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A27 3341 1 � �. �► � �...-.. � � �� ,/ `�...Y � � � � 1i:.ar�11L'�.:ii°a[D.�it,]t7r71�3i']l.'�.�A..Mi 11 JL�:.iU,JJ.��ih �uilding Additions/ Mobile I�ome Replacements Tax Map #: � a'1 Approval Requested for: Parcel#: 33�1 Mobile Home Replacement x Building Addition C�o.� a� x a� Applicant Name: � �,�1� s �,�4�„-.d, �� 1 ►�. : 'Me.H �� Address: ai �� .-, `� �o x��o � N L z'l S?�/ -- Phone #'s: ��i - �Fs�� Permit Located: Yes No Installation Date: 11-1 S-0�-1 Design flow:�(� �(gpd) Current Contract with Certified Operator on file (if required): '� (�- �Water� Supply: � Well Public or Community , Wastewater system shows no visual evidence of failure on: �-/ -v (date) (Applicant's signature if site visit is not required) ' Comxnents:� .� aQsr'� o.�- l��- 1� -�►- ��- �..�� n�. a�.cxal:.�., �;,.�. , -n ddition/Replacement Approved � � . S - �/- U4. Environmental ea Speciali Date 11/15/OS - � PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: _=/`t � I Parcel # �� Zoning Township V� , `� C, �� 1' Applicant:r�1� , ��'S�� Locatlon: �� V vt �� Subdivision: Type of Water SupplV: Requirements: Site Approved by Grouting ApprgvE Weli Log t/ Well Tag. � Air Vent,/� Hose Bibr/ �S � Section: �at= Well Permit �(ndividual Community Public d by � -'fl l i Concrete SI �S ` Well Driller: ��5� Well Approved By: ' P��, � � �-3�_�-� � Date: I- 3 �� J=� **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions PCHD, rev. 11/29/99 IF ----------�" �� (,��G� �• ��,�� se� �lC�-f� � ,.._ �r'� ��""� r'�t�L�T' �l C Yyl�t�� r �� _ �a�Z �3� RONALD C. OHNSON P . 705_ _' D.B. 239, Q P . 27-2 �" r P.�. 9, � O � � / �i Q � a� � � � Z � !� � (,(�� . way l _ _ IF _�__—__— � � � � S�' i 307 '— � � �'� d�c �.� �2-��y .%� n � � .s� N 19.3� 7 4'' � � � S85°26'S3"E 205.08' � Q r �� r O 31 � / �' l� r l_ 01 tr co � ; � . � • t � � co t - ' J ��-�; � , � , /� , ; � 1 ��! � 1 � ! / � � � � � �, � � �.� , , , , � r r � r � � � ` � . ; , � �' �� ! ; ,� � � , ;� � �� ' � � ; ;' �, ��,,,��-f- + � Z ' ',� �z�� 7 /^ v� ' � 1,1. cu f ., ,: / ( `�, ;; `-�,� ��.� �� =`� ` � � �.71��I"�Y ��ra�n��rn�rnca_�aaa.�:.s9..Il g 3C�.a..Il�IEa �. � � � DriTlei t � H •� ComE��tty Nan�� . _ � ' ' Cl��,t�e D i i�l!k e ci % n Grout Lag - Owner: � �- l'� i P� 1M«� Tax Map ,�,._�%Parcel #.3�'`% Location: � � Subdivision: Lot # _______.�. Well Coastrurtion Distarice From nearest Property Line (Minimum 10 feet} _ t O Di$tanc� from Se+pric System (Minimum 60 feet) �� ft Total Dopth: g� � S R Yield: GPM Static Water Level: �._ � ft _ft�� ft Water Bearing Zc>nes: Depth 'S _ C�sing: g(�i�iametet: _ 1,�.�- is� Depth: Fram �,_._ tp ��-- Type: Galvanized Stcel �— Weight: Thickness: r � Height above Ground: —/�2 � Urive Shoe: ,��'es No Any probl�rns encountered while setting aasin8? Yes �Na Yf "yes" give reasnn: Grot�t: Nest: Sand/Cement ►� Concrete GraveUCement , - Anxiular Space Widtn _�,_ ��hes Watcr in Annulaz Sgace Yes i�No Method of Grout: Pumped Pressure Poured � DePth J t° -' `� F� '.VviAterials Used: Wei t of 1 Ba po�� 3�To. Bags Portland cement _ Sh g If mixture {sand gravel, cuttings) - Ratio to ID plates: �es _ No 4 x 4 s�eb � Yes _ No l.iner: Grout� Inst� Depth• _ Date Installed• - ��o$ �g Location From -- To � by: . _. L7 �.