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A27 335/Y �.w Application Date: � p Z �Q � J3�t v � Tax Map: Amount Paid: �LY,DO � �d �`� Parcel #: ,L '3 :� S Receipt#: � I I� ,zi �G�f G�'�� j �� 7�7 ��_S_f �� --- � � �r�7�r �I' �,1 1L... a'�^a� �� •ss'�.Ca 1ca ]<Zc]a.r.. �'�iy �L.,cn. 11 J..L�"�.< <e.^_, tR. �� 4::.11-n. Application for Services (Septic Systems and Wells) Services Re uested O Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the e of s�stem ermitted) � Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired $75.00 0 Well Permit (New/Replacement/Repair) U Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e 1� Services Request }� �% , /�� Name: Y/� Address: D ' Phone # (home): �3�_s9 — �.�d�� (work/cell): — /703 �-- , 2)yName and address of current o��ner (i differe t than pplica t): -. �" f� ,- Name: ,7% ,9�1/ v — �' l� `�F �/"o�f� i��o Address: � /�� 3) Property Description: Lot Size: �_ Subdivision: �J� �l�duJS Lot #: �_ Addre and/or directions to Property: ��g .s�1lr� �% _�u� ia� �ur�p ✓�e�.� � — � �c. ,0/: ,,�9" 4) Proposed Use and Type of Structure: Residential � Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes No /(with plumbing: Yes No _, Garbage disposal: �Yes No ✓ 5) Water Supply: Private Well �Proposed Existing _, Community Well: Public Water System: Are there we]Is on. the adjoining properties? No Yes (please show location on site plan) Note: A completed application musi also include: ➢ A plat/site plan of the property that slzows property dimensions and the size and locatioft of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying tliat tlte property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become in��alid. . Signature (Owner/Legal Representative): ' Date : � p 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� S.f� ��$.�� .� ' �' � � �� ]L�.�']L 7t' QD ]t7L3Y]r]L <G�� 7t11 �.t.11. JL � � atA. �L �� Applicant: ra� Location• L� �nY M on n. 0 7 Permit Valid for V Five Years Type of Facility: � VA y+. e # of Occupants rY1n Y i o# of Bec Proposed Wastewater System: Proposed Repair: � T�x M�p � F�rcel # Subcl!ivision r.. ��. � . Ph�se Sect,ion Lot # Improvement Permit No Expiration ��, New Addition Water Supply �� s Pro ected Daily Flow �_ g.p.d. �� lo �e.�uci-►��r.� Type: Type: Permit Conditions: M�t iv►� i►� � S�i'haC�S Owner or Legal Representativ ature: Date: �-3l� %� Authorized State Agent: , Date: 3— J� —/2 The issuar.ce of this permit by the Health Depart�ni in does not guarantee the issuance of other pernuts. It is the responsibility of the applicanbproperty 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 Disposal 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 ( -). Proposed astewater System: Type Wastewater Flow 3�� g.p.d. New Repair Expansio) _ Soil LT ,' `� � g.p.d./ ft 2 Type of Facility: ��i J�y �pS, d.n .P —� k�f� Basement _ Yes _�1Qo Wastewater System Requirements Tank Size: Septic Tank: (i�t� gal Pump Tank: — gal Grease Trap: —� gal Drainfield: Total Area: �� sq ft Total Length �dD ft Maximum Trench Depth �� in D��• Trench Width � t Minimum Soil Cover: _� in Minimum Trench Separation: � ft Distribution: �Distribution Box �/ Serial Distribution Pressure Manifold , Specifications: Authorized State A� Permit Date: _3-- � Date: � /Z /? The type of system permitted is C ve tional �Accepted Alternative. I accept the specifications of the permit. Owner/Legal Representative: '1 Date: �-- ,3l} �—�%/ PCHD rev. 11/10/OS :�� 1�:I�.I�.