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A27 87Application Date: �� S(� �� Tax Map: �� 7 Amount Paid: Q CJ4 �-"� � Parcel#: � Receipt #: °� 0 9 91 T � �_ �' � �� IE��-� nn�x�vnv�raa�sn.daaIl 7[-�3I�.�..]t�::lr. Ca `` l iJ Apulication for Services a • �^ � � Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) Mobile Home Reptacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$ 75.00 � Construction Authorization (Fee is dependent on the type of 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 �plicant Infor atio : ' 3�` ,,/ Name: � 1 2(i • ,(,?i� Phone (ho e): l� �% `1" �3 �>' � � Address: �'�D ?�t2u�t.�.r�� - �� i�/J- (work/cell): 2) Name and address of current owner (if different than applicant): Name: � Phone: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Lot #: ❑ yes ' no Does the site contain any jurisdictional wetlands? ❑ yes ��- Does the site contain any existing wastewater systems? ❑ yes C�'no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ��_�� Is the site subject to approval by any other public agency? ❑ yes [�no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ew Single Family Residence Maximum number of bedrooms: �_ ❑ Expansion of Existing System If expansion: Current number of bedrooms: �� ❑ Repair to Malfunctioning System Wiil there be a basement? ❑ yes � With plumbing fixtures? ❑ yes CTno ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: • 5) Water Supply: ❑ New well L1 Existing Well ❑ Community Well ❑ Public Water ❑ Spring �� Are there any existing wells, springs, or existing waterlines on this properiy? � yes LSno If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate� r if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. _� � Signature (Owner/ Legal Representative*) * Supporting documentation required. �02' .� ao// Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��e ' I � � � �� : 1 � ' i �s �,�� I � � � .d. V� � � J,L...l.�i...��.�{��.i�.�.n%n.�ti�i�.11.a�.� 1S. 1L(�'i:�.��.fS1L � �u�n��aa� ��a�fl��a�/ I�,/g��flc� �i�� fl��ffi��n�� Tax Map #: Z� Parcel#: $ � Approval Requested for: ✓� Home Replacement Building Adciition . Applicant Name: ) n Address: ^a �Si�d� 54.� /�C�r�or� �) Phone #'s: 5q�j - RL�37 Pernut Located: Yes �No Instaliation Date: �- Desi� flow: 3c� a��d} Current Contract with Certified Operator on file (if required): Water Supply: V Well Public or Community Wastewater system shows no visual evidence of failure on: I Z� 1 Z' 1 j (date) (Applicant's signature if site visit is not required) Comments: N�rr�e,reC ��n�oa��pla��aa��a�� A��°�d�� jZ-lZ -f/ Enviro ental Health Specialist Date � 1 ? /15/OS :��,�� 1�)�1t�.��l� � � � � � �� .��-�,�,,,�, ��¢.�.�. �t��, ..�- ��.r � � .. • •� ��.._ i �•■ -. � - '••� SiTE SY�ETCH Taz Map #��Pa�ce1 #� Section/Lot# ,2 -/Z -// • Date . System cnmpo�ents rrepresent u�iproximate�contours only: The contraclor must g th� stem prior to beginning the installai'ion to i�sure that propergnrde i.r maintained _,� ' : ��I� �� I- -� Sc�l� �L R n� e r�"Sor� I� f� • ` -�- �vu5e �a � � Whet�c Su�p�r �''��' °�'� I ' -�'b �'a n K Cros5e5 c:l r i v�l.�.a � i 1�' S%, du lcl I�J I � � li�� b�. 36'' o�eep Cr'� ��si��-) �r � i h/ o�uc� �� I/�n 7� �rd � S �e�eY�eo� , ,� -�ra �� fr�c , �� ICIL�ILIL c�]La]YIr11.�IC�LL.f1L1L Jl �<�'�51.11�:� August 10, 2012 Hugh Whitt 473 Robertson Road Roxboro, NC 27573 Tax Map: A27 Parcel: 87 Re: Bacteriological Water Sample Dear Mr. Whitt: nsuring a healthy environmenE Your well water was sampled on August 7, 2Q 12, by Justin Smith, and tested 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 Total coliform bacteria were detected in the sampte. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil and fecal colifortn 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�roperlv 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. There is a$25.00 re- sampling fee. 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 fmding 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 individuuls with compro�nised immune systems are especially vulnerable and their physicians should be notified of the results. Water can be disinfected by bailing for one minute. If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from 830 am to 5:00 pm. Sincerely, �t`�fut t-�9�..�,�1� � Bonnie Holt, REHS Environmental Health Specialist Person County Health Department liCVISeQ (1 1/13/0b} phone 336.597.1790 fax 33b.597.7808 325 Sot2th 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 Address � �.3 �a ✓-��ov� �, County �� o Collected By�S Date Collected �� (� Time CollectedJ 8� �, S Source: �Well ❑ Spring ❑ Other Location: ❑ House Tap ❑ No Charge �Charge �ell Tap ❑ Other ........................................................................� ************************************************************************ Total Coliform FecaUE. Coli Results Pre�nt Absent ❑ ❑ � Reported By Date Reported �� 112 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: HUGH WHITT P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27617-8047 htto:/lslph.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 473 ROBERTSON RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES080812-0004001 Date Collected: 08/07/12 Date Received: 08/08/12 Sample Type: Raw Sampling Point: Well head Sample Source: Ground Temp. at Receipt: Sample Description: Comment: Time Collected: 10:35 AM Collected By: J. Smith Well Permit #: GPS #: 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 6 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 0.16 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 2 mg/L Manganese < 0.03 0.05 mg/L pH 6.4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 5.70 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 25 mg/L Total Hardness 25 mg/L Zinc 0.40 5.00 mg/L Report Date: 08/22/2012 Reported By: �old �a�l �'1+�Y'� !�1 v��i Y 7Y"�i1 L�'�i.�i./.d.:iid 1✓ 1J.:1�•' auG 2� 2o�z BY: Page 1 of 1