attached, indicate that the site is unsuitable for installation of a ground absorption sewage system for the following reasons: , Due to the limitations on your site, this Department is not aware of any modifications or altemative measures that can be implemented to upgrade the c(assification from °unsuitable' to °provisional{y suitable.° Your application for an improvemeni permit musf, therefore, be denied. You have the right fo an informal review of this decision by the environmental health supervisor of this health department and also by the regional staff of the Department of Environment, Health, and Natural Resources. You should contact the health department to arrange for fhis further review. You may a(so wish to obtain the services of a private consultant to collect site-specific data and submit such data and a system design to the health department for technical review A site may be reclassified to provisionally suitable provided wriiten documentation, including engineering, hydrogeologic, geo(ogic, or soil studies indicates to the local health department that a proposed septic tank system or a proposed altemative system can reasonably be expected to function satisfactorily. Page 2 The substantiating data from these studies must indicate tha� A. The effluent (wastewater) will receive adequate treatment; B. The effluent (wastewater) wiil not contaminate any ground water or surface water; and C. The effluent (wastewater) will not be exposed on the ground surface or be discharged to surface waters wfi�ere it could come into contact with people, animals, or vectors. Finally, you have the right to a formal appeal of this decision if you file a petition for a contested case hearing with the Office of Administrative Hearings, P. O. Drawer 27447, Raleigh, NC 27611-7447. A copy of a petition form will be provided to you upon request. The petition must be received by the Office of Administrative hearings within 60 days after the date of this notice. The hearing will be held in the county in which your property is located. If you file a petition for a hearing, you must send a copy of the petition to Mr. John C. Hunter, Office of General Counsel, P. O. Box 27687, Raleigh, NC 27611-7687. Please call or write this office if you have questions or need additional assistance. Sincerely, Environmental Health Specialist Environmental Health Division Person County Health Department Enclosure � m v ,�� °� �� .� � n a � `b� � . .�� ;,,u� i : . . � . .t � H O � 1 l -02 7- � � r .�+['' . .i''.::::..£z�.w:; - lmprovements Pecmit (Established/Recorded Lot) Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) _ Repair/Replace extsttng Sepcic System � improvements Permit (Mobile Home Replace) _. Permit for New Well 3 �_ Improvements Permit (Addition) _ Replace Existing Well I. permit requestedby: . INilbu,r �a.�h� Qwner/prospec[ive ownedagent: W� MOj" ns Address: `� 3� 8 Dx�°Yd �d� ome Phone #: 5q�- `�� usiness Phone #: �R4 - �� 13 W � Name and addre�s of current owner: '3 y Description: L.oc size: �a •��5 a�� Tax Map#: Az� - Parcel#: _ �-�'� `Z��--- Township: ��!�-�-�� Directions to property: State Road #& Road ames;�tc. :.! w ��$W r/� i�„� �� i� 7. Dimensions or Proposed Structure: Width: �D 8. What type (if any� additions, expansions, or I replacement is anticipated to the structure or facility Ithat this sewage disposal system is intended to serve? — �ta 9. Wat�r,SupplY �}Pe' . . privat �l . public❑ community ❑ spring ❑ Are any wells on ad�otntng propercy?Yes ❑ No j�j �If so, identify location: 10. Type of st�ucturelfaciliry: Proposed:�Existing: Q Type of dwelling: House�] Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: `}" Garbage Disposal? Yes ❑ No.