A35 154Sit�`.�'.;aa'ruation Application
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APPLICATTOid FOR IMPROVEMENTS PERMIT
1. Permit requested by: owner�prospective owner:
agent:
Address:
3
Home Phone �i�: 9l0 - Sy9- y 6 l�' Business Phone ��:
2. Name and address of current owner:
3. Property Description: Lot size: 3 cu�,
4. Tax map ��: Township:
Subdivision Name: ____
S. Directions to property: State Road �� & Road Names, etc.
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Lot ��:
6. Permit requested for: New Installation: ✓ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
�1 �v�-GYJL�OD� � �
10. Water supply private? � public? _
Other source? (Specify):
Are there any wells on adjoining property?
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community? spring? j�
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If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: �/ Mobile Home: Business: _
Type of business• Number of Employees:
Number of bedrooms: � Garbage Disposal? Yes ro �
Basement? Yes �o�»t.Q,.Qy Iv'o If so, number of basement fixtures:
12. Clearly stake all. corners of the property and the corners of all proposed structures.l
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
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Signed ner or�t�horized Agent
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Permit Issued -- ���_��C' ���i��
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Permit Denied
P1 t O�served
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i?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 ARF_A 4
1. SLOPE (X)
2 . SGIL TEXTURE ("12-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRtJCTiJRE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (zn.)
S. RESTRICTNE HORIZONS (in.
(Im�ervious Strata, rock)
. SOZL DRAIt1AGE/GROUNDWATER
(bcternal � Internal)
. SOIL PERMEASILITY
(Percolation Ratc)
$. OTHER (specify)
S S
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9. SITE CLASSZFLCATZON �
(See below)
SOZL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt-4�NDATIONS / COMMFS2TS :
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PS
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S:�:TE CLASSIFICATION �LAGRAH (Include: Soil areas, property lines, roads, streams, gulZies,
Wet areas, fill ,3reas. c�ells. crater bodies, sZope patterns, ete.)
�
; �. PERSON COUNTY� I�EALTH DEPARTMENT
WELL E1ND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # ��7 � Parcel #
Zoning Township
Owner/Contractor � � Date
Location/Address <�r.k i 3� � �. s ._e� 1 � 3 � � S2 �' /337 '�" f2` �l?. r��
Subdivision Name
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SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area 3� �,�-e S Size of Tank �`'G .� •,
� Mobile Home Size of Pump Tank NJ�1
ness # of Bedrooms_� Nitrification Line 5' D(� �>C 3�
Max Depth Trenc;hes a2 � � �
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered te de us� changed.�
Well and Septic Layout by
Comments:
Date 6—/ 3— Installed by��.a.,�-ti-« Approved by G�.�Q .c9 �.��
'' , - WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved �. Required Well Lo ;
Well Head Approved Well Tag �/
Grouting Approved
Comments:
Date
Installed by
Approved
Tlils report is based in part on Wonnation provided the homeowner or his/her reQresentative in the application submitted for Uus pemut The
environmentai health specialist is not responsible for false or misleading infonnation 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 wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will recnain potable. c:�amipro�permit.sam O1/95 rev.1.0
ORIGINAL
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\1r. T'ra��is Car��er
3b18 Bo�i'lin� Drive
Ralei�h. \C ?7606
Re: Bact�riological Vl'ater Sample (Taa Uiap: A35, Parcel: 18�4}
Dear �1r. Can'er:
nsuring a healthy environment
June 27, 2013
Your ���eil ���ater ���as sampled on 6/2�/2013 by the Person County Health Department for biological
contaminants (total coliform and fecal coliform bacteria).
Th� results of your water sample are as follows:
I�o coliform bacteria ���ere found in your well water and therefore your water can safely be used for
� drinkina. cooking, �Vc'iS�11Fla dishes, bathing and showering.
1 Total coliform bacteria �vere detected in the sample.
Fecal coliform bacteria ���ere detected in the sample.
Total coliform bacteria are naturally found in the soil and fecal coliform bacteria are associated with animal
and.'or human �vaste. The presence of either total or fecal coliform bacteria in well water may indicate that a
ne��� or repaired ���ell has not been properly disinfected pi7or to being used, or that contaminated groundwater is
enterina the ���ell. The „�ell should be properlv disinfected using 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 s}�stecn, 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
canstruction. A ��-e11 eontractor or the Health Department can assist you in identifying the problem and finding
a solution.
If colifor��t bacteria are prese�rt ir1 yvur ivater saf�:p/e, tlte�t t/ee water may t:ot be safe to trse. Young children,
1ITI[' �Id�.�f•1�', f!)2f� ltlCl�ll'ICt1lCIIS 11�it1� compromisec� inzmune systems are especially vulnerable and their physicians
�jrv��id he norifred of tlic 1•esidts. Ti�irter can be disinfected hy boiling for• one minute.
tf �-ou need further information please feel free to contact our office at 336-597-1790. We are open weekdays
irom 8:30 am to �:00 pm.
Since(�rel�'. p�
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Derrick A. Sn�ith, LSS, REHSI
I,m:ir��nincntai Hcalth Snecialist phonc 33b.5�7.179�
Person County f-iealth Department f�x 336.597.7808
3?5 Sout11 Morgan Street, Suite C, Roxboro, NC 27573
.
PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant I Rr�v� s �riR��CL.
Address �i� �1rlar.x.soti ��� '� County P��
Collected By 1�eR.x��� /�� �''�
Date Collected to��l i3 Time Collected l�'-��' �M
Source: Q� Well ❑ Spring 0 Well Tap ❑ Other
(�tt, �Yi�c"S'�
❑ No Charge �l Charge
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Results
Present Absent
Total Coliform � �
FecaUE. Coli. ❑ �
Reported By,
Date � I�(.P � ��
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Report To:
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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:
TRAVIS CARVER
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sloh.ncqublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
41 ANDERSON JONES ROAD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
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EIN: 566000331 EH =
StarLiMS ID: ES062613-0009001 Date Collected: 06/25/13 Time Collected: 11:24 AM
Date Received: 06/26/13 CollectedBy: Derrick A. Smith
Sample Type: Raw Sampling Point: Outside spigot Well Permit #; A35-184 ��
Sample Source: Well Temp: at Receipt: GPS #:
Sample Description: _ j
Comment: � h
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 < 1 A �.. mg/L
Chloride � 25.00 � 250 � � � °..�'mg/L
Chromium < 0.01 0.10 mg/L
Copper _ _ . 0.22 ._ _ 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 < 1 A , I mg/L
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Manganese - <' 0.03 _ t � 0.05 . mg/L
pH - �� �'.6.2 � ' N/A
Selenium <A.005 .0.05 ' mg/L
Silver ' ' < 0.05� . _ : ; 0.10 z : mg/L
t_a _ � _
Sodium ,, 29.00 m9��
Sulfate < 5.00 250 mg/L
Total Alkalinity 27 mg/L
Total Hardness < 7 mg/L
Zinc 0.17 5.00 mg/L
Report Date: 07/09/2013
Page 1 of 1
Reported By: Arno/d Ho/l