A29 285�-�-i .�
Application Date: ��0 � 0� �� S� ������ Tax Map: A��
Amount Paid: . O � � � �,► • �r. Parcel#• a � �
Receipt #: �% 3 9 I 0 Z 9' 3.2 �' � �% ����� �
�— IE�a�na-omm � ��a�.Il 7E�o�.Il�ll� � T�U
(���� C red �� Cc� r� , C.��-
A lication for Services � `�¢ ° �
_ Services Reauested
Improvement Permit (Site Evaluatioa)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.001$200.00/$75.00
- '�1) Applicant Information:
Name: � �� �R �u � � ,,,��� .
U ..s.
Address: -
Construction Authorization
(Fee is dependent on the type of
Permit Revision
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
2) Name and address of c�rent ownGr (if�ifferent than applicant):
Name: �c� � � � b h -e
Address: w � ,
Phone (home):
(work/cell): _
Phone:
j 1 �ark .
�e��e �oi�►
�
O U'�
you
3) Property Description: Lot Size: ^�A�Subdivision: Lot #:
Address and/or directions to Property: r-i� 9_ �—� c�.�� r +� p q� R�rl i u r�cv� P�c%�
❑ yes j'� no Does the site contain any jurisdictional wetlands?
O yes ,� no Does the site contain any existing wastewater systems?
O yes E� 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) �' � 3a
4) Proposed Use and Type of Structure: �
�tesidential �
�New Single 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 O 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 systera type(s):
%" �Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ qny
�v `" �
0.aa�; o►�
; +� �-�
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inacc ra e, or if the 'te is subsequently altered, or the intended use changes, all permits and approvals hal be invalid.
y� G��. ,?�
ignature (Owned Legal Representative*) D e
* Supporting documentation required.
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.
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Applicant:
Address/Lc
Tax Map: A� � Parcel• � g 5
Subdivision N%}
Phase/Section/Lot # /� �
Permit Valid for: Five Years
Type of Facility:
Number of: Bedrooms. /
Proposed Wastewater System:
Proposed Repair: _��,p,�
Improvement Permit
pinng ��/� 1
Jew �Addition _ Water Supply: U�G� `
- A
mploy es / Seats: Projected Daily Flow:�g� allons/day
�o uc ��r� Su�l�Pm, Type:
Type:
Permit Conditions: ��; ai;� ��1 �',��,Gc.,(��
Authorized State AgE
(X) Owner or Legal
Date:
Date:
�
The issuance of this permit by the Health Dep�rtment does not guarantee 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
a�rr1 Rules for Sewaee Trealment and Disnosa[ Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environarentai
Health Specialist warrants that the septic system wili continue to function satisfactorily in the future, or that the water sapply vvill
remain potable.
Authorization to Construct Wastewater �,ystem
See site plan and additional attachments (�
Proposed Wastewater System: o (*)T�pe � Design Flow .3(¢Q gal./day
New ✓ Repair Expansio _ Soil LTAR: . 2� gal./day/ft2
Type of Facility: ' ' ' —� Easement: _ Yes _ o
(*) System Types Illb, Illag, IV, and V, require p2riodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �DOp gal. Purr�p Tank gal. irease Trap gal.
Drainfield: Total Ar�a � 9�O sq. ft. Total Length ��0 ft. Max. Trench Depth � in.
O. C,
Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft.
Distribution: Distribution Box ✓/ Serial Distribution / Pressure Manifold
Specifications: e
i O�nrn Q" -
Authoriz�d State Agent:
Issue Date: 7—/3—/S
Permit Expiration Date: � /3—Zo
The system permitted is: Conventional /Accepted 1/ / ative / Innovative . I accept the c ditions
and specifications of this permit. �
(X) Owner or Legal Representative: Date: �% � �
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Name Da��� r►b��IP.
Subdid 'on
A orized State Agent
���,Sf 1�J�J�.��1�
- � c� � ����
�' gnwna-��n.�na����.� �'���.���a
SITE PLAN �
Tax Map # �� Parcel # � " �
Section/Lot#��
�,7---�—/<,
Date
System components repsesent app�oximate contours only. The contractor must Jlag the system prior to beginning the
installation to insure tlrat propergrade is maintained
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WELL �RNIIT
(New ��Repair _ )
Tax Map: �°2� Parcel: � g �
Subdivision: rj �� Lot: �
Applicant's Name:
Mailing Address: _
Phone Num6ers:
Location of Property:
Permit Conditions:
���vi� `�' b� I�
�
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 guarantee a potable water
Other Conditions/Comments: /V9 a«��q r h a ll Se�in�
�
!