�l Basement? Yes❑ No� If so, # of basement fixtures: 6 Number of occupants or people to be served' 2- � CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the T'erSOII COUI1ty Health Depat'tment for a site evaluation foc the on-sice 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 Permi[ can b issued, I must present a survey plae of the propeny lo the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. �2� 6',,n.� ,�a'l W -� � �''"R`' �'; . � pecmit Issued ❑ ,, '��'`' permit Denied ❑ "`' Plat Observed ❑ �;,.;'� Ri� '�, �, V �T' ` � � � � � �I�bA � � l!V � � �., E - . � 7Y�'�� ~ � � � / (/l.i� 1 ��L/ t� . � � � �.: : �� o� , .�:. � � � � �� :� `� pG _ , � v� l � � �06 �� . �, � �� , v��avG�'��,� u-S S ,. s��«,= SOIl. TF7CillRE (12-M IN.) �1NDY. lAll�Sl'. MYEY. NOTE L•1 CUIY) SO[L STRIKiURE (11361N.1 U1YEY S011S) SO[L DEPT}l (ItIJ {. RFS'(R1Ci1vE HORiZAHS (R1.1 :UiPERYlO(1S SfRATA. ROCK) 6. SO[LDR/UNAGFJGROUNDWATER (FJCTFRN/lL & QrTERNAI.1 7. SOII.P£1U4FJ18[UTY (PF�tCOLOATIOK RATfI E. AVAIIASLESPACE srrE a�ss�c�noNcs� s�t.ow� socc. sEx�s � ,��/.'. -� �1 .. 1 � i � � Y� l �_ 2 �_�,� v- . \ r �- �O S� �30 6 .� , �.d�c � a.� 7 s �o�s� � _ � .�-� v S S � � � U S S 3G �� u �� s � U � U � N� _ M U �n„o U S S � � 3 �l � V S S u bl\ u I SSU[TABLE PS�PROYlSIONALLYSUITA6t,E U-UKSVCTABI,E RECOMMENDATIONS/COMMENTS: � � � _ � U S PS U S � u s � U � � U S PS U S � u s � � s PS � S PS S PS v s PS U 5 � U S PS U S FS u �T-.-� ,�.T ��c��rrnri nTnnn nM fTn�in�le- Soil areas, orooertY lines, roads, sereams, gullies, wet areas, PLAi OF SIlRYE1► PAUL �. ADH4lLA OiiVE Mllt ��•• � L�1T, M.C. FEe:�UAJtr � �7�1 LYlEfl�rllf'��NZS,� ASSOC[A?ES _ - _ , , , : , -- s ......�... _,,. � •�� N : : : : �...�.�.. �.... o... •t ►/�Ir M+r I -•-•-_._._�" yi/I /rK I K�l �� M rA� A t�r �! naf ��'� N NMs�r� /� /1� � M ! .M.. RN tMl�M_" r '"_..' f �� ./� !Nfl�� ._...�.-... _.�.�..... �ws M�r. :ts r� wo. Ma a a MIil1PM1� . � �R I�A PIO �t � �1 '��jt��i[s '� ti M�a vM ' � MIIM��» �"�_ �� 1 ' — . �..... .p V. •.•. 1N. �. rf W\ _ , � '.�, . �9 J + � 1 �,: ' , j. �f ,� . � .�,....... .... �,.. .. �. � � � i 1 � • ► wr. r. � trt t. �F� � •.�. M�. �. M �� .�. N�I. r. r ' . • r ' d t ��r , . ,.... , _,, � � » .l � - � f �' � � . : t ..» 1 . � - f�, � � ; � ,r.. �.r \- j '3 � r r �.R �. �. N \ o �' ` '": s � " y �.� • ,��. ,�. � li� r � � •�4 -------�--- �.�. � t �� s� � �1.69 � ' � � . )�4 , � � � 11CRES j '� � a ''- � `�� . �^�� t � _. ,�:;� �: . .�...::: �� --- . -�---- .... ...: /• Ir ��.•�� ,�, �, .�- '.. r �� •, II-- � � � �'.' 7�.M' � "�— -.�.- J_.� •�+, ~ . �A ►. �Mf1N. . " AC�D��` ; a�. w. •. t t t � .. �r r�N � �� . �. _ �•� r �a�+w �_ �. w +� � �Rr +� � -� -i� I ._.[�..... •� 1f �,�t,� a�►rs � �w « � M _�....... � ri � M � w w .0 M '�►JY i�C�l�II� � � -._�. �. * v'f�'t' • N1.N 7�t.M fy.M' lw•My 1M.M 1��_._..- . v � �a�-ay�o PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant R+�SEI.L 1'�5�k.� Address 110� RoS��Rxsa� � County PERSON Collected By �. SM� R�, Date Collected '7��a l Time Collected 9:�3 �`�`� T Source: � Well ❑ Spring ❑ Other Location: ❑ House Tap ❑ Well Tap ❑ No Charge '� Charge � Other `,O+�TS�OE 5�1��, ........................................................................