A29 23Application Date: ��"8� � 3 ��� S(� ������ Tax Map: ���
Amouat Paid: 7�� � —�,� �,. ✓' �,r- Parcel#• �, 3
Receipt #: 8 y q6 ���Y- � ������ .
IEl.�ra�nn•�cnnnmca�aan4;,zn..11 ).�-���.s.11�ln.
�
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Q Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
for Services
❑ Construction Authorization
(Fee is dependent on the type of
� Permit Revision
$75.00
C Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In�mation:
Name: � t GVfS (�A�n�IfG
Address: 6 i/! � �Jn � a
pY ��O � Z7S7�/
2) Name and address of curre t owner (if different than applicant):
Name: ,/�; c �t�� � ��"� rl
Address: T �S (ZoSe ��� p ��pP (?�
[�oX1,��e NL 215��1
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Prope Z� 5 (� �
HeS��rs �� orc I��, -��� ZnZ en��a
Phone (home): 33 �` s�j� � �12 �r
(work/cell):
Phone: gl°I - �13 -sl� �
�e1,;�rr ! o D
#:
� yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes � no Does the site contain any existing wastewater systems?
O yes ❑ no 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?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
on 12
4) Proposed Use and Type of Structure:
❑Residential
❑ New Singie Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats;
5) Water Supply: � New well L�J'Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intenried use changes, all permits and approvals shall be invalid.
��<�y�,----�
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
� P�� �3
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)
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Date: Ll �D l��i
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Re: Bacteriological Test Results
Dear Well Owner:
Tax Map:� Parcel:�2�
Your weii ivater was �ampled on f Z I�/�, and tested for both total and fecal coliform bacteria.
Your water sanlple test results are noted below:
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 onlv.
X Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Tota! col�orm bacteria are naturally fo�ind in the soil. Fec�rl col►form. bacteria are asse�:ated sv:th
animnal and/er human ��aste. The gresence of either total or feca] coliform bacteria in wetl 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 coliform 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 well that tests positive for total or ecal col;orm bacteria should be properlv �isi;ifected astd retested
prior to resumin� 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
flushed out of the system, �lease cuntact 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,
��
�s�� .
Environmental Health Specialist
Person Courty Fiealth Departmert
(rev. 420/16)
Person County Envi:or.mental Heal:h, 325 S. A4orgar� St., Suite C, Roxboro, NC 27573, Plione: 336-579-1790, Fax 336-59i-78G8
North Carolina State Laboratory Public Health
Environmental Sciences
Nilicrobiology
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: ES120616-0078001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
JESSICA WILSON
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slqh.ncpubiichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
255 ROSEVILLE LOOP RD
ROXBORO, NC 27574
Col lected: 12/05/2016 10:30
Received: 12/06/2016 08:20
Sample Source: Well
Sampling Point: Outside tap
Susan Beasley
Well Permit Number:
A29-23
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Present 12/0�/2016
E. coli, Colilert Absent 12/07/2016
Report Date: 12/07/2016
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.
���c
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nc department
of health and
human services
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For inorganic Chemlcal Contaminants
County: Name: �j �G t on)
Sample ID #: 9 - Reviewer:
TEST RESULTS AND USE RECOMMENDATIONS
1. [✓�Your wel l water meets federal drinking water standards for inorganic cliemica[s. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may
I�ave other water sampling results that are not taken into account in this report.
2. ❑ The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, uniess you install a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inor�anic chemical results onlv.
Arsenic Barium
Manganese Mercur
Cadmium I Chromium
Nitrate/Nitrite I Selenium I Silver
Fluoride � Lead � Iron
Ma�nesium Zinc nH
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on
tlie i�rnrQanic cl:emical resu[is on[v.
❑ b. Levels over 30 mg/i may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably
the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the
lead and/or copper.
6. ❑ The fol(owing substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inorQanic chemica! results onlv, but aesthetic problems
such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system
to address aesthetic problems.
Barium � Cadmium � Chromium � Fluoride � Iron
Manganese Selenium Silver pH Zinc
For n:ore injormation regarding your we// water results, please cal! tJre Nortle Carolina Division of Public Henith at 919-707-5900.
