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A29 248Application Date: ��- � � �O ��—� 02 �� C� ��' Tax Map: Amount Paid: � 6. v0 '`� '�� Parcel #: _ Receipt#: �� 0 d D 6 - C�� , ��,5� �� ` ' �� Y I-C�.�rav-au �caaa�*�*-�.c��rn�:.aa.71 IC-3C.c�,.sn.11�l�a Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system ermitted Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Requested b�: n Name: �� e. c q= Y Address: S 7 b �'a� S� / Le !(�2r"/�s 11�.,r ,�sy� Phone # (home): �3 � - �� s (� 3 � (work/cell): 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: �arM Address and/or directions to Property: 4) Proposed Use and Type of Structure: Residential Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes No _� (with plumbing: Yes No _� Garbage disposal: Yes No 5) Water Supply: Private Well ✓(Proposed� Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No Yes ,�o�ev� 11 � �� Lot #: (please show location on site plan) Note: A comvleted apnlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properry is ready to be evaluated. I am submitting this application to request services from the Person County Fiealth Departmeut. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. _ Signature (Owner/Legal Representative): Date : 3 -a � � j 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) I" I . � � , ► `,/ \. Tax M2� i ' P�rcel # � ; � �•) t \ I� Subd'ivision i■ �� I � � , . � , , , � , , , , , , I ( I , . , I , I , Fh�se Sect�ion Lot # Improvement Permit Permit Valid for _ ive Years No Expiration � Type of Facility: � va New +/ Addition Water Supply �� # of Occupants �x (� # of B�rooms Projected Daily Flow -�(e 2 g.p.d. Proposed Wastewa er System: Type: Proposed Repair: � Type: ' Permit Conditions: /�. P nn��1' f��P r,►no1P�J .,� nn �ivt� 1 Q�� /�an�r�►hv�� 5��2 �� Owner or Legal ] Authorized State Date: `��z—�� Date: 3'30 —ll The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewa�e Treatment and Disuosa[ Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Speciatist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) See site plan and additional attachments (�. Proposed astewater System:�►70y�thv2 Type� Wastewater Flow �0 g.p.d. New �Repair Expansion Soil LT , 2v .p.d./ ft 2 Type of Facility: �r; y,�.� QS i�J� ��,Q . Basement _ Yes _ No Wastewater System Requirements Tank Size: Septic Tank: (Ob� gal Pump Tank: � gal Grease Trap: ""—�'gal Drainfield: Total Area: Q(¢b sq ft Total Length .3� ft Maximum Trench Depth '�� in Trench Width � ft Minimum Soil Cov r: �g_ in Minimum Trench Separation: � ft Distribution: Distribution Box V Serial Distribution Pressure Manifold Authorized State Agen �s� Date: 3- 3u � 1 Permit Expiration ate: 3- 3 0-1(a The type of system permitted is Conventional Accepted Alternative. I accept the specifications of the permit. .�� ' / Owner/Legal Representative: 1�GtG� o� Date: �7-.�� // PCHD rev. 11/10/OS �n�►ovQ��v� �e✓ 3S°lz ��e�xn ��ues� hY �f'P�,`eayr� : ��';� )� �� `�� = � � �� ]E��sm,ro a,,.* ��.]L 7E��.m.Il�Iln. � Si'�. S�.'rc�: . . Name �� Taz lYlap #��_.Pascel #...�� Sub n ' � Section/Lot# 1 Z J �'" 30 '�� Authorized State Agent • Date . °. sy�,�„�o,� „�„�� p„�,��tou� �ry. The coniractor must, flag the system prior to begi�nning the i�nstar�'an io insure thatlbr�opergnade is mainiained �� -- � y. o� � a � �� . . � ' � � � 8� � �� ► "l ` l � � _� � • - - � - -- - _ �- '' ,w�- � fi ,, A _. .,.� . � -�-- �" 1 � oo� . � , � � � ,_...-.- ,.,�- . , _ ` � �� £�' � �.� �9� � � �� , � � �� . Q�, . ��' � � �� ,L ` 0 ��1�" � �L�J �� .r r�^ � � � � � � �.71.71�T717r cm 7L�L]L�. Qa7i]L'�affi.JL 11 1L CL:. e2.:11.�'�.lYn. V�I,� �'ERMIT (New �/ Repair� Tag Map: � Parcel• 2-�$ Subdivision: �arm �, Ro�evi lle Lot: f 7 Applicant's Name: �,onn ia. Pi x�e / Mailing Address: 570 lvti�e5 R. �a,�� I� �t� �is . Nc 27.