��U1y . � � � � �°IC� 7��,��-m,r„ ,r,.., ��.31 7E3C�.�,.n�. . . ._ `� . SITE SBETCH �= Name = PY�;r� � e. �� Taz lYla. #. � Parcel Subdivis . p �` #�— . Section/Lot#_ � _—�/2-/2 � uthorized State .Agent . � L�ate System com�orients rre�rerent a�li�firinxima�te �cimtours only: The con�ctctor must, flag the rystemprior to beginning the instcillation to insure thatpmpergrrrde rs maintained ' ��`/� ' � r' v�o � c _. ..._�' "11%i_�� .. • . , �i 3 � t ► y ► � .... ��.. , G �� 1� _---------- _--- --_ --._ - _ 1..h�{�'� S�w► — 3(�0 � ,�, 3 6�! �9 P P�� — 3 °b �ccT.� 0 D"601G 6� SefIR! �� r ♦ _� � -�,ox �vW c�� n eq ua � j � li�Ps d � � � � ��{' �►'er,�� o��i -�-- --- -- _- _._ . _ : _._ _.. .. . _�._._ `.-- ---._�, _� . . _ _. _ _i. �'�.�•t�p'3g'•� w�� as` t �� ]�,a�� b �`" �� _ • �. ��.s.f ��.� �� IE��.�-�� .Il IE—IC��.II�I�a. Applicant: ` r ,.,...+:,.�. r-, . � � � � 0 Tax Map � Parcel # 3 3.S Subdivision �e Phase/Section/Lot # # of Bedrooms ,� � ' Operation Permit � System Type (From Table Va):�_ 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. ,- (a - Z�-(2 Authorized Agent) (Date) � � 1,�n�a� (� 2s ( Z (LiLv:�s Contractor) � ; �,� QI 15 (Uate) p,Y � � J Wa�� u.�a, � �5� 5D —,�'7 -'I l'1 / _(', , 1t �°° �0 3 � Scale: ��Ssa �� ► , -I � � 0 �� o� 30� --� � � �r, �� Line Len h (,e 6 � 2 6� 3 ' 56' Total 3 Od ' Taz Map: � Parcel #: 335 Septic Tank System Checklist (Type II-I� System Type: � Notes • Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: Copy of OP (Revised 12/09 BH) e-mail Date: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES071712-0115001 � �� ES Microbiology ID: 38235 GPS Number: Sample Description: Comment: Name of System: FOX MEADOWS, LOT 1 Col lected: 07/16/2012 12:00 Received: 07/17/2012 08:40 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htto://slph.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 J.Smith Angela Heybroek Well Permit Number: A27-335 Environmental Microbiology - Colisure Profile Method: SM 92236 Test Name: Water - Colisure Analyte Test Result Analyst Date TOtal Coliform, Colisure Absent Darneice Lyons 07/18/2012 E. coli, Colisure Absent Darneice Lyons 07/18/2012 Report Date: 07/19/2012 Explanations of Coliform Analysis: Reported By: Susan Beasley ��:�'�-% Z-„r-. �,r�ti-�r ri--�-� 1 �. : � �Lx '�: s:..�_� JUL 2 4 2012 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: North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES071712-0058001 Date Collected: 07/16/12 Date Received: 07/17/12 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 4.5 Sample Description: Comment: Name of System: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 httq://slah.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 FOX MEADOWS, LOT 1 Time Collected: 12:00 PM Collected By: J. Smith Well Permit #: A27-335 GPS #: New Well 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 17 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.2 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 9.50 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 80 mg/L Total Hardness 59 mg/L Zinc 0.07 5.00 mg/L Report Date: 08/07/2012 Page 1 of 1 Reported By: �e�ie �%%��e�l �'"_��` )� �� ' � � � �� 1� .�� a n- � � a� � � � . �. ll IH �I � .�►. ll �.1 �. . W�+ I�I, PERMIT (New �✓4aepair� Taz Map: 2 Parcel: 33s Subdivision: Lot: � Applicant's Name: ` (.ew i NYailing Address: C 2757 Phone Numbers: S—$ — D L� Lacation of Prop Permit i'onditions: 1) Seg attached site plan for proposed well location. Z) All applicable State and County regulations governing consiruction and setbacks apply.