Permit issued b • - ,.,,
Certificate of Completion
ew Well:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
HS/Date
�3v-{ 5
,�z� ,o-3d-lS
l -(8�� S
Pump Installer:
Approved by:
�Av,,,-e��.
Additio�al Comments:
Date: 7 /3 /�
Di.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: ��i'l�"%
Date Sample Collected: �-2�'��P Date Results Mailed: 2�2�{-l(�
EHS: �_
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnrhnrn NC 9757R
Phone:336-597-1790 fax:336-597-7808
„ncH�
Barnette Well Drilling
WELL CONSTRIICTIQN RECORD
tl�is ror,ncan ba atoe tar cin�,lc ur mult:plc wals
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L1s! atf applrqpble we[! cons�ry yion ne�aJn (� e. Caunry, S�vre. YarineKe. e�c�
3. SYeil Use {check �vetl nsej:
OAgricuttural � ❑Mur;icipaVPublic-
IIGmtF�ttrnal (Heating7Coo]ing Se�ptY) ORtsidential WaCer5upply {singlc)
a�a�v;,vcom�a�;� i]Residuiaai WaterSupplY{shared)
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Si at�eaECertified We1I Cantnctor p�
6. ]s (arcJ thc �vel!{sj: OPermaneut or QTemporzry'-
$y slbmlr�a!ris form, t hereby cur�y ihar lire� well(s) was (wcrc} corrstrrcted ie rrccorrfcr�ce
w:16 !SR NC�COZG.OIOO w� ISet NCAC 01C .0200 J�d! Cervtivc�ion Star� arid rha! a�
7_ Is [his � repair to an e�cis�eg.�dl_ I7Yes oc �JpE� copyoJri,fa,cw„thar6eo, pro„tdadro�lrar�dl owner.
.(f dus rs n ir!»[r, fil! aar h.own �re!/ wrurneerton lnforoiatmn a+d.espfnin the aaairr oJlh_u � . . �
K�+� unde�sll rcru..,,4r seuion or as rhe hacf ofihtr jorm. ?3. Sit� di8gcatn Or addiLioaal wtll dctai) s:
,I Yov may use du back of.ihis page io provide �dditional weEl site deta�ls or well
B.Namc6crolwcOsconstnictcd: l ' constntsiondUails, Youmayatso.attachadditidnalpaysifnecessacy.
Far muNiple rnjrcrion ur nws�mlu.mpply N�dls ONL wi�h �l�c syyrrte epµrpwr(iaR, y�u etm �
s"�'n'4O"dfOR"' , 5U[3M[7TAL INSTUCx'IONS
9_ Tobl w�Q dept5 belowJand surfaocc (ft) Z4a For Afl Wdls: Submit this . fioan wrthin 39 of com lcrion of k�ell
/'ar n.uluple x�dLc liu a!! dep�As i d �YS P
J�Ere� (er.vmple-3@2P0'ond 2Cilop7 eonstiuetion [o tfit foqowing:
10. Sfatie water ]svet bdow top of t�io� �ry ? Divisian ot�Yater Qualih:, Iufurmalian Ptocessiag Uniy
Ifrn:erJevelu obove cosrng, rse "+ ^ 16b7 Mail Serviae Center, (Lalei5l��'.�'C 2769}-IG17
11. Borehol� diameter. ��_ ��� 246_ �or [niection We1Ls: in addition to sending tlze fotm to the address in 24a
above, also submit a copy of this farru ariLhin.3D days of cornpldion of`vuell
12 Welt constrnc6on mdbod: car�Ktu2iontothe foklawir�
(.c. �*. i�7, �ble: diroU puSti, efc.)
D"uision of �Vater Qnality, C udergrva nd. [n jecti vn Con tro['Ptt era m,
FOR Wil'f�i2 SUi'PL?' R'ELIS ONf�Y: , 1636 Mail Servive Centcr, Ra[cigh, NC 27699-1634
13a.'Yidd (gpm) � M�=hod at tes� BfownZQ minute 7.4e. �'or \Vater Suoolv & Iniectiun Si�eUs• Tn addi[ion to sending ihe fam to
tha addr�ss(es) abp"vo, aiso tubmit one cqpy of tl»s farin within 30 days af
13L. p'�sinfectioo typ� HTH Anr000h ��2 Cup �A��an of we7[ eonstruction to the county heafth dcpart�neni a1' tfie county
whae corssuvtted.