��( Phone Numbers: 33tE. S g D-5431e Location of Property: �� 5 ? '�;,,-„ - => Permit �onditions: � 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply.� 3) Permits expire S years from the date of issue. Other Conditions/Comments: � � � � , � � ,� - Pe�mit issued by: 1`1ew Well Inspection: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: �� I�ate• 3 30 -!r CER'i'�+'�CATE O� COldIPLE'Y'IO1�T EHS/Date , � z�%� << �� n 5 rv --� -« � �� q I �� 1�� ✓ � /D -(�'!t Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: �-�v,dSor Pump Installer: ,- �Vell Approved by• Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 License #: License#: Date• - - ��e,��.o, l � � It�l� I Date Results Mailed: �(�pmd, ti��-i1re�-� � �� Phone: 336-597-1790 Fax: 336-597-7808 3/1/08 RESIDENTIAL wEc.� coNsrRucriorr �coRn North Carolina Depaitrnent of Enviconment end Nuwal Raaurcw Divaian of Wsta Qual'uy WELL CONTRACTOR CERTIFICATION i� �� 1. WELL RAC J„ r WaM tracDot Nam� � ' I-iu�qori W�11 Co. =,�tC„ ' . W eM Contraetot Canparry Nams t• ' STREET ADORESS � � j��__��!'Q.II �� /�Z2[IT a Tcwn � S� z�ip cads � �'�?7- 3-7�` Are� cads- .�hans tuunber 2. WELL IN�ORMATIOt�k �^ � — a� � � StTE W •�LL ID �(u apptcaw.) "� STATE WELL PERMITi(ItappueabM) DWQ or 07HER PERMR �(if appAcable) WELL USE (Check Applkabb Bootr ResiderWal Watar Supply Q� DATE DRl�LED �" a" 3�� l l TIME COIIAPLETED I�•�G AM O PM B� S. WELL LOCATION: cmr: �oXbor� couNrir e on /'C�/M �� S'E U 1� ( C G (StnN Nam�. . Canmunity, SubdMalon. lot No.. ParcN. ZJp Cod�) TOPOGRAPHIC I LAND SETTIN(3: p Stops p VaNey D� O Ridys OOthe� (� �aa�a+u. �o� M,y � � a��, LATRUOE � _ mirwta, seca�dt ot LONGfTUDE in a decimai fortrut [atitudellongitude source: ❑GPS pTopographic map (bcatbn of we/ must be slwwn on a USGS topo map and etfeched ta ffMs Aa►m I not ushg GPS) �. WELL OWNER ,Q OWNER'S NAME Cc'� 2 0 � STREET AODRESS -�"r%O ��r'1 eS - 1��..r�Qle rt,ils �1 � �.-�sv! cnr a Tcwn sc�e z� code ,. (._� Area code - Pha�s nwnber 5. WELL DETAILS: � Tor�u, o�r� I a� b. DOES YYELL REPLACE EXISTUdf31fYELL? YE3 O NO � c. WATER LEVEL Below Top d Casing a�Z FT. (Use't• N Aboue Tap d Casinp) d TOP OF CASINIi IS 'E+ 1 FT. Abas Land Surfaca• 'Tap d casinD taminated af/ar below land suriaca may requira a vaianoe in acca� wilh 15/1 NCAC ZC .011 e. •. YIELD (9Pm1� �`� METHOD OF TEST Q�vl �!� �:�?T: �7 �M 1:�:. � p, WATER 2CNE8 (depth� From�s To�9�" From 9"_S To� From To From To From To From To 8. CASIt�Ki: �o-� Thiclmess/ From}�_�� Ft� � (�� Fram To Ft , TG� From To Ft � (iROIJT: Deplh Materi�l From O To �'� Ft ��'-S From To Ft From To Ft .�_ !. SCREEN: Depth piart►etx S�ot gfr� , Matxid Fram To Ft in. h. � From To Fl in. in. From To FL in, in. 9. SANOIGRAVEL PACK: Dep1h Size pAatarial From To Ft. From To Ft Ftam To Ft 10. DRILLING LOG From To �� S � `� C7 y c7 �c7 C% (o �.S / a- 11. REMARKS: FoRnatb� Desc�tbn O 1�il�i'' �' `OL S K le (r��,,,,o- Gr�A� � 100 NERESY CERTFY iNAT TMS WELL WA3 CANSTRUCiEO N ACCOROANCE W(iH 1SA NCAC 2C. WELL CONS7RUCTqN STANOAROS. A/q THAT A COPY OF 7FNS aEcono Fus a� �ovoeo 7o tt+E wEu ow►�a �� S �-as��l SIG RE OF CERTIFIED WELL CONTRACTOR DATE �dy C�l/,� S PRINTED NAaA F PERSON CONSTRUCTING TH� WELL Submit the origlnal to the Dlviston of Water Quality withitt 30 days, Attn: informatlon Mgt, F�,�„ �yy_�a 1617 Mall Servtc� Cenb�— Raleigh� NC Z7699-1617 Phon� No. (919j 733-T01S ext 56a. R� �� .sf ��..�� I��.