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A28 63�� o b� F m 1� � W�J��o-vl`� � � �'�rson�oun� �ea�t�h De artment � Well Permit p � � � Date: y g is P it id Aftej� V,�M � �� Owner: k� I.ocadon/Directions: Subdivision �1ame: t #_+�_ Drilling Contractor. W L� WELL CONSTRUCi'ION Distance from Nearest Property Lane Distance from Source of Pollution r- Tatal Depth: . Yield: 3 GPM Stadc Water Level FG Water Bearing Zoncs: Depth Ft. F� �Ft. Casing: Depth: From _� Ft Diameter: ��_ Inches TYPE: Steel Galvanized Steel � ff Steel, does ownet approve: 1� No Weight: Thiclmess: � Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: _ . / _ Grout Type: Neat _ �S�t►d/Cement Concrete Annulaz Space Width �-- Inches Watet in Armular Space: Yes No Method: Pumped Pre� r�,� Poure�� Depth: From � to L� FG Mazerials Useci: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes � No 4 x 4 slab Yes —�� No ►-3 �'e � � � ''d c� I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � 'THIS WELL WAS CONSTRUCTED IN CCO DANCE WITH RE TIONS SEf ,� FORTH BY THE PERSON COUNTY P . � �� Signanae of Contractor ate � � k.... �• GPa.. � lev,�.�. �r� d , S'''s Signa Date Is ued �t1 °Q O _ Sanitarians Signature Date Complete3 Sketch well locauon on reverse side. .►� ; ,:. , � � r�erson County Health Department Sewage System Improvements Permit D�: �"? This P rmit Void Af�e r 5 Years Permit # �� g Q Owner: �' ��: r��,• l�� " !�-� t/ lf r„ f� �! S�#� �, Location/Directions: i ,, l� � �— Subdivision Name• �?i� f: ll� �'��fj�� I�'� I.at #�� L.O[ $1ZC: �/ �/ ,' � r 'r}�E Of DWCllIIIg r3 � y "-i=-�-� -�r ��. : i , : i +' Water Su 1 Pri ate: � Public: � PP Y� d � Community: Bedrooms: Garbage Disp� Basement Basement ,, �-''� � � INFORMAT'�ON CER�TI�JED BY , � � S, $8I11[8ti8i1: /f// . ' •!� � �� i�t,�� a repres tative REPAIIZ: `�� ' ' � � ALUATION: � ------- ----- � Size of Septic Tank: ��` //) gallons Size of Pump Tank: ---- � Nitrification Line: � � �X �' � Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump ' L,pp p�mp Remarks: Date Well Approved: Well should be 100 ft hom any sewer system BY Sanitarian Date Se ge ys Approv d: II— ��- 9 Z-. BY � Sanitarian �C'ERTI�ICATE OF COMPLETION y Contractor. � F„� L s..�i c� � ------------------------- � Sewage System location, installation, and protection must meet state and local � regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrificaaon line must be inspected and approved by a member of the Person Counry Health Department before any portion of the installation is covered and put into�. If the site plans or interded use change this perrnit is subject to revocation. �� (G.S.130 A-335F) _ _ ' � L.ocation of sewage disposal sewage system sketched on back. �Q' c� � s � � (OVER) ��,� O � � _ . . �� . ' 4 � � .� �('y • �` � � � � � � J.L. 1�+��rn�>n�r�c➢ic-�.�r�n�.untL.zn,� I��:,enl�lL)�n Date: � / q /� Tax Map: Parcel: Name: �4��_�-7,sz.z r Address: 2 �� t�: �C,�,�,�� v . �.�� . ►� 2?s�� Re: Bacteriological Test Results Dear AJ�@. ti+Z.a. � Your wel l water was sampled on �/�/t �, and tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). 'fl�e results of your water sample are noted below: � No coliform bacteria were detected in the sample. Your well water is safe for normal use. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total cvliform bacteria are naturally found in the soil. 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 was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If co[iform bacteria are present in your water sample, the water may not be safe for irse. Young children, the elderly, and individuals with compromised immune systems are especially i�ulnerable and their physicians should be notified of the test results. A u�ell that tests positive fos• total or f�cal colif�rm bacteria should be properly disinfected and retested ��rior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist yoli if needed. Once the chlorinated water has been thoroughly Ilushed out of the system, please contact the Health Department (597-1790) to request a re-sample. I�or additional information, please feel free to contact Environmental Health at 336-597-1790. Our office I�ours are 8:30 to 5:00, Monday through Friday. Sincerely, � I�nvironment Health Specialist Person County Health Department Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808 (revised 07/29/13) PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant MM1C� Z.