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A31 13812/29/206B 11:42 3365977868 PERSO� CQUNTY ENVIRO PAGE 61 d Application Date: 1 �2 �29-D� � �� O q Ta.�c 11rlap: �3� �raount paid: �D� O � 3 � � � �'arcxl #�• /S Rece;�t#: 4�j 0 3�q 7 ('�� 2� ��. ...��.:�.� ��..� � . —�— c� � �tL� �'I� � 7E�azT.w �Lzr-.�:s�...nrar�•� u�,t;.m7� i'L"��.�7iit]k-s� A,�JpliCatipil �v�' �ePVnCEs (Septic Systems and Wells) 1) �erviccs R nest y; Name• �'W`- s Address• 3 t 7o v� h.w� y�a-x��,ro �c , Z �'S % Phone # (home). .�3`J •55 7 — 55 38 (wot�c/cell : � v3 2 2}�Ta�ae s�d Address of caro�e�t owner (if dii�e�re�t t6an applicant): Name' � o. �.D c.�. '��-Y �' �,ddr�ss• 3) Praperty�escriptioa�: Lot Si�.e: �� Subdivision: �r�^^' � t#: � Address and/or directions to �roperty: S�� C r ie � r-4 le Pel —3 � Nc�..�rv��- 2c1 _ � Pro�osecl U�e, apd Type of Structuxe: Residential V Busiu�ess/Type: Other Namber of bedrooms �,� / Numbc= of people served (scats/empioyees): 7 Basennent: Yes No t/ (with plumbing; 'Yes No _, Garbage disposaI: Yes No __� � Water Svpply: Private Well v(P�oposed t/�xisting �,) Connmunity Well: �ublic Water Syst�em: . • . A�re there wells on the adjoining properties? No �Yes (plesse show lacation on site plan) ,�'ote� A comnl¢ted a�plicanon must also ir�clude:_ � A plQf/site p�an o,f �I:e property rhat sJ=ows property dime�sions ar:d the ,�ize and location of a11 ,�roposed structures. � . � A sigr:ed copy of the `,�ot l'reparativn' form verifying that tlie prnpersy is �eady to Se evalualed � anm submittin�� this apQlicatiou to request sErvices 1'ro�na the P�rson Coam� �ealth �e�axtpae�tt. I t�nderstand #hat v,F r�e information provided is in�corr�ea� �r if tl�e ' is s sequentiy a1�erEd, o� '� ti�c intcnded nse c�an�es, a�l permii� am� approvals si�alI 3�eco�e invalid. �i�atur� {O�c�vnexlLega� �Ze�resentat��e) �Date : lOiQ$ Person County Env�xonmental Health, 325 S. Mvrgan St., Suite C, Roacbora, NC 27S i3 (336�SQ7-1790) � a rn � 0 c� rn rn � � c� ch � m c .c c a� ? � a� � m 2 n c� c�'� iYi 0 rn 0 � N .fl m L.L ��. � f � ��.� �� J��-��<��«��.11 �I��.11�I� Applicant: ' ~ i Tax M�p : F�rcel � ; Pha�Subdlivision ►n . .�. � ■ • t+ion Lot # � Improvement Permit Permit Valid for �/ Five Ye rs No Expiration � Type of Facility: riva Si cipn�.P. New ✓ Addition _ Water Supply � r i # of Occupants Mu� # of Bedrooms Projected Daily Flow 3�� g.p.d. Proposed Wastewater System: Cc �� or {.o.Y. t,r 25 %� Type: Proposed Repair: �„IP Type: Permit Conditions: Owner or I:egal Represe Authorizecl State Agent: Date: �( / � Date: ` 6 0 The issuance of this pernut by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property 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 far Sewa�e Treatment and Disnosal Svstems' _(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to fuuction satisfactorily in the future or that the water supply will remain potabie. Authorization to Construct Wastewater System (ltequired for Building Permit) * See site plan and additional attachments (_). Propose astewater System:��d ([Z, �'�aW ar � e�_��ype� Wastewater Flow �g.p.d. New � Repair Expa si n Soil LT S g.p.d./ ft 2 Type of Facility: Prive�2 �Psic�encQ, Basement _ Yes o Wastewater System Requirements Tank Size: Septic Tank: DDo gal Pump Tank: gal Grease Trap: gal Drainfield: Total Area: OSO sq ft Total Length 3� o ft Maximum Trench Depth � in o.c. Trench Width t Minimum Soil Cover: �n in Minimum Trench Separation: � ft Distribution: Distribution Box Serial Distribution Pressure Manifold 1 Authorized State Agent: Date: Z�i D'� Permit Expirati n Date: Z- Z The type of system permitted is Co 'onal ✓ Accepted Alternative. I accept the specifications of the permit. � Owner/Legal Representative: Date: CHD r v. 11/10/OS � � ♦ ��J�,� �,a ..