A30 156f�pplicatioa Datp: �-a3-1'�
Amounr Paid: --�av'p•�av
R�ceipt #: 43°111�
cv►�� ayr�
G-�$'� �
t}�0 ,°
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C 1-ed r t-
�A �
t�l Improvement Permit (Sit� Evaluation)
5200.00/�300.00 (if> 600 gpd)
❑ 1�Iobile Home Replacement or Building Addition
� 1 � 0.00 (if site visit required)
0 Well Permit (New/Replacement/Repair)
�300.00/$200.00/$7�.00
�� �5 ) � � � � ��i`' �•LJ�. `y
`�'�^�- �� �D �77�fi' ,�'
����i33'113'K�]L1.�:C1�C:Il.Q:.LRi� J� i�Q':, l..�li:.�-1.
tioa� for ��rvi�ce�
Servi�es Requcsted
� a:c i1��p: -� 3c7
��r�e�#: �._
� • � fr `�-('l15 '_i'0 d� `
c,,� o� �a� � .
0 Construction Authorization
(Fee is dependent on the type of system permitted)
� Permit Revision
57�.00
� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �' ��.{-� - "Tmnn�i � �� Phone (home): ��(�-��"1 -�j��,
Address: Q ur � �a� (�vorlJcell):
��,r1� r;� •'(� Z�S1 �I ` �4�: ✓�7 � S� 7�,Z_
2) Nams and a ress of current o�vner (if different than applicant):
Name: a �___�_� � Phone:
Address: � > ��{
� � 7�(, C, Z�S� l
3) Prop�rty Description: Lot Size: .�_ Subdivision: Lot #:
Address and/or directions to Property: _� ~j�j � . �?�(f - -(�,,.`.
�—
❑ yes
❑ yes
❑ yes
❑ yes
❑ yes
no Does the site contain any jurisdictional �vetlands?
no Does the site contain any existin� �vastewater systems?
no Is any waste�vater going to be generated on the site other than domzstic se�vage?
no Is the site subject to approval by any other public a;ency?
no Are there any easements or right of �vays on this property?
(if `yes' is checked, please provide supporting documentation)
�4) I'roposed U�z and 1Type of Sta�uciurz:
�Residential
Ne�v Sin�le Family Residence NlaKimum number oi bedrooms: �
Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to 1�lalfunctionin� Systzm �Vill there be a basement? ❑ yes ❑ no �Vith plumbing fixtures? ❑ y�es ❑ no
❑�1on-Rzsidential
Type of business:
Maximum number of employees:
Total Square footage of Buildina:
Maximum number of seats:
�) Wata�- Supply: �Ne�v well ❑ Existing VVell ❑ Community Well ❑ Public �Uater ❑ Sprin�
Are there any existing �vells, springs, or existing ���aterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Constr�ct', pl�as� indicate �referred sys#em typ�(s):
�1, Conventional 0 Accepted ❑ Innovative 0 Alternative � Other ❑ Any
I certify that the if for�rtation provided above is complete afzd cot�rect. I also arnderstand that if the inforniation provided is
irzaccurate, of� if tl� site is sa�bsequently altered, or the intendec� use changes, all pertnits and appr�ovals shall be ifzvalid.
Signature (0 vner/ �aLR�presentativefi)
�� Supporting documentation required.
�� Z3- Z� ��'
vat�
Permits are valid for eithei• 60 mont6s or are non-expiring ��•hen accompanied by an approved plat.
A completed `Lot P-repa�afioji' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 32� S. Ylorgan St., Suite C, Ro:cboro, NC 27�73 (336-597-1790)
�_� ?t ) � ���� ��
` � � ����
7E����a���-�,-,Y„ ��.��.:1 IE����.Il�1�
Applicant: �,
Address/Locatian:
Permit Vatid for: Five
Type of Facility: �
Number of Bedrooms '
Proposed Wastewater S
Proposed Repair: �
Permit Conditions:
Improvemeni Permit
ears � Non-expiring
New �Addition
� / Occupants / Employees / Seats:
Taz Map: � Parcel:�
Subdivision
Phase/Section/Lot #
Water Supp;y: e��
Projected Daily Flow: O gallons/day
Type:
Type:
�
Authorized State Ageni: __ Date: !�/«/i�
(X) Owner or Legal Representafive: ' ( M �( - �,._ .�,, .t ` Date: ��� �, ���� _
The issuance af this permit by the Health Department does not guarantee the issuance af other r;,quired pertnits. It is th� resFonsibility of
the applicandproperty owner ±o insure that all Person County PIanning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject tu 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 witl� the provisions of the North Carolina `Laws
rutd Rules for Sewa�e Treatrnent and I)icposal Svstems'(1SA NCAC 18A .1900). lYeither Persao County nor the Environmental
Health S�Cecialist warrants t�at t�e septic system �viil continu., to function satisfacto;:Iy in thc future, or that the water su�ply �rill
remain potable. __
Authori�ation to Construct Wastewater Syst�m
a�ee site plan and additional attachments (�.