� ************************************************************************ Total Coliform FecaVE. Coli Results Present Absent ❑ I� ❑ �i Reported By ��1� ��_ Date Reported � ��`1 Report Called ❑ YES �O Called To: PERSON COUNTY HEALTIi DEPARTMENT SUBSUR�ACE WASTEWATER SYSTEM[ NdONTrORING REPORT --E=—�---�-- �—a�r�� Date of Inspection System Installarion Date Typa j�5 �Cohe�fi�o�, ✓1cQ�_ 1�� Property Address �� Tax ap Parcel # �25? Instructions: Check yes or no for appropriate items and explain insgace provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate hy "N" and explain. Not� thai thts monitoring form is not totalIy inclusive for all systems. All maintenance and monitoring items specifiec� in the permit are to be carried out. INSPECTION RE3ULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of i�ltration and surface water diverted 7 5eptic tank needs pumpin� 7 �Inches of solids: G- 3 Septic tank filter cleaned ? F,FFLUENT DOSING 3YSTBM: Required pumps present & fucctional ? High water alazm operating proparly 7 Floats, valves, etc. in good condition 7 Cantro! panel & components in good condition 7 Eft�uent free of excess solids ?, �,� Inches of solids(pump/dose ):_�__ Elapsed time readings 7 Q Counter readings ? n Drawdown rate: � ■ 1: li ■ ■ ► '1 ■ i ►� ■ : ■ ►i ■ �� ■ DISPOSAL FIELD: Evidenae af efftuent surfacing 7 ❑ Evidence of effluent ponding in trenches ?❑ Surface si�ater a�ectively diver[ed ? "� Dieersiaas/swales propsrly mai.ntainPd ? � Vegetative cover mainiained ? � Frotected from trafiic/unauthorized uses ? � Distribution devices in good coa.difion 7 Fielu free of settted or low azeas ? '� / / / / / / / t': � ■ ■ ■ 1 REMARKS � �(�� e��u��.� .� l�e,� � s','�4 l � (�� c -f -l��eQc� c.� �; �v. ''►`�„��✓ �i01�✓L-, G��f��'e �•�'C✓`rQet�A�t� � � �P� � �°Q �1�,`� a�� o� � ✓� ha �'�'1 ��5 OT C.e�-t�u r '� �' S a ^— `�Wd�,�► : J. 5 1►�;�� 1��1��. P i p��e�P � ��d�P ��-�r��, PRfiSSURE DISTRIBUTION SYSTEI4I: � �0 C (�„�o ��{-- Tumups/cleanouts/valves/taps intact & accessible? ❑ � ❑nlq � Fressure head properly adjusted ? ❑/❑ h�C� �'� ✓�° S w'`� coNrnLr�rrcE: Compliant Non-compliant Nee3s N12inter.ance ,A.i)17iTioNAi, co.Ml�ivTs: ►: ■ ■ T� t � �� 7 Application Date: Amount Paid: _� Receipt #: ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Perrait (New/Replacement/Repair) $300.00/$200.00/$75.00 �� 1) Applicant Inf�tpi a1 � y Name: /C�s Address: � L � 2) Name and add s of � Name: r�SSt �� Address: �6 �� ?�}�; �� ;Yl V � � �� Caa�as�a .. .�TM* �aa�.mIl I�-3Cm�m.11+t�ia for Services Taz Map: �' � 7 Parcel#: _�� ,� ec�ll � 4•e.� Co M� N�. o u.'i- — Services Re uested 0 Construction Authorization ee is de endent on the e of s stem ermitted) ❑ Permit Revision . $75.00 Repair of Existing Septic System Application: No Chazge/ CA $150.00 or $300.00 �hone (home): l� '�7' �d�� (work/cell): i asr than appGcant): /33� j �� y��y �.�,OD,��i%�,B/�i��hone: l � � . . 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Lot #: � 1 ca �e � N� N�� z� ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systemsT ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? � ❑ yes ❑ no Are there any easements or right of ways on this property? � C� (if `yes' is checked, please provide supporting documentation) � � ------. 4) Proposed Use and Type of Structure: �� OResidential ' ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: Cl Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures7 ❑ yes ❑ no . ❑Non-Residential Type of business: Maximum number of employees: Total Squaze footage ofBuilding: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property7 O yes ❑ no Please note any known ground .water resfictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify ' ormation provided above is complete and correct. I also understand that if the information provided is inacc ate, the site i subsegu� alter� the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Leg�1 Representative*) * Supporting documentation required. 02 v��% � Date • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �! ��l/G-1 / /�.