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A29 249,/ � �� 4,, I�I�I�..��T Application Date: g 3 j �`� g'Q, Od ��.:.�� 1� Amount Paid: DO a0 �i' ..r.,, i..,t- ��7�� Receipt #: $ N 0 $ � � �G �� unv i�u oanmra�;uadmll _IH�c:,enlld:lln_ �� Application for Services Services Requested Taz Map: � � 9 Parcel#: � N � _ Sa�e Improvement Permit (Site Evaluation) Construction Authorization $200.00/$300.00 if> 600 d ee is de endent on the e of s stem ercnitted Mobile Home Replacement or Building Addition Permit Revision $150.00 if site visit re uired $75.00 Well Permit (New/Replacement/Rep$ir) Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: TO N y W z s� ev ��-1n � Phone (home): Address: (work/cell): - 7 2) Name and address of current owner (if different than applicant): Name: Address: _ _ Phone: nO�eVi �l� F 3) Property Description: Lot Size: Subdivision: �°�rN` Lot #: �� Address and/or directions to Property: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ 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) 4) Proposed Use and Type of Structure; ❑Residential � ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Cunent number of bedrooms: 0 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 � 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 ❑ Alternative ❑ Other ❑ Any 7 certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is s�bsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signatu�'(Owner/ Legal presentative*) * Supporting documentatio required. g 31 Date Permits are valid for either 60 months or are non-ezpiring 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) ��.sf .��.�� .._ � � �� )C�sira�au-��ra�*-� ��rn��.11 IZ��.II�I�a Applicant: ; Address/Location: Improvement Permit Permit Valid for: Five Years � Non-expiring Type of Facility: New � Addition _ Number of Bedrooms / Occupants / Employees / Seats: Proposed Wastewater System: Proposed Repair: �p�tl g,�'��r,i/•Ll Permit Conditions: Tax Map: � Parcel:_;�� Subdivision ��a,,t/ �1�� Phase/Section/Lot # � � Water Supply: Gl��'ZL Projected Daily Flow: ? gallons/day Type: �� Type: � Authorized State Agent: Date: '"' (X) Owner or Legal Representativ . Date: The issuance of this permit by the Health Department does not gu�rantee the issuance of other required permits. It is the responsibility of the applicant/property owner to insure 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 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 mrd Rules for Sewape Treatment and Disaosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply wili remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �p,ti/✓i:�?t��i�'/L( _(*)Type,� Design Flow ��Q gal./day New � Repair _ E pansion _ Soil LTAR: .� gal./day/ft2 Type of Facility: �;,� Basement: _ Yes � No (*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank !�A gal. Pump Tank ga(. Grease Trap gal. Drainfield: Totai Area 7�ts sq. ft. Trench Width �_ ft. Total Length � ft. Min.Soil Cover � in Max. Trench Depth � in. Min.Trench Separation ft. Distribution: Distribution Box �/ Serial Distribution / Pressure Manifold Specifications: T�_��vV�d� �.�►.�� n L�f> � Authorized State Agent: Issue Date: 23 Permit Exptration Date: Ti�e system permitted is: Conventional �/Accepted / Alternativ / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: Date: Person Countv Environmental Health, 325 S Mor�an St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev S/121 ��'?�� - �. � �� ]Eaav nxc-��a��.¢�.11. IE��am1t�7�a. SITE PLAN i Na�ne � Tax Map # .�2 Patc�! #_.;� Subdivision ' �/i// f� Section/Lot# � _ f� Auth rized State Agent ate System compoaents represent appmadmate contours oaly. The conrractormust tlag tbe sysrem pdar to begianing the installaaaa m insrrre rhatpmpergradelsmaintained. 3 e3�2ao� � �!E - 3�0 5 �� _ . � GT� /200 �Ta��oO t�/: �i." Cv�/✓. ��i �� - ��a�o�1 ,� /DDD ,��G-� � � � _. � � �s��a �� s� � �s� �� EA � ti 0 ��/1/� : / ''= l�� I /✓d7"�� : !^7-�� ¢ � t�/�t/�...� ' Cr 1ao ' 20" �e�'r�l�e� ,��t� � ' �'� �j��,�, �it,�o2 �a ��/s��ho.�l • � i✓�t .��,�'i�/ �i►/ sf�i��G � . �/ QU�tir�o�/s G��fr.�� ' �J7 �/79b , �J„! /,�cc�j�,�,.� �>>✓� �'1� �Q��c� G►�ih/g-P Co��l. �s. ��,sf ��.�� - � � �� a�n�ro�auzra��ra��.Il g��Il¢�n WELL PERMIT (New �/ Repair _ ) Tax Map: �� Parcel: _�� Subdivision: ,,�1� ,.�i�._��? .