n
Proposed Wastewater System: ��f�p, �� %1�y ��,At�ia�/ 1(�`}Type� Desi�n Flow �_ aal./day
New � Repair _ EYpansien � Soil LTA:�: •�0 gal./day/ftz
Type of Facility: �^�� —� 1?, R $asement: _ Yes �C P�o
(") System Types Illh, Ilibg, i I; crnrl V, require periodic systsm inspections by the Person County Health Department.
,��.������.� .�.�
Wastewater Sysfem Requirements
Tank Size: Septic Tank �dbo gal. Pump Tank !" gal. Grease irap — gal.
Drainfield: 'Total Area t ZOD sq. ft. Total Length �_D ft. Max. "french Depth e in.
Trench Width _� ft. Min.Soil Cover _� in. Min.T�rench Separation % ft.
Distribution: Distrihution Box / Serial Distribution� / Pressure Manifold ____
Specifications:
Authorized State Agent:
The system permitted is: �'onventional
and specifications of this permit.
(k) Owner or Legal Representative:�
lssue Date: /L i
Permit Expiration Date:
/Accepted �l Alternati�e / Invovative
`
I ac�ept the conditions
Date: -1 - �
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
;
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L
� -{ (�� � SITE PLAN
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� � -� T Name /✓ l Tax Map #��Q Pascel #��
� �. o Subdivision �1�. Sec[ion/Lot# i
� _ �
N c�i o Autho ed Stat Agent Date �
� L I
Sysrem compoaears represent appmximare contours oa/y. The cvatraerormustflag t6e sysrem pdor to beginnrng rlre insra!lnrion ro �
insare rhatpmpergradeismaintziaed. I
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IE�daa-��.����.�.Il 1�33I��.11�.7�
WELL PERMIT
(New ✓ Repair _ )
Tax Map: �� Parcel: J �o
Subdivision:
Applicant's Name: �„A-�/T�r,��/�1�
Mailing Address:
Phone Numbers:
� �i i' ��• .:/�C� s .•iv�....., y1
Lot:
Permit Conditions:
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 supply
Other Conditions/Comments: _ _
Permit issued by:
�iew Well:
HS/Date�y s
Location:
Grouting: - �-� �j
Well Log:
Well Tag:
Pump Tag: �—
Date: ��z�� �
Certificate of Completion
�L,iner:
EHS/Date
Depth: �r %I-1�-t�
Grout: ��c 19-10-1 y
� �v�
Air Vent: V
Hose Bib: t/
Casing Height: �—
Concrete Slab: t/
Well Driller: �Q'�'��
Pump Installer: �
Approved by:
Additional Comments:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: �-1
Date Sample Collected: —2��1 � Date Results Mailed: Z Z'`�--1�
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro,NC 27573 11/26/13
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I-�" �n.�a���n,.-„-„��n��n.Il IF—ZL��.Il.�I�n.
Location:
Operation Permit
Tax Map � Parcel #� j S(�
Subdivision
Phase/Section/Lot #
# of Bedrooms y
System Type (From Table Va): _ Product (IIIg): EZ
Type V& VI Expiration Date: 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
Authnrization.
Authorized Agent)
MI KQ� 1.,2,�.r� S
(Licensed Contractor)
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Scale
PCHD, rev. 2/14/12
jo - 2Z-I S
(Date)
to-22^t5
(Date)
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Tax Map: 3D Parcel #: ( 5(p
Septic Tank System Checklist (Type II-I� System Type: �EZ�
Septic Tank
State ID & Date: S-�=�
4-11�-
Capacity: ��'S- �pp
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set)
Serial
Pressure Manifold
LPP
Notes:
InitiaUDate Nitrification Lines InitiaUDate
- ZZ- � Trench Width: � ft. _ �
' Trench De th: 2, in.
� Total Length: d0 ft. .r�
Minimum spacing: ft. ✓
Rock denth/aualitv . , le,
Grade (< .25" in 10
Cover (6" minimun
Setbacks
From wells N�'1 r� �(e
Property lines
Foundations/basements
SurfaceWater
Other:
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca a 'ty:
Riser ( " min.)
NEMA 4X x
Model: �
Piggy back lug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of ta s:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
�
-2Z
✓
WELL CONSTRUCTION RECORD
'[his form can be ¢tcd fa siogle � multipie wclls
1. Wdl Coa etor Iaformatio -
�,r/l� / � � /✓ /7' %l �Y �i • � "G
w�u coo+�w� N.m�
2 �l 5 �i
xc wa� coa� c�s�� K�
Barnette Well Drilling, I�c.