�ZZ-� Address a 3� R�c.t-t�.Ae•�p P.� County PERSON Collected By D�� . S�CT}� Date Collected 8�r`11 i3 Time Collected Source: � Well ❑ Spring ❑ Other Location: 'y�House Tap ❑ Well Tap ❑ Other 0 No Charge � Charge ........................................................................� ************************************************************************ Total Coliform FecaUE. Coli Results Present Absent ❑ ;�l ❑ � � Reported By _ Ql.�v� � � � �� - Date Reported �6- � - I 3 Report Called �I YES ❑ NO Called To: �ar�l c) �Q ( � � I 7 :Site•Evaluation Application Fee Collected YES � NO Date: �-�'� � �-Z APPLICATION FOR IMPROYEMENTS PIItHIT z 1. Permit requested by: Address: ,1 / Home Phone ��: owner/prospective owner: , agent: . Business Phone ��: 2. Name and address of current owner: � 3. Property Description: Lot size: -��' �',/�i � 4. Tax map ��: Township: �ll�✓'�-�- /Ffi�� Subdivision Name: dQ�p_ , �� Lot ��: 5. Directions to property• State Road �� & Road Names, etc. .� i_� /�,0.._� � i a %?� n/r�z R ��-,,, � /� .�'�, �d �.3-,a ..� 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? 10. 11, Water supply private? � public? community? spring? Other source? (Specify): Are there any wells on adjoining property? �� 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 No Basement? Yes No If so, number of basement fixtures: 12. Clearly stake all corners of the property and the corners of all proposed structures. 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 hereb, granted to enter the property for the evaluation. G.S. 0-335(F) ,� ' • igned Owner or Authorized Agent � � H w � � w r 0 � m b � H � r• �t � � t I _ ` Permit Issued �v( , Permit Denied Plat Observed L/ ._ ) rACTORS — SITE EVALUATION AREA 1 AREA 2 ARF� 3 AREA 4 S S S 1. SLOPE (X) � . SOIL TEXTURE (12-36 i.n.) tSands, Ioamy, clayey, Note.2:l clay) . SOIL STRUCT[JRE (12-36 in. (Clayey soils) 4• SOIL DEPTH (in.) 5. RESTRICTIVE HORIZONS (in. (Impervious Strata, rock) . SOIL DRAINAGE/GROUNDWATER (bcternal � Internal) . SOIL PERMEABILITY (Percolation Ra.te) $ . OTHER (specify) � �� U $ PS U S � S s PS U PS S � PS U s PS U PS U _� S ��X PS U S PS U $ PS U S PS U S PS U S PS u s PS U PS J S PS U S P$ U $ PS U S PS U S PS U S PS U s PS U 9. SITE CLASSIFICATION (See below) SOIL SERIES S- Saitable PS - Provisionally Suitabie U- Unsuitable R ECO2�44EIZllATIONS / COI�41EidITS : S�TE CLASSZFICATiON DIAGRAM,(Include:�Soil areas, property lines, roads, streams, gullies, aet areas, fi1l areas, wells, water bodies, slope patterns, etc.) f To: Environmental Health Page 2 of 8 2016-03-17 13:58:27 (GM'n 19198821207 From: Stephen Nicolas j i. � - ! Application Uate: 3/17/16 `..�� S � ` �� `� Tax Map• �� Amounf Paid: (�d �`-�' �.- ��'" ��"� ' ; Parcel#: � Receipt#: i674 ~� �� ; �[ IL�..nS�+su�aasaax��,ua.sra.� iF'1Z4�.ce�4.�:a � i��'G1� C,� Applicatian fvr Ser��ices Services Re uested � Improvement Permit (5ite Evaivation} C] C:onstructiou Aathuriaafion $2U0.(?(�!$�UU.OU (if> G00 �pd} , {Fee is dependent on thc typc of system permitted) !� !�tabiEe Ilarnc Reptacement or �uildin ; Addition $150.00 (if site ��isii required) ❑ Well Pennit (New�lReplacesneniJ{2epair) $ 3 0 0.00%�200.OQi $75.0 � ❑ Permit Revisian ��5_00 ❑ Repair of F.xisting Septic System Ao»licatioii: No Char�:e;` CA $150.00 or 5300.00 1) Applicant Iriformation: ;�,(��; Chris BAker (NC Solar Now, Inc.} Phone (liame): Address: 3401-101 AtEantic Ave RaleigM, NC 27604 (ia�oricic�ll): 91�33-9096 2} lYaine and adciress of current owner (ii'different than applicant): N&trie: �:Ghaei Zizzi Ph�ne_ 919-323-0720 Address: 235 Richland Rd, Roxboro, NC 27574 3) Prapert}• Description: I.ot Size: �ubdivision: Lot #: Address and;vr directions tu Properiy: Attached Seperateiy ,__� O yes �J no Daes the sita contain any jurisdictional weiian�ls^ ❑ yes Cl nc� Uoes ffie site contain any cx.istin� waste�vater systems? � yes 0 no (s any wastewater going to be generated on the site other tftian domcstic se�i�age? ❑ yes 0 no 1s the site suh�ect to approva] by any other pu6lic ageney? ❑ ycs ❑ no Are 11�ere any easements