-,e'' I h�reby certify that the above informatian is �orrect and that this well was constructed in accordance with regulations set forth by the Persan County Health Department. Signature Qf Coutrs�ctor ��'��-�' . ID#.c�P_� L nAte � d � Pnmp Instailment Pump Install�tion Cnntractar: ___ State Reg,istration Number: , - pur:p DCpth: ft Static Water Level: --- ft Pump Make & M�del: Yump Size an3 Rating: hp �_ gpm I hereby certify that t}us pump was installed and the well head campleted according to the Persor. County Well Rules in effect on this d�te and that a capy of this record has been provided to the v✓Pll owner. P�,mn Tnstaller SiQnstare _ Date: PCHD rev O1/27/04 �—�� ?,) f �� ...� ' �. � �� n�n��cn.gnaa��n��n.� ��.ea.�� Tax M�� F�rcel # Suheiivision Ph�a�se Sec�t�ion Lot � � Improvement Permit Permit Valid for 1/Five Years _ No Expiration � • Type of Facility: 3�JQ-� �D New ✓ Addition _ Water Supply � # of Occupants �� # of Bedrooms 3 Projected Daily Flow 3(o a g.p.d• Proposed Wastewater System:'(� �► Type: Proposed Repair: -f-, Type: w ` - Owner or Legal Representative Signature: Date: Date: 1 / — $-�� Authorized State Agent: �,p� /u..P .�' ��Z�11r�� -1--,— v � The issuance of this permit by the Health Deparhnent 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 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 Ru[es j'or Sew�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the.septic tank system will continue to function satisfactorlly in the future or that the water supply will remain potable. . Authorization to Construct Wastewater System �Required for Building Permit) * See site plan a�id additional attachments (_� Proposed Wastewater System: i�l � v+n� C�"-Q �P Type 3�-b Wastewater Flow �n g.p.d. New l/ Repair Exp sion _ Soil LTAR: . 0?5 g.p.d./ ft 2 Type of Facility: �� . 5 G1\ Basement _ Yes _�Pdo Wastewater System Requirements Size: Septic Tank: �� gal Pump Tank: ��j� gal Grease Trap: N 1'q gal Drainfield: Total Area: �� sq ft Total Length �� ft Maximum Trench Depth � 2_ in Trench Width� ft Minimum Soil Cover: _� in Minimum Trench Separation: � ft Distribution: Distribution Box �/S'erial Distribution Specifications: Authorized 5tate Agent: Permit Exx The type of system permitted is the permit. Owner/Leeal Reuresentative: Date: ! I � !" �Conventional Pressure Manifold Date: " '� Innovative Alternative. I accept the specifications of Date: Application Date: �' I I -D � Amount Paid: Receipt#: �� S � ��.�..� �� - - �- <C � �1�7�IC'� IE ��rn.wn �c-¢a aa.:rraT.•r^. �ta.�.�..Il. IE�C a�.en. I1. S:.jEa Application for Services (Seotic Svstems and Wells) ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Buiiding Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: /a-v2 7 Parcel #: 3 3 LT Services Re uested ❑ Construction Authorization (Fee is de endent on the e of s: ❑ Permit Revision $75.00 0 Repair of Existing Septic System ' No CharQe Important: If tl�e information in t/ie application for an Improvement Permit is incorrect, falsified, or t/ie site is altered, t/ien tlie Improvement Permit and theAutltorization to Construct sltall become invalid. 1) Service equested�by: Name: � Y11 Phone # (home): �� - �� Address: (work/cell): - 41�� Z 2)Name and address of current owner (if different than applicant): Name: '� l�}'�� :Address: - � 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: 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 _ Approximate size of building foundation: Length� Width � 5) Water Supply: Private Well 'f (Proposed Existing _� � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes #: (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): � �Z�W��- Date: l I 1/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� i � �� ,y } � �s.