(1� S�r� �/�S�`�f �� 9�arr+, � %� ��j/� (/��nC� � � �,� � .,� ! / u/Qr2 �-{— �e.tKe,�cua � I��lr►,P rt�� ✓k�2.,� �T�� S�a.��►�-- �1�. �� Q �Qs�-�4-t� c��.,,�.. � '"1�'�° � ��,,,�( �� ( � .�, tQ,Q �-�, �--� c�,L ( , s-� �'c c�� .--. . ' � �(-S1' G STC P�RSON COUNTY ENVIRONMENTAL H�ALTH WELL LOG Dzt�:�o--15-4 Ow�ie�: '�� UI� v(ci.l� � �� SR# Location./Directions: . Subdivision Name: L�t � Drilling Contractor: ��JK�� u�� I.0 �M sc� T.N � � WELL C S Distancc from Ncarest Properry Linc Distancc from Source of Pollution Total.�ep.th: � FG Yield: � 2. GPM Static Water Level Ft. Water Bear:ng Zone�: Depth Ft Ft. F�_ �t. Casing: Depth: From � t— o��Ft. Diameter: � Inches TYPE: Steel � Galvanized Steel ✓ , . If Steel, does owner approve: Y�s No Weight: Thickness: •, ' Height Above Ground: Inches Drivc Shoe: Ycs No . Were Problems Encountered in Setting the Casing? Ycs No If "ycs" givc rc:i.sor�: vrout: Type: Neat SandjCement Coricrete Aruiular. Space Width 12. Inches Water in Annular Spacc: Yes_, No .. Method: Pumped � Pressure Poured �� Uepth: From O to ZO Ft. Materia]s Used: No. Bags Portland Cement Weight of .1 bag�lbs. If mixture (sand, gravel; cuttings) - Ratio: to � ID Platcs: Ycs '� No � ' 4 x 4 slab Yes ✓ No I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED 1N ACCORDEINCE WITH REGULATIONS SET FORTH BY•THE PERSON COUNTY HEALTH DEPARTMENT. . , ' � .... Signat�ire of Contract � Datc �'.� B 2882 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � 2,-] Parcel #_ Zoning _ Township Owner/Contractor L cation/Address L }% Subdivision Name � " • � . - �jr� � �� i � �I� i e . c� ' SEWAGE SYSTEM SPECIFICATIONS � Repair Lot Area %D.g �/{� Size ofTank�� SFD � Mobile Home Size of Pump Tank_ � Business # of Bedrooms�_ Nitrification Line � Max Depth Trenches � U � a � � Permits may be voided if site j Well and Septic Layout by � Comments: � �,. . s _ _ _ r, Date /p -a`� -�►� Installed ell Permit Paid Site Approved�� Well Head Approved Grouting Approved � Comments: �� c��y� or inten�ed use changed. Approved � -I -� a �._ SYSTEM SPECIFICATIONS Semi-Public Required Slab te�placement Air Vent Required Well Log /� , Well Tag �� /� � � � �t�l j/[.,� Date �- 2�� Installed by �� Approved by This report is based i� part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. 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 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. c:\amipro\permit.sam O1/95 rev.l.l -- � �=_ - - NF - - �N TROL �RNER � � � � . � z �' P UI�P L I NE ----- EASEI�ENT � � 24 RE , TIC FIELU �4FtJ1 IS TOTAL � 1 � r�^ � v( � 4 � � . � . �� ' � / , � . �� l �� ,- C? �� d-ao- � � I EXISTING 60' � � ( ACCESS EASEMENT ��13��9 � ,� �� .5 � I P� � � � � �,�� I � - a�' ��',�2�.�-� � � � �; I " I � I JAf�ES A. FRAZ I ER , JR . � � D.B. 200, P. 99 � � � 1S I - � J I � I IS � -------.--- I- �--�----- J` ' � � � i � T[MOTHY W. TAYLOR ' I ;; � 4 �i D.B. 241 , P. 482 � �� .� y., ;, :e � I i . _-i�� ; � r l � 1 �� -----� ' %:j � 1 � � Vt � • 'Ll ;? � I ��y � � f ' f } `I''�'% . . . � I .. I�z . . - .. I �. . . . ' � / � � . � � r �s�, . 3 .' - . . . � � ' �' i - . KEN R. Dl1NEVANT � ��h — — — — — — --� D.B. 266, P. 311 � ': ''� � � I ' i' � � I � ► I I� � � � � �� i . � � � � i t I �> ` � i � `� � i � � � , o � �� , � � _- /' I � F�i',/ I _ _ ---- � i � � � RANDY L. CASH �� G?� 1 NF— --—� � I � EXISTING 60' CONTROL , I ACCESS EASEMENT CORNER ' i� I II I w � � � � - o � o ,n � '� " � N � Z I JAMES A. FRAZIER, JR. 20' PUA�P L INE ---- � i D. B. 200, P. 99 EASEA�EN7 I i , ii � � � � � . 24 TOTAL ACRE\ IS �MP IS i SEP7I C \ ,� f f DRAINFIELD A / EASEi�ENi • �Z' ( IS 3 IS � � — — — — — — — — — — — — — — — — — — — — — — — —�— — — — — — — — — — �