� 3) Permits expire S years from the date of issue. Other Conditions/L'omments: � � , . . . � - ; P�pmit issued by: New Well Inspection: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: I)ate: 3' /� —/ 2 C�RT�F�CATE OF COlVIPLE'I'IO1�T 5-IZ Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: � �''�/J-Q��2 License #: Pump Installer: y^ � _ � , License#: Well Approved Date Sample Collected: 1- �(��( 2 Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 I)ate: � — 2� �2- , Date Results Mailed: '" Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 .� ';,a SiAT1,'.. .: �P� � ,y 'Z\�Z : ��.,.. �ID'. � � �A ' �� : � ��g ''��' RESIDENTIAL wELL coNSTRuc�riorr uEcoxn North Carolina Deparhnent of Environment and Natural Resources- Division of WaYer Quality WELL CONTRACTOR CERTIFICATION # � �� '� 1. WELL CONTRACTOR: � �� Well ConVactor (Individu ) Name F3amP.ttP �l�%@�� DCl��lflp �f1C. Weli Contractor Company Name 611 Barnette Tinaen Rd Street Address Roxboro NC 27574_ Ciry or Town State Zip Code g. WATER ZONES (de th): : Top��,_ Bottom�_ Top Bottom � Top Bottom Top Bottom Top Bottom Top Bottom Thicknessl 7. CASING: Depth Diameter Weight Material � TopQ_ Bottom� Ft. �'/� S� Z( �U� � Top Bottom Ft. : Top Bottom Ft. c 336 � 599-0015 Area code Phone numbe� 8. GROUT: Depth Material Method 2. WELL INFORMATION: �. � � Top� Bottom � Ft. Sand/Cement Poured WELL CONSTRUCTION PERMIT# /"(. � Top Bottom Ft. OTHER ASSOCIATED PERMIT#(if applicable) GL ( 1! S Top Bottom FL SITE WELL ID #(if applicawe) 9. SCREEN: Depth Diameter Slot Size Material 3. WELL USE (Check Applicable Box): Residential Water SupPly � : Top Bottom Ft. in. in. DATE DRILLED (�- Z� �� Z— Top Bottom Ft. in. in. TIME COMPLETED �O 0 AM ❑ PM L�7 � Top Bottom Ft. in. in. 4. WELL CATION: • 10. SANDIGRAVEL PACK: � � Depth Size Mate�ial CITY: D{9/J/� COUNN US� n : Top BottOm Ft. �0,�� ad'n�✓5 �i � 2 Top Bottom Ft. (Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code) . Top BottOfll Ft. TOPOGRAPHIC / LANj�'SETTING (check appropriate box) ❑ Slope p Valley �lat ❑ Ridge ❑ Other LATITUDE 36 "��" DMS OR 3X.XXXXXXXXX DD LONGITUDE �"Q�_ � U�" DMS OR 7X.XXX�OCX)(X DD Latitude/longitude source: �GPS propographic map (location of.well must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OWNE p��l� L�✓/5 Owner N�rne �u/ 2- Stree ddress � ��C. �j Ciry or own State Zip Code �� 5zl%'�� S� Area code Phone number 6. WELL DETAILS: a TOTAL DEPTH: � b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L9� c. WATER LEVEL Below Top of Casing: 25� FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS � FT. Above Land Surface' 'Top of casing terminated aUor below land surface may require a variance in accorcJance with 15A NCAC 2C .0118. e. YIELD (gpm): � METHOD OF TEST BIOWII 2OI11 f. OISINFECTION: ry� HTH Amount .1/2 Cup 11. DRILLING LOG Top Bo� �� _�_/ 32� / / / / / i / / � 12. REMARKS: Formation Description ��j, a ! -T �y n,c �Y � a i DO HEREBY CERTIFY THAT THIS WEIL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THiS RECORD HAS BEEN PROVI D TO THE W L OWNER. °� r �-- � ��- (z SIG A E OF C IFIED E CONTRACTOR DATE h n n r` PRIN D NAME PERSON CONS RUCTING THE WELL Submit within 30 days of completion to: Division of Water Quality - Informa�on Processing, Fortn GW-1a 1677 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev.2/09