North Carolina State Laboratory of Public Health 3�12 Distnct Drve
Environmental Sciences Raleigh, NC 27611-8047
httq://slph.ncpublichealth.com
inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis -
Report To: H. KELLY
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
JESSICA WILSON
255 ROSEVILLE LOOP RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES120616-0024001 Date Collected: 12/05/16 Time Collected: 10:30 AM
Date Received: 12/06/16 Collected By:
Sample Type: Raw Sampling Point: Outside tap Well Permit #: A29-23
Sample Source: Well Temp. at Receipt: 0.5 GPS #:
Sample Description:
Comment:
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
Chromium
7
< 5.00
0.017
0.10
r < 0.05 1.3
Fluoride < 0.20 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015
4
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.1 1.00 m
pH 6.4 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 9.70 mg/L
Sulfate < 5.00 250 mq/L
Total Hardness 33 mg/L
Zinc 0.05 5.00 mg/L
Report Date:12/14/2016
Page 1 of 1
Reported By: Deddie .�tancol
The Districf Healfh Deparfinen#
� Orange, Peison, CaswelL Chatham, Lee Counties
SEPTIC TANK �PERMIT
� . . : DateJ.-� - �� -�- �'
, ; , _�
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Name of owner: � .��'{.s4-/- c�-_ .��%
Name .of contractor: ""°�'� �� �"
Address and Directions - �'f'" � ����;� �'�'-�s-��� � :
n 1-� ��fi�.+t ��` 9� �ar� � �' L� :�/
, ,► �-
Person or firm doing installation: � s"� ��.S� �? �
3� � .
Address �
No. of persons to be. erved � Bedrooms 1, 2, 3, 4.
Add.itional appliances to be used: _ Disposal, dishwasher, washing
machine ��.5��"� ��
Recommended• Septic ta � � � � d
Nitrification
Above rec�
soil condition. S�ptic tank and nitrification line must be inspec3ed ead
approved by a a�ember of the� Districi -Health-Depaztment'staff before ;
any portion of the installation is covered.
Date Approved:.,.,��- �� �
By:
SignPr� �
' Sanitariatt
O. David Garvin, M.D.� M.P.H.
District Health Officer
Couatersigned �
(Over)
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"O
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The District Healt�h Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water- -Supply_ and Sewage Disposal �
IMPROVEMENTS PERMIT No
Date_
�.Owner: � �a/' ( ����' ,
�
Location: ' �
_ �� � /1,�� .
s
Contractor: �
Water Supplps private Public
Sewage Disposal Facilitias: NO. bedrooms Dishwasher� Disposai,
washing machine, other sutomatic appliances
Size of tank: � - NitriBcation line:
� I v► c� o� �,�6 � SctN�l�led
Other disposal facility: Q ;
• Water supply and ;sewage disgosal facilities location, installation and
'.; protection musE meet state and local regulations. �
Septic tank. should be pumped out. every 3 to 5 years and shall be main- '
tained by owner in such:a manner as not to create a public health hazard.
� R,O�'ED BY A 1VIEMSER OF THE DISTRICT HEAL�TICiT EPARTMENT
� STAFF BEFORE ANY `PORTION OF THE L TION IS COV-
ERED ANII:PUT�iNTO��JSE:
Date approved• Sig
Well: Sanitarian • �
Sewage Disposal•
By•
CertiScaie of Completion
Date Approved: � � L
or his representative)
_ (OVER)
Location of well and sewage disposal facilities sketched on back.
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PERSON COUN'I,Y HEAL'TH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # %� oZ a'1 Parcel #.2 �
Zoning Township
Owner/Contractor �_ Date ' � __ __
Location/Address
S.R.#
Subdivision Name �Y Lot#
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by
Comments:
Date
Installed by
Approved by.
WELL SYSTEM SPECIFICATIONS
Individual �/ Semi-Public
Public Replacement
Site Approved�_
Well Head Approved
Grouting Approved ����L��i '
Comments:
�►%
Required Slab _
Air Vent
Required Well Lo�
Well Tag
Approved by
l%
This repoR is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this permit The
environmental health specialist is not responsible for false or misleading infoRnation contained in the applicatioa The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false o� misleading
statements provided to him in the application. 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. c:�amipro�permit.sam O1/95 rev.1.0
ORIGINAL
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Tax Map: � (
Subdivision:
WELL PERMIT (New_Repair� !�-/��r`
Parcel• ��
Lot:
Applicant's Name: �aC J � � �ar�� �
Mailing Address: oSev � lle L
Phone Numbers:
Location of Property: �0. �„�e Q�- � b o V�
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable 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:
Date: ��� �3
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller•
Pump Installer:
Welt Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C'
Roxboro, NC 27573
Liner Inspection:
Installer: . S/Da`� ►�e��. j w 4�+� W' Z�f
�
Depth: �
Grout: o-St-1 3
Well Abandonment:
EHS/Date
Completed:
Method/Material(s):
License #:
License#:
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
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