+,� � � � � � � �� -d�C11.�'71.]Y"dCb1i�.3i31C71.fi�''r7YJl.¢a�L� �t�`id:{1.11.l�:� �uilciing Acflditions/ 1Vlobile �oane l�eplaceanents Tax Map #:� Approval Requested for: Parcel#: Mobile Home Replacement �_ Building Addition � ' �� .t .� - ,.� - � -�.��_t_• • �� - � � _,_ '.� —� . r i � � �� --�'� • ,� Permit Located: ✓ Yes No Installation Date: �(- ��, -�� Design flow: 3��_ (gpd) Current Contract with Certified Operator on file (if required): � I� Water Supply: ___�_I 0_ Well Public or Coxnmunity Wastewatex system shows no visual evidence of failure on: �— (date) (Applicant's signature if site visit is not required) ��,c,(,U-� .� C�y rwt,--. • � ' �a u. . '�!. - / ' � . - • ■ : ��. Additioa�eplacem�nt Approved ��v,�� 1��+- Environmental Health Specialist `� 11/15/05 a��► l�� Date S LD C. JOHNSON . 239, P. 705 . 9. P. 27-2 __,_______ IF 38.g� WILKERSON HOLDINGS LIMITED PARTNERSHIP D.B. 273. P. 658 S85°26'53 205.08' 1.72� ACRES P.C. 11, P. 60-8 0 � _ IF . -� - 1 - �p7 `? _' -�-_ n -� - M _ � ' _ NF Ng7•06� 28°W 144.03� � TO SR 1305 �� i ' _ ' NF � - �_ S� ' � _ _ CONTROL �-' �� 1 7 �- - _ _ - CORNER J46 — _ � n �- � � __ NOW OR FORMER�Y M. J. DANIEL ES7ATE ,,,,,,,,,,,,,,,,, . r�n_ �� i .1 � �� ' .:..i, �, �� , � � � �� 1rn.�na-��a�n:bc�s�.��..�. ��.�.��a . � Applicant: �, Location: r1 , �'�, � g! �Er�a,� / T��x Map P�,rcel # Subciivi�s,iom Pha�se Section� Lot # � of Bedrooms C'�perati�n � Perrn it System Type (ln Accordance With Table Va): ��b THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WlTH APPLlCABLE NORTH CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. �^ � Authorized ta e Age Date Instalied By: �� -(�r 5 Oa . 1 c'��'� e%S ! av c� S?r� 3 2 `{ 'S`S. �'r � �v �= �C,.�.�w-� �'� P�L Weo 3��1,� � �=,T( Y^`�"l�:1, •;s r_-- � �_��_ .. .�� —.-s =�rr- � . _,t._: :.c=:,=, ;� _�:_;� � �� 11.. � _. �..�. f�a_,= �'��-;r;'�� r �. - �" �Q�'i�►L��L'r �'_ ~'� - - ��-�-- �--� - '' -' �.::�►f=i 1*}� �,c c� c =1'C� ►':_�� i�� E�`�� 'J�' i.t{'� •,c�ti-�~ ., tnr*i-� •; - _t :• _t �a}7s1;_ =.}t��,� �I�t�a��i7`=.tFr+ .i[_ •��If sl�i��j�� !_�IL• i!';�_��^ �:� r �,�:� � tlii• �: �• e_ i .• _ ^�• a._.`F�r-1� ��j.-=��i�-_It��;��.1 j'� -.�.1 =-1'=! �1 _-' � f �'L'� i.+'`�- 1( �'�_��',�i �� - - �`i� - ►�r �Ir�' 1 i"=�Ti=..ir- _1�;� C:1 ■ i'��.��1rc•� <<.-�.�ti� � : `; ;� . _, . . - ..- ��: �.� - �• ' •�c�-� �. i� - - �� «t i-=- j-r+--=:�f',=tl�-= rT'�� i C- • c�. 4��-�.L� � i fi�r!' r= i I ��. �;�i., _�:�� ` 'r.�.".��. =•��.r_: ♦ :ti + r�°= � - _:�, .- - ! �=:il. •��.�_:�: s`.-r�� ._ _ _'�*'=:�Ic.��ai_�i ' •: •ia - =�f1'�-� t�:_ —.- �-•� �•:_� ��r��tt��a l:s:-� �. ♦�i *_:1�ter_Si- : •�E=�='th=i ,.�:.�ft.� PERSON COUNTY HEALTH DEPARTMENT SLJBSURFACE WASTEWATER SYSTEM MOIVITORING REPORT 11�a� Date of spection 5�0 11 � 19 �� _ Aah 3�`� System Installation Date Type Tax Map Parcel # qY133�+a. ��, a'15 ierty Address Insfructio�s: CYeck �+es or no for appropriate items and explain in space pr�vided For remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infi(tration and surface water diverted ? Septic tank needs pumping ? Inches of solids: �� Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Reqnire3 aumps present & fuacti�nal ? High water alazm operating properly ? Floats, valves, etc. in good condition 7 Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose tank): L 3 Elapsed time readings ? Counter readings 7 A Drawdown rate: Stl .'15 f�,PM YES / NO ❑ � � ❑ i ❑? ►'� ■ t� � � ■ �� ■ !:� ■ � ■ DISPOSAL FIELD: Evidence of effluent surfacing 7 ❑ Evidence of effluent ponding in trenches 7[� Surface water effectively diverted ? �� Diversions/swales properly maintained ? ❑ �eget3ti�e cever rn�in±ained ? Protected from traffic/unauthorized uses ? Di�tribution uevices ui good condidoa ? jRJ Field free of settled or low azeas 7 �� / / / / / / / � `: ■ ■ ■ ■ �■ PRES�URE DIST�IBUTION SYSTEM: 1J�A. Tumups/cleanouts/valves/taps intact & accessible ? ❑ / ❑ Pressure head properly adjusted ? ❑ / ❑ COMPLIANCE: Compliant Non-compliant Needs Maintenance i� ■ ■ REMARKS � cLci�t'� ��"S� Aw�.�,4��C aaL`'i • E rw.��c F�cF.�c. w�a►S cw��'4 �,Jrn� t,rw�c;� c.Ra.s�-q �..�g.>.n � �- ^�, tl�c N•�a `19•5 �„>3r�. 5�1•`15 2� c�.L � �.as►�� j. 3ti...\ ^ so:15 ��. � tlDuilivl3iiLCvivilvir,ilTS: •�AVrc ":1Aa\�S 1�L1t'`4CQ �,v�cil�'Y 3"S �E�1`'7S � ClI�G►�1� -,-� �� t��. Arlawa�� ; w�., s� s-�-. n�� -ro �3� ,� 6ano �ao�o�J. EHS ��C�L i� - S�ST�� :, *,,, `',=��t, e.�� x ..,. �.� �. �� ]m�Illr" � Im]YIYn cc� Im � �1.11 Jl Jl � �.11 �lY� Charles & Denise Aultman 900 Robertson Road Roxboro, NC 27574 Re: Bacteriological Water Sample (Tax Map: A27, Parcel: 334) Dear Mr. & Mrs. Aultman: nsuring a healthy environment July 19, 2013 Your well water was sampled on 7/17/2013 by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). The results of your water sample are as follows: X No coliform bacteria were found in your well water and therefore your water can safely be used for drinking, cooking, washing dishes, bathing and showering. 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 and 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 has not been properly disinfected prior to being used, or that contaminated groundwater is entering the well. The well should be properlv disinfected usin� the enclosed chlorination procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, the Health Department should be notified so that the well can be re-sampled. If the well water continues to test positive for coliform bacteria, then there may be a problem with the water source or with well construction. A well contractor or the Health Department can assist you in identifying the problem and finding a solution. If coliform bacteria are present in your water sample, then the water may not be safe to use. Young children, the elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the results. Water can be disinfected by boiling for one minute. If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from 8:30 am to 5:00 pm. Sincerely, ��...Q �. �, Derrick A. Smith, LSS, REHSI Environmental Health Specialist Person County Health Department phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant JA`( 1�o�hiprx�£R. �►s� Au�-Tthttl�l Address 9aa �o�e.-�5oti.i i�-ort0 Collected By �u� � _ ��k County PERSON Date Collected 7 t7 13 Time Collected d:�S P►''L Source: � Well ❑ Spring ❑ Other Location: '� House Tap 0 Well Tap ❑ Other �x ��.,� S,a 1 ❑ No Charge '� Charge ........................................................................� **********************************************�************************* Total Coliform FecaVE. Coli Results Present Ab�ent ❑ � � � . Reported By � �` h Date Reported � � � ( ( 3 Report Called 0 YES �NO Called To: � � � � vz-� �� 7lr �� vc� � r�a ,� �� 2 � � - � -�-� U ►1 e�s� ti �� ` . w�� r � � �,� c� /�'��vE'. � GYv(,a��IP� S/ 7�'.• �l�rlr� v�� ..�-P.� �a � cv�.� r( f�c� -��3 w� �'�w l c�r%C��✓: �6 /