��/% Applicant's Name: ��/,j �r� �� Mailing Address: Phone Numbers: Location of Property: _ _ �Q �. Permit Conditions: Lot: � 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. 4.) Issuance of a permit does not Other Conditions/Comments: / Permit issued by: water supply Certifcate of Completion ew Well: EHS/Date Location: `�� Grouting: — i q' � � Well Log: Well Tag: � Pump Tag: Air Vent: Hose Bib: 3 —��'�4 Casing Height: Concrete Slab: Well Driller: �l d S o r� Pump Installer: Approved by: Additional Comments: Date: �� ,?��,� y .�_� DI.iner: EHS/Date Depth: Grout: DAbandonment: Date: _ Method/Materials: License #: License #: Date: 3-/ � / �, Date Sample Collected: �'Z�i-��P Date Results Mailed: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Phone:336-597-1790 Fax:336-597-7808 11/26/13 ��► WL�LLl:V1VJ1KUl;11V1V 1(L(:VKU This farm can be used for single or multiple wells 1. Weit C ctor Infonrga�ion: /� ,); � / � � ,�� iJ' L� Well Con or Name ?, i 7G NC Well Conhacxor Catification Number .� � ��, �(�� ;. �, c...�j�/l G� � � Company Name 2. Weil Constrnction Permit #: List all applicable we(l permits ('t�e Cormty, S1al� Yarimece, etc.) 3. Well Use (c6eck well use): WaYCI' SnDDIV WCI�: OAgricultura( �MunicipaVPublic �Geothetmal (Heating/Cooling Supply) idential Water Supply (single) OIndustriaUCommercial OResidential Watet SupP1Y (shared) Non-Water Supply R'ell: DAquifer Recharge ❑Groundwater Remediation DAquifer Storage and Recovery �Saiinity Bazrier �A.quifer Test �Stormwater Drainage OExperimental Technology OSubsidence Controt �Geothem�al (Closed L,00p) OTracer pGeothermal (Heatin�JCooling Rehun) OOther (explain under #21 Remarks) 4. Date Well(s) Compieted: '� '+� Wdl ID# Sa. Wel tion: / � � ) �Z c"i �'� +� W�' S% r' t1 _ c;i.\ G%i %� �� Fac�7ity/OwF�r Name Facility ID(k iif ap �cable) ! �`�1ll� 5 �� Y � l' : �/C Physical Address, City, and Zip �Ql f r�,� - �1=Fo1 Ll � �ty Parcel Identificabion No. (PIl� -�' 56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �if Weu fiela, one latnong is suf��senc� N R' 6. Is (are) the well(s): flPermanent or OTemporary 7. Is ttis a repair to an eaisting well: OYes or �1Vo Ijthis is a repair, fill oat Amown weU construction information and ezplain ihe nature of the repair under #21 remarks sedion or on the back of this form. 8. Number of wells constructed: I For multiple injection or non-water supply weUs ONLY with the same construction, yon can submil one form. For Internal Use ONLY: 22. Certiiisation: � s�,� -j ��"s'., —/�' 1� _ Si of Certified Well Conhactor 1» Bv signing this form. I hereby cert� that the wel!(s) was (were) canstructed in accordmrce with ISA NCJIC OIC .0100 or 1SA NCAC OIC.O200 WeU Construction Standards �d thal a copy of tieis record has been provided to the well owner. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBNIITTAL INSTUCiTONS 9. Total wett depth below land surface• /�� (ft) 24a. For All Welis: Submit this form within 30 days of completion of well For multiple wells list all depths rf different (example- 3Q200' and 2Q100'} consttuct►on tA the following. - 10. Static water level below top of casing: �t� (f�-) IJwater leve! is above casing, use "+" / t 11. Borehole diameter: �% �_ (i�) 12.�'ell constructioa method: �� I7 �(�l (i.e. auger, mtazy, cable, direct Push, etc.) FOR WATER SI7PPLY WELIS ONLY: � ]3a. �dd (gpm) � V Method of tes� � � � 13b. Disinfection type: /'� � � � Amoun� Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Iniecfiou Wells ONLY: Tn addition to sending the form to the address in 24a above, aLso submit a copy of this foim within 30 days of completion of well construdion to ffie followin� Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Italeigh, NC 27699-1636 24c. For Water Supply & Injection Wetls: . Also submit one. copy of this foim within 30 days of complelion of well construdion to the county health department of the county wbere consttucted. ��.ss ��.�� IE��a�� .Il IE��.Il�I� Applicant: � System Type (From Table Va): Type V& VI Expiration Date: 1�I s. �� r��-«�7� , � � � � � . Tax Map � Parcel # 2� Subdivision �„r„„ �_ Ros�.v;lle_ Phase/Section/Lot # � �' # of Bedrooms ��-8-r 3 ��°� Product (IIIg): �z- Type V& VI Renewal Date: ? 