�.a-�� .Il �33Im�.Il�II� Applicant: � � Location: ��9 � Operation Permit Tax Map �a- Parcel # a`��U Subdivision �'-o,rmQ Rosev'��1�e Phase/Section/Lot # 1�7 # of Bedrooms � System Type (From Table Va): � Product (IIIg): LZ - C'�-> This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. Scale: � "Lt 4 �� -�C . (� i'�S (Authorized Agent) `— M`,k-� �ew� S (Licensed Contractor) 10�1��11 (Date) �' � l� � 11 (Date) Tax Map: � Parcel #: c,�y� Septic Tank System Checklist (Type II-I� System Type: ��_ 0 i �. .s �►. ' �� .r . . ,t. L. s i� .�,� _f [ � � _ � ■ � • � Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP �e-mail Date: �0�17��1 � �� e �g� � `� P � a ` M�. � � � e.� � � �� n.�n��n�n�c��n.��.� �c��.��n. November 16, 2011 Connie Pixley 61 Jaxson Lane Roxboro, NC 27574 Re: Bacteriological Water Sample Tax Map: A29 Parcel: 248 Dear Ms. Pixley: nsuring a healthy environment Your well water was sampled on November 7, 2011, 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 sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil and 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 has not been properly disinfected prior to being used, or that contaminated groundwater is entering the well. The well should be properly 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 system, 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 construction. A well contractor or the Health Department can assist you in identifying the problem and finding a solution. If coliform bacteria are present in your water sample, tlien tlte water may not be safe to use. Young children, the elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the results. Water can be disinfected by boiling for one minute. If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from 8:30 am to 5:00 pm. Sincerely, ��;��5 Bonnie Holt, REHS Environmental Health Specialist Person County Health Department Revised (11/13/08) phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH CONNIE PIXLEY 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES110811-0084001 � �� ES Microbiology ID: 31850 GPS Number: Sample Description: Comment: 61 JAXSON LANE Collected: 11 /07/2011 10:00 Received: 11 /08/2011 09:12 Sample Source: New Well Sampling Point: Outside spigot P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph.ncpublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 B. Holt Angela Heybroek Well Permit Number: A29-248 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Total Coliform, Colilert E. coli, Colilert Report Date: 11/10/2011 Test Result Present Absent Explanations of Coliform Analysis: i�ECEy�7�E]C� NOV 16 2�ti BY: Analyst Susan Beasley Susan Beasley Date 11 /09/2011 11/09/2011 Reported By: Susan Beasley ; ,r . "i�.� 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. s� North Carolina State Laboratory of Public Health . .,-. ; -, Environmental Sciences '�'�'��`✓ Inorganic Chemistry NOV 2 2� 201 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH CONNIE PIXLEY 325 S MORGAN STREET 61 JAXSON LANE ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES110811-0042001 Date Collected: 11/07/11 Date Received: 11/08/11 Sample Type: Sampling Point: Outside spigot Sample Source: New Well Temp. at Receipt: 8.0 Sample Description: Comment: P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htto://slah.ncoublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 Time Collected: 10:00 AM Collected By: B. Holt Well Permit #: A29-248 GPS #: 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 19 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 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 7 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 6.6 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 10.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 92 mg/L Total Hardness 77 mg/L Zinc 1.20 5.00 mg/L Report Date: 11/17/2011 Page 1 of 1 Reported By: �e�le %%LoKeal �� ,� . -�S lX C� � Cc N �V' �'" •