�41 �J� . L� ti ...L` � � �7� .1L �l. .t ' �]la"9>'Il]C�e[Dml.7lY�.i�EJIl9.�.�1.A ��¢� � Ir1a1�e _ ��1 _Qh N�rk65iiV Subdi ' ian 5 (� . Authori.zed State �.�:nt �.1� 1. � �' U��i Jl Ta� 11�Iap #��.Pa�:�el. �r�' s�cti.an/Lo�#_ �re . _ Z- 2�}—�s4 � � Date .4', y�ar�a c�a�nr�i+ones��ts rtia�rn�r�na� a�i�bn�xra�te �cees��o�rs o�dy: i�i� crosa��r v�sasst f�ss� ��e sys7ts9n p�dor �� . b�,�s��'8,� a'hr� irss�taTf.a�ion fo s�,�srsre thut jir�o�i��gs�crd� is rvsrr�s�tai�c� � �. � �y� �'`�s� I� �hs �� '�'� , a � Sj,�,�,,,,� c9.� .P,vfrh�'�'. � 'y�u,r� Soi' a5 ��1'�- a5 /�6SS� b�� ' ��Q� ��ea��n (o-� .� ( � . ( s� �aC� �¢��, Q�d��o�al �I . � P. �ver s+(s�-ew1 � �ee t�el I ou-� � Poo� P -�-a o ra h P S P � �. �,` 5� laCpJv�v,n� Wl �, ��'t�CMi�,Q� 1-��u P ��,-F� 6 �r ;� S�Si��"� 15 9 l . V U�� Sc�� : � "= I60' 5�9' l2' C�� ni�.8�� ! �.�� 1 t 1 �. �( � �..J ' �� V --��``� =� � � �T��' °� �� ` ZZdR.iZ` � _T"1 "t"'1'� ��3 �c:Y� � � c3.��G�i1. Anpiicani: Loca�ion: �f�£T �� 3 � ��airC�� i� ��J� �� tn o o �u�OG .��-,�'itl,�� r? t/�/ �� c� s � l°r'�`�'^`�c -�.'�3�QQtZ9�rJi� ;M 1 � ��'-a� oo � � � . . . �� . S Jst�m Type (in Ac�ordance Wiih Ta�le Va): �� EZ THIS SYS�'�� iS �E�� i��i..�L.L�t� Ih� CO�#IN4_l.��C� VVITI-� �PP�.ICASLE . tUQR?H G�,FcOL1�A G�i1i��L S?�1TTt,JT��, ��3U��5 FOR S��iI��C� TR�A7'�itE�? �ND DISPOSAL, �i�1�D •�LL CONDlT1C3�lS �� ' THE 1fl�PR01l�i�lE1�3T P�3�ili �$�D GQNSTRiICTIO�i �C�T�l�� TION. _ � . . ��=. � � � -- � �-a� - � uthoriz�d Stat� Agertt Daie 1 nstalle�. By: 1'1 "� t'� Date: ��% Z-�-I ,ti J ' � '� '�o� ` u'll, �'� 4'`3��2 _ 3� .�,v,�.�. Q I2o' �Co�,/ . �Z ?CHC�; r�t�. G � 12�i��,� ��:� ;� 3� � �� i�� "i.�� a � � �� 9 a ��_ i� iVi�p .-"�r ��_ F2�C2� i Sys�e:� Type (Tahie Vc) � Z-) O��v�er�A�piic�ni � � S�bdivisio� � aw�err�l -_- Addre�s/Lo�c�ion Se�fPha�� L� :" �(v_ ��a�&�. T�tr�� a�i�a9��$� i`�o$E'ar�c��a� 3�� n�$�� c� i� ' S#a#e�ID/date � -�2 /o-21_Lg S _ �. � re�cfi UVid#� � fi�. ,� S. -i(� - Capaci S- ev al. � � Trer�ctt De�� in: Tea and Filier " • T.re�ci� Ls� th 3 0 �• � Baf�e . Tres�ct� Ga�a�+e � � Sealant Tres�ch S ac9n � . . � � Ris�s- ifi a�piicable) � � �oc� De and Qu�d"' . . � Tank Outie# Sea! � �am�lSte dov�� etc. � Pem-tan�nt ►i�a�icer Pressa��e Lai�rals � ' . ��mp �'an�s • � Hoie Spacina � � S$ate /date - . o e izs - � Ca�a ' ai. � Pi��. Sierve � . . Waie roof /Se�l�n# � Turn-u s1P.r�e�tors � � . Rise�- ��ui�d' �e�� Water Ti ht � � F�om� Welis . . _ ► � �-� . � � ��ana� �rom Prap�riy fines � Che�fc ValvelGate 1/aive Strvcturesl�aszine�is � � �� Anti-s� on o e � �ic� es / rainaa� .� � F�oais/Switches � • � �Surfac9 Waters . �iarm visai�le and a�tc�ibl� Public V��ater Sup iies �- � �ieciYical Com onenis • 4ter�icai Cuis >Z �i. • � Rate m .. 1I1�ater Lin�s � A �-oves� Pum i4�ode� Ve�iici��Traffic � � � ' 8loc� U�d�er Pump. Ad'acQnt st�ms � - � Pump R�movad Ro e/C#�ain • .��esn�nislRi hf of Vtla s . ~D'as�a�u�aon:��rn . O�ea� � � Se�ial �istribution - � 5 - �as�mer�s R�ard�i . � �ress�re �anrra e e �eratar orit�~act Lnw Pressure �i � � �r�-��rtaie A re��nes�� Appr. Pip� ►U�i�e�ial a�d G�d� �' - . Valves - � �a��a�ent� . . . � n�:�� . �r��c� ,r,;<< �� )�� 1� �i�� ..r�-� , l /� r � 'V VJ � li Jl �,.��:� ��--��.<�.11 1Hi � �..11��. ��I�Z�� 1��'�' (P�te�v��a�r� �� : � 3 ��Wu: 13g �aa�d'av�sa��• �a�: �� A��DflIlC�YB$9S 1 j��fl�: ��1�� i�6�Q��'ES�: _ ��Il�IDYi� 1�flflHIl�110��: ��:on ��-a�e�: �AS �� s��nit �oncd�8i�n�: �) See attached site plan for�roposed 1ve11 location. 