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. (Authorized Agent) � , p �� ( icensed Contractor) P�`'� 7 ��- Scale PCHD, rev. /14/12 3 (Date) � 3_i(��p (Date) �-2, L �'n 2 ,ti Tax Map: � Parcel #: �_ Septic Tank System Checklist (Type II-I� Notes: System Type: -� ��) � Pump System Checklist Contracted Certified Operator (Type IV Systems): Notes: North Carolina State Laboratory of Public Health �rtvirQnrnenfal Scier7ces inorganic Ci�emistry Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: TONY WESLEY P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http:/!sl ph. ncou bl ichealth.com Phone: 919-733-7308 Fax: 919-715-8611 FARM @ ROSEVILLE, LOT 18 ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: Sample Type: Sample Source ESO42616-0038001 Raw New Well Sample Description: Comment: Date Collected: 04/25/16 Date Received: 04/26/16 Sampling Point: Well head Temp. at Receipt: 4.4 Time Collected: 09:45 AM Collected By: A Sarver Well Permit #: A29-249 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 m�/L_ - - -- - -------- -- - -- - ---- -- - -- Calcium 17 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 < 0.10 0.30 mg/L -_ -- -- - _ -_ Lead < 0.005 0.015_ _ _ mg/L _ _ _ - --- __-- ------ -- ----- - -- Magnesium 6 mg/L -- - ---- _ _ ----- -- Manganese < 0.03 0.05 m�/L__ _- _ --- - -- -- --- ---- - -- - _ _ -- - Mercury _ < 0.0005 0.002 mg/L_ -- -- - -- ------ - Nitrate < 1.00 10.00 mg/L __ - - -- - --- -- - Nitrite < 0.1 1.00 mg/L _ _ _ _ - _- _ pH --- ____- -- ---- - 7.3 _ N/A - - -_ -- - _ _ _ _ Selenium < 0.005 0_05_ __ __ _ mg/L_ ------ - - _ __ . _ Silver < 0.05 0.10 _______ _ mg/L __ - -- Sodium 9.00 mg/L __ -- ---- ---- - - -------- _ — Sulfate < 5.00 __ 250 _ _ _ _ mg/L _ _ - -- -- _- -- --- ------ Total Alkalinity _ ___ 76 _ mc,�/L _ --- - -- - - - - - Total Hardness 67 mg/L _ _ --- --- -- - - - - ----_ _ _ _--- Zinc 0.65 5.00 mg/L Report Date: 05/05/2016 Page 1 of 1 Reported By: Cin�iyPrrce �� 711/1 — ne depa►tment af health and humen serviees r ' e �'� � 4; � r' �` 's:� S ,S ` f_.,S -�. /�� t � � 2 E i. �.�, r fn';�� i ,;. ,r '�`� � � .., F i r LI� y L: `�' ii L � � � � _ ! T .,S i ! { � I� t � �/ i F ¢ � � r � . � � � >•�� r-,, , '„A � _'j r,q � i °,"° �� r-, f � �',i � �'��',i i�, k" t1 � i -at �{� � ,^ � it "p i., {��cj i I�.. a �....,.d' �� L.t � `Z �l �.J' � E� e Z ��••✓ 9l f`,� iJ: i� p t,? ! i�i Sample ID #: ��- For Inorganic Chemical Confaminants Name: �,i/PS Reviewer: , w� r' ' TEST RESULTS AND USE RECOMMENDATIONS 1. Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for dri king, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may have 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, unless you install a r��ater treatment system to remove the clicled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inorFanic chemical results onlv. Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride ( Lead � Iron Man�anese Mercurv Nitrate/Nitrite Selenium Silver 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/1. 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 the inorFanic chemical results onlv. ❑ b. Levels over 30 mg/I may pose aesthetic problems such as bad taste, odor, staining of porce(ain, etc. 4. � Re-sampling is recommended in months. 5. 0 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 I S minute sample at the well head to determine the source of the lead and/or copper. 6. ❑ The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the innr�anie chemical 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 Man�anese Selenium Silver pH Zinc For more information regarding your we!! water results, please ca!! the North Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory Public Health Environmental Sciences �licrobiology 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: ESO42616-0078001 ( �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: TONY WESLEY P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 FARM@ ROSEVILLE LOT 18 ROXBORO, NC 27574 Collected: 04/25/2016 09:45 Received: 04/26/2016 08:28 Sample Source: New Well Sampling Point: well head A. Sarver Angela Heybroek Well Permit Number: A29-249 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 04/27/2016 E. coli, Colilert Absent Susan Beasley 04/27/2016 Report Date: 04/27/2016 Explanations of Coliform Analysis: Reported By: Susan Beaslev / r ', 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.