Form GW-[ Nprth Carolioy pepa�trtr�t of Fnvico�mcat aad Nal�al Recosrces—D:vision of Water Qiul�ry
Rcviscd 7au. 20 � 3
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Tax Map � Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms 3
Applicant: ��r►" �'l /r:%j�
Location: /1► � . . .
Oueration Perniit
System Type (From Table Va): �
Type V 8c VI Expiration Date:
Product (IIIg): �Z ��� G''
Type V& VI Renewal Date: �
►S ��.
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment nd Disposal, and all conditions of the Improvement Permit and Construction
Authorization. /-� �
�, l� ��ri� �li �-! 3 �l
�
(Authoriied Agent) � (Date)
� (�2w+ � 1 v �� 3 -��
(Licensed Contractor) (Date)
Scale � ��
PCFiD, rev. 12/14/12
�,5,►
2��
� �,i�'{-�.�� �'� �%�
Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I�
Notes:
System Type ��Z
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Bog
Model:
Piggy back piug
Hard wired
Alarm functioning
Mounted on post
Above grade {12")
Conduit sealed
Pressure Mani%ld
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
��
���'��� 1 / 1
ne department
of health and
humen serviees
�k ! �
:� , .
� �,., ' ; � �_.s � ��; � E � �� � Ef � "� f" r�. � Fp ";f`� r's �; jE; ° �''�f
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(I� E ! l_' .....a` a....^ ��... E �'� i_.: 4�' �.� E � e ! i ' _i a ( _� �.. E �..•' i �.i
For Inorganic Chemica/ Confaminants
County: � „� Name: �, �-�
Sample ID#: Z- Z� Reviewer: aw�e �
� TEST RESULTS AND USE RECOMMENDATIONS
1. ❑ Your well water meets federal drinking water standards for inorganic cheneicals. Your water can be used for
drinking, 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 insta(1 a water treatment system to remove the circled substance(s). Howevzr, it may be used for
washing, cleaning, bathing and showering based on the inoreanic chemical results onlv.
Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Man�anese Mercurv Nitrate/Nitrite Selenium Silver Maenesium Zinc nH
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/l. 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 inorQanic chemical results onlv.
❑ b. Levels over 30 mg/1 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 I S minute sample inside the house (preferably
the kitchen) and if possible a�rst 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,
cooki�g, washing, cleaning, bathing, and showering based on the inor�anic 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� � Magnesium
aneanese Selenium Silver pH Zinc
For more information regarding your well water resu/ts, please ca![ the North Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: ADAM C. SARVER
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
DAVID TRIBBLE
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sl ph. ncou bl ichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
4305 BURLINGTON RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID:
Sample Type:
Sample Source:
ES012816-0061001
Raw
New Well
Sample Description:
Comment:
Date Collected: 01/27/16
Date Received: 01/28/16
Sampling Point: Well head
Temp. at Receipt: 2.0
Time Collected: 1:55 PM
Collected By: A Sarver
Well Permit #: A29-285
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 11 ��� __ ____
----- -- -- -- --
Chloride — - ---- --- < 5.00 _ 250 -- ---- - m�c /L-- — — _---_
---..
Chromium <0.01 0.10 m�c/L _ __
Copper <0.05 1.3 ____�/L__ _______
Fluoride < 0 20 4.00 mg/L _
Iron 0.58 S 0.30 m/�_ _ __ _
Lead < 0.005 0.015 mg/L
Magnesium 2 _ mg/L __
Manganese 0.120 S 0.05 mg/L _
Mercury < 0.0005 0.002 mg/L
Nitrate 1.80 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 5.60 mg/L _
Sulfate < 5.00 250 mg/L
Total Alkalinity 36 mg/L
Total Hardness 35 mg/L _
Zinc < 0.05 5.00 mq/L
Report Date: 02/19/2016
Page 1 of 1
Reported By: Deddie.r'�fonco!
North Carolina State Laboratory Public Health
Environmental Sciences
i�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: ES012816-0097001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
DAVID TRIBBLE
4305 BURLINGTON RD
ROXBORO, NC 27574
Collected: 01 /27/2016 13:55
Received: 01/28/2016 08:34
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph. ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
A Sarver
Angela Heybroek
Well Permit Number:
A29-285
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present Denise Richardson 01/29/2016
E. coli, Colilert Absent Denise Richardson 01/29/2016
Report Date: 02/01/2016
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.