A28 142Application Date: `���'� �
Amount Paid: �
Receipt #: �'J-l�-k \ a ►
cka-�a,`�
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
� Well Permit (Ne e lacement/Repair)
$300.00/ 2ba:90/$75.00
�—.�,?,�f ������ Tax Map: a$
�,.; � � ���� Parcel#: ��
����aa-�mm���.��.11 ]HC��.11�.
tion for Services
Services
0 Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $ t 50.00 or $300.00
1) Applicant Informati n:
Name: ,���j1S � � �i�2TL`n-
Address: /y 5 TN� NLs � 2v�
T��Bo�,v ,�c �.75�N
2) Name and address of current owner (if different than applicant):
Name: �,,,c- .
Address:
Phone (home): (3 3�� 599' � �j �
(work/cell): � 3 3,� ) 5by- 9Za�
Phone:
� �'kft.Cs
3) Property Description: Lot Size: 3�Z Subdivision: Lot #:
Address and/or directions to Property:
� �(�-� ���i(I�e..�-
❑ yes C�no Does the site contain any jurisdictional wetlands?
C�]'�yes ❑ no Does the site contain any existing wastewater systems?
0 yes �o 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?
C1'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 �
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
E�Repair to Malfunctioning System Will there be a basement? ❑ yes 0 no With plumbing fixtures? ❑ yes �o
�Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply.: �New well ❑ Existing Wel( ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the in ormation provided above is complete and correct. I also understand that if the information provided is
inaccurate, or ' t e site j,s subsequently alterefl, or the intended use changes, all permits and approvals shall be invadid.
SignatureC�bwner/ Legal Representative*)
* Supporting documentation required.
� %� %�
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)
vvEz,�, carrs�cxuc�torrx�coxn
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Jj,�terlcx! isabove coring, urc ^+- 1617 Ma� Swice Ceater, Itx�cig6, NC 27699-1617
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FOR' WATER S[J�PLY WE%.I,S OTiLY: 1636 Ma�7 Service Ceuter, Rafrgh, NC 2769�I436
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whaa corestructsd.
Form G�L'-1 Nortl� Gv�olina I7epa��eoi o?Envirvnurcnt and Nalural k�onrees—Division of Water Q�mGq
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North Carolina State Laboratory Public Health
Environmenfal Sciences
�1licrobiology
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: ES070314-0060001
� ������� ������ ��� ����) ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
DOUGLASS E CARTER
145 THEE HESTER RD
ROXBORO, NC 27574
Col lected: 07/02/2014 14:26
Received: 07/03/2014 08:50
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://siqh.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Derrick A Smith
Angela Heybroek
Well Permit Number:
A28-142
Environmental Microbiology - Colisure Profile Method: SM 92236
Test Name: Water - Colisure
Analyte Test Result Analyst Date
Total Coliform, Colisure Absent Susan Beasley o7/07/2014
E. coli, Colisure Absent Susan Beasley o7/07/2014
Report Date: 07/10/2014
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
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
Name of System:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph. ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
DOUGLASS E CARTER
145 THEE HESTER RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES070314-0044001 Date Collected: 07/02/14
Date Received: 07/03/14
Sample Type: Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 3.9
Sample Description:
Comment:
Time Collected
Collected By:
Well Permit #:
GPS #:
2:26 PM
Derrick A Smith
A28-142
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 10 mg/L
Chloride 8.80 250 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 7.00 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 7.0 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 9.20 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 21 mg/L
Total Hardness 43 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 07/14/2014
Page 1 of 1
Reported By: Arnold Hall
�.��, j e.l. f �lll/ �� ��. V
`r''' �'`'_ CC � �T���
��;.�.�a���n-���.���.Il ��r��..�i��.
WELL PERMIT (New�Repair�
Tax Map: Aas Parcel: Iy�-
Subdivision: Lot:
Applicant's Name: Q:�euas �.• CA�E.�
Mailing Address: 1'�� 'r4t�.E +\�s�� I�.O
R�cc���, �c. a�5�1�1
Phone Numbers: 33�-5�� -�b�5 33e� say- 9��
Location of Property:
�E ���� � �
15g W . � � o.�o
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicahle State and Counry regulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit issued by: ���c�l. �- ��1 Date: �j ���a
New Well Inspection:
Location:
Grouting:
►„���. i-a� Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
CERTIFICATE OF COMPLETION
EHS/Date
s se��}
�
flas s i�k ��{
�AS S i5 {`E'
A�s �s ��
1� s isi
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: �R��c`t� License #:
Pump Installer: License#:
Well Approved by: _,�.J�. Q�. Date: �G5 1`�
Date Sample Collected: 7 a 1
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date Results Mailed: 7 11� 1
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
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IEan.osnso aaaxca�an�m.Il IHL� �mll�ll�a
' SITE PLArT
Name ���AS 'E, ��'+�-� Tax Map # A'� Parcel #(��'
Subdivision Section/Lo #
�.v�s,c� a. �r,;ca �}�� :�a ►
Authorized Snte Agent Date
System camponents tepruurt sppmadmate contours only. The coamaormust flag t6e sysrem pcat to begianing the install�tion ro
insvre rhatpmpugrlde is mainraiaed.