or riglit of w�ys on t6is propem�? (if `yes' is cl�ecked, pleaso provide supporting ciocumentation) 4) Pr��posed Use and Type of Structurt: �Resedentia t O P:ew Singie L'amily Residence tiiari�num number of bedrooms: r Uccupants: ❑ Expansion of Existii3g Systeni If expansion: Current number of hcdrooms: CJ Repair to �falfuncii�nin� System �i'ill lhere be a basement? ❑ yes O no With plumbing fistures? ❑ yes � no �Non-Residcntial Type of busincss: I4'Iaximum uumber of employees: Total Square footage of Building: �taximum number of seais: 5) Water Suppl}: ❑ NeH� weIl ❑ Existing Vv'e!I ❑ Community Wcll ❑ l�ublic lt'ater ❑ Spring Are il�ere any cxisiing u�ells, springs. or existin� waterlines an this property? � pes C] no Pl�ase note any known �round «�ater resteictions or sourees of ca�itamination: G) lf ap�lying for `Authorization ic► Cunstract', please indicate prefeY•red system ty�3e(s): O Conveniional D:lccepted 0 Innovative � Alternative L3 Other ❑ rAny 1 certi�� ilrat the informutivrz prnvicle� abvve is cora�plete arrd correct. 1 cilso understand thcrt if tfie irtf'of•malion prt»'ided is inarcurnle, the sit.,trr�s��sec�irczntly aliere� vr the it�tencfed use chrrrl�es, ul��e�miis ar:d approl�als shcr!! he invalid. S�atGr`e (4wner/ Leg�l Rc:presentative*} * Supporti»g documentztion required. 3/17/16 lla te • Permits are valid fnr eitt�er 5U months or are non-ezpiring when accompanie� by an approved plat. + A completed `,Lot Prepurutio�r' f'orm must accanipany any application requiring a site cvalaation. {]0;15) Person Cc�unty Enviranmental Healtl�, 325 S. Morgan St., Suite C, Itoxbora, NC 27573 {33C-S97-i790) � I � 1 � � : �.�y► {.. ' ':: " •: �•,. .... ,.: .''::::-' . � :.... �' � �.:� � � �T�°�°� . . .. .. �.�.��¢�.�. ��.�.��.. Suilding Additions/ Mobile Home Replacements Tax Map #: 2�i Parcel#:_ �p� Address: `�'�s � C 2 ,� Approval Requested for: Mobile Home Replacement � Building Addition . Applicant Name: Address: P�one #'s� ( ... N Permit Located: Installation Date: � Yes ��-�QfZ No Design fIow: � � (gpd) Current Contract with Certified Operat�r nn file (if required): � Water Supply: �_ Well Public or Community �� Wastewater system shows no visual evidence of failure on: 3�ZZ' C�_ (date) (Applicant's signature if site visit is not required) S Addition/Replacemea�t Appraved � �� E viranmental Healt Specialist 3—Z3 —(C� Date a4s � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.nersoncountv.net � ) l � *,. � �� '`� �/ � �1.J � � � I�m►.�nmona.n�nca��a��.Il IHI��.II�IEa Date: -7 / �� / /!v Name: � Address: �Z.?, ��t r��,� �D , —�� 2?-� �� Re: Bacteriological Test Results Dear Well Owner: Tax Map:��Parcel:�� Your well waier was s<unpled on 7 J?�/�, and tested ior both total and fecal coiiform bacteria. Your water sample test results are noted below: x No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total col form bacteria are naturally found in tl:e �oil. .Fecal c�lifarm �a�teria are asse�iated t�:th animna! and/or human waste. Tlte p:esence �f either tetal or fecal ccliform bacteria in wzl► water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. Ijcoliform bacteria are present in your water sample, the water may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A we.11 t.hat tests positive for tetal or ecal coliferm �acteria shou:� be properlv disinfected ar;d retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushzd out of the system, please contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� Environmental Health Specialist Person Coanty Hea;th Depurtment (rev. 4/20/l6j Person County �r.vironme .tal Heal.h, 325 S. b4crga;� St., Sui,e C, Ro;:boro, NC 2'S73, Phone: 33G-579-1790, Fax 336-59i-7808 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS , Name of Owner or Tenant �i �� - Address �zj� �,�t�aZZ1�� • County Collected By �- � � - Qats Go!lected 7 [� Time CQll�cted ��"5 Source: e�Well ❑ Spring ❑ Other Location: ❑t�House Tap ❑ Well Tap o Other ❑ No Charge d�Charge ..............................................................................� **************************************************************************** Total Coliform Fecal/E. Coli Results Present ❑ ❑ Reported By Date Reported � � � � � � Report Called Called To o YES ❑ NO Absent