��°�N�` ls 4
a wd� coata,usoo r«,n�r a: � 3f�
Llsr alf oppJlmble wr(/ construuion permiu (r.c Cmmry. SImG Varu+nce, e=G)
3. wa� uK ��n«k w�u �x�:
� Water Sapplg Wdl:
Qpy��(� ❑MsmicipaVPublic •
�Gcothczma( (HeatinglCooling SuPP�Y) t�+��dcntial Watu SuPA�Y �single)
pindust�iaVCommercial OResidmtial Water Supply (shaced)
Wdl:
OAquifex Rsd�arge OCrroundwater Remediatim
�Aquifer Storage and Recaive�y ❑Saliniry Barriu
❑Aqwfcr T�t �Stortnwa[cr Draiaage
pE�etimental Techno(ogy OSubsidence Contml
C7Cieothemial(Closed L.00p) OTracer
nr .ti..;;,�1li-Ir.,Nr,o/(MlinoRrh�ml �Othu(omlainunder#2IRemai
4. Date V1'etl(s) Compteted: I( � 4� w� �
Sa. WcII Locadan: .
� B � ...�. /.. ��! { /
Faei6ty/Qwn� e Faa7iSyID#(ifapptiable)
A�SSv� �wi' �O/yr Ci" ��iuY��tl�0 -
��A�.Gry.�,d� 2?�'�y
,shSv�c.r �-3D /S%
�o� Parul fdeaoificatiouNo. (PII�
56. Lafitude snd Langifnde in degreeslmiuutalsccocds"or decimal degcecs:
('�fwep fie14 one lat/lon8 is sa�cieut)
�..�o �9. % N 7`I• �•�'7 w
�"1s (arc) tho wclt(s): [�8tinianmt or OTempoKry
Fa I�ecml Uu ONLY_
1 I
1�. WATER ZOIVES'
FROM TO '. IOLSCItIPTIOh
4 o rc i ri 7
l 3S " � �/�`
�s. aurEx caswc ra� mnin-�.xe �a� ox i.uv�x �r
p�pM rp I DL1H1 7��
' Di � ' £� �°- SD� �4
16:INIVEIi GASINGOttTOBING 'mtLetenil cloSed-ioo
Frtont ro i ouMrrEa �nnciaress
k ft- � R ia
R I � �
I it tr.
tt �-
ROU7' • . -`
� ro i
' c�. � rc
I ft I CL
; f� � ft
i ft I ft.
i ft I R
2R,:DRILLiNG'IAG aits
FxoM ro i
rc , ta
L ft � It
�y I fk
� ft , ft
! fr. I ic
R I �
f� ( ft
Zi: t�matucs �'
�
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22. Gt G 'on: i �
i
$ignauuc ofCctsifiaj R'cll
�Y �8+�y+E�Tf i f hen
L
wtrh ISA NGC OICL0100
7. Is tfiib s repair to an esisfing:weU: OYts or �� copYafthts rec»rr!! �
If this It u rrpwlr, fill out brown wefl oonsuvdbn Lrjarawtfar qraderpl6in tln repnwr ojlhe 23. �te� diBgl'ao�
rrpairLnder �21 rcmarlcr seuron or wi th4back of thls�orta
l Y��,��
8.: Namber of weUs constrnctsd: edt�strucuon dGai
Formu(tipftiryxrionorrtort-watersu�ilyvrllsONLYwi�hllesmrtteo�du�OR.Y°�� SUEMIITALIP
subm7oeejornc / ,
9. Tatai wdl depti beloa land snrface: �`( � (ft) Tita'For All W
Formult�pleweusitstaltdev+�l��+(�+P►�-j��'�ZC�� �criontot�
Divisi
I0. Sta6c water levd trelow fop of casia�g: .� � t�'� 16
,f,�wr�rua��;nx � -+-
11. Borehole diameter_ �n:) 24� For Iuiecfi
abovc, also 3ub�
12,We1teonstruelionmethad: �D�dlh� ��10°tO�
(ia auga, rotuY. cabk; diced posh, coc.) Division of
FOR WATER SUPPLY WELFS ONLY: �6
Meu,od ufta� B1own20 minute z4c or iV ter
13a Yidd .(gpm) tttt addtess(es)
136. Disinfectiou type: HTH 1l2 Cup ���
ftmouut
Form GR�-1 Natfi Carotioa DqfacimwatafFnvicowrcut aod
���
/
�ntraeWr Datc
i arrtJy rhar rhe. �vetl(s) war (irael comrrrued 1n axorrlm+ca ,
� l5�4 NCRC OZC .02(10 {Yt!l Conswcticn �rds and lhd/ a
mvtded w du We11 oaner.
iOn� Wti� IiCtA1�5: '
thiS [r�C t0 prbvidc additionaZ adl. Sit� ddails qr wdl
�y �.�a� aae,uo� p��;e�y.
t. _
this.5ocm v�nthm 30 days of compldioti of
o[ xterQeulitS, Infotmation Pcocessiug Uui4
ylsil rv,ice. Ccnter, Italeigh,l�C 27699-1617
Wd : Tn addition w saiding the fnmi to the address in 24a
a eopY of tfiis focm within: 30 days of complet7on bf welt
Uadagmand.Injection ControCPcogram,
Ccntcr, Ratci�4. NC 27699-1636
dob Wdls. In addidon to seading the form ta
mit one copy of.this form within 30 days of
W che counfy healtli dcpartmait of tfic county
Revised.Jan. 2013
��
„'',f ��
ne department
of health and
humen services
5.� r � � $ ; l 4 �
�.., � yS � l_ S � r�� I � � �J � E � � S' r�' � �,-'s i ''-'3 .' {� i �� ;�—.
zt � ` � r1
� � f � ` �f i ��i �` �z `J ljl 4 � � � i i,s i i ( @ �{ e� f �. E F
� } d{ �f' 'e •
�.` �^� �^;� ; ; !^�` ��� .�-� {�1 � t� p'f" ^ �^�. ^�{ 1� i� E �r-.1 a � � 4�� ! ~� �,
�—�� g f�_' ��w.� a._.' '�..r F `t �1 �J' �• E� a E i'••._i a T•i ��� �� E t,? � E �
��
For Inorganic Chemical Confaminants
County: .�,✓'�rr�,�t Name: n •
Sample ID #: 3 D— j S Reviewer: , ,r-,�,r-
� TEST RESULTS AND USE RECOMMENDATIONS
1. �Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for
drinki g, cooking, washing, cleaning, bathing, and showering based on the inor,�anic chemical results onlv. You may
have other water sarnpling results that are not taken into account in this report.
2. ❑ The following substance(s) exceeded federa! 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��vater treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorPanic chemical results onlv.
Arsenic _ � Barium � Cadmium � Chromium � Copper � Fluoride � Lead Iron
Manganese Mercury Nitrate/Nitrite Selenium Silver Maanesium 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 shawering 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 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 following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inorPanic 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 Ma esium
Manganese Selenium Silver pH Zinc
For more information regarding your well waler results, please call 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
ROXBORO, NC 27573
EIN: 566000331 EH
StarLiMS ID: ES012816-0063001
Sample Type: Raw
Sample Source: New Well
Sample Description:
Comment:
Name of System:
CANDYCE HILL
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sl ph. ncoublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
1300 HASSELL HORTON RD
Courier # 02-33-15 ROXBORO, NC 27574
Date Collected: 01/27/16
Date Received: 01/28/16
Sampling Point: Well head
Temp. at Receipt: 3.5
Time Collected: 1:45 PM
Collected By: A Sarver
Well Permit #: A30-156
GPS #:
New Well I (Profile) -
Analyte Result Allowable Limit Unit Qualifier(s)
Arsenic < 0.005 0.010 _ _ m�/L
-- — --- ---
Barium < 0.1 2.00 _ mg/L _ ________
- ----- -- ----- - -
Cadmium < 0.001 0.005 _ m�c /L
--- -- ------__ ___— --- --------
Calcium -------- - 10 ---- -- m9��------ —
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 4 mg/L
Manganese < 0.03 0.05 mg/L _
Mercury < 0 0005 0.002 mg/L _
Nitrate 2.20 10.00 mg/L
Nitrite < 0 1 1.00 mg/L
pH 7.2 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 _ _ m9/L _____
Sodium 7.80 ------ m�/L -----------
--- -----
Sulfate < 5.00 ___ 250 __ ___ mg/L ___ ____
TotalAlkalinity 37 -- --___ _---__----..__m�/L ------------
Total Hardness 41 _________ m9/L __ _
Zinc < 0.05 5.00 mg/L
Report Date: 02/19/2016
Page 1 of 1
Reported By: Deddie.r�lonco!
North Carolina State Laboratory Public Health
Environmental Sciences
fl�icrobiology
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: ES012816-0098001
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ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
CANDYCE HILL
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
1300 HASSELL HORTON RD
ROXBORO, NC 27574
Collected: 01 /27/2016 13:45
Received: 01/28/2016 08:34
Sample Source: New Well
Sampling Point: Well head
A Sarver
Angela Heybroek
Well Permit Number:
A30-156
Environmental Microbiology - Colilert Profile Method: SM 9223B
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.