2� All applicable State and County regulations gove�ning construclion and sPtbacks a�ply.� 3) Permits expire � Jears fronx the date of issue. // ��,�er �dnd��z�n�/�a�faaanents: �a�.r�ai:, a/� SeYbac�t � - � � v � � �-- ��-�a� ��a�es� �5�: �a�t�: 2 ' lli - D f EC�+ ��'�+'��'� ��' ��1�� +'�'�� I�� `�✓��Il ��n�p��ta��n: E /Date Location: Grouting: / �t.��lVell Log: �/ tiVell Tag: � P��1 31� l� 9 Pump Tag: ,�,c,�,,,�\� � o„ we ��-{ ag Air Vent: ✓ Hose Bib: ✓ �13y51� Casing Height: / Concrete Slab: � �a��° ��s��: EHSIDate Install_er: Depth: Grout: �� a��do��ae�a�: EHS/Date �ompleted: I�Iethod/Material(s): _ '�� le�-> �Vln� �.a��sa�e #: Pump Installer: " License#: �I�� p�r��a� ��: �2c� f� �a�e: U`' oC.S'1c�9 Date Sample Coilecteti: ��,5_��_ P�:son Counry Environmental f?ealth 3�� S. l�iorgan St.; Suite C Roxboro, NC ?7573 Date Results Vlailed: {' 2- d rhone: 3�b-�97-1 �90 r'ax: :36-�97-7808 8/1/03 � .. _ .. . , . . � NorthC�rolinaUivisionofPnb�oHealtb . . . . Occupa�onal and �nviromnental Epideminlogy Br�mch, Bpidemiology Section INORGArtIC CHEMICAL ANALYSIS REPORT Prtvate �eIl r�ster inform�uHon �tnd recommcndatlong County: �fw^ Name: �'� '�1 ' Sampla Id Numb�r: ��9.9� Location: • Reviewer � �i ANALYSIS REPORT � Your well water was tested for 15 metals, plus nitrates, niirites, and pH. The results were evaluated using the federal drinking wa�r standards. The pH is a measure of the acidity of the w�ter. Drinking water may contain substances that can occur naturally in water or can be introduced into the water from man-mada sources. ('These recommendadons are based on inorganic chemical analysis o,�.) TEST RESULI'S AND USE RECOM144�EENllATIONS Your well water meets federal drit�lCing water'standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering. _, The following substance(s) exceeded federal drinking water standards. Your water can be use� for drinldng, cooldng, washing, cleaaing, bathing, and showering, but � problems such as bad taste, odor, staining of porcelain, etc. may occ�n�. You may want to install a house�old water treatment system to address aesthetic pmblem�. The following substance(s) exceeded federal drinldng water standards: We recommend that your well water not be used for drinkinQ or cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing, and showering. Re-sampling is recommended in months. . .. Re-sample for lead and /or coppe�. Take a first draw, 5 minute, and 15 minute sample inside the - house (preferably the kitchen) and if possible a first draw, S minute and a 1 S minute sampla at tha well head to deterniine the source of the lead and/or copper. Contact your local health department for re-sampling assistanco. � OTHER CONSIDERATIONS � Routine we11 water sampling for the above substances is recommended every two to threa years. Sample your well water when thero is a lrnown problem or contamination in your area, after repairs or replacement of your well, or after a flooding event. Contact your local hoalth departmont for sa�npling instructions. Contact your loc�t heAlt6 department for more Inform�tloa er to to p�tp�//wmv epl et�te ne%dVoiUp�factsheet.html MarcB 10, 2009 North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Address: 88 Harvest Rd Zip: County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Ste C Roxboro NC 27573 (336)597-2371 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Courier: 02-33-15 Collected By: J SMITH Date: 5/5/2009 Time: 3:50:00 PM Location of sampling point: Well head Remarks: Permit # A31 -138 } Parameters Results Units - Date Analyzed: Silver <0.05 mg/I - 5/6/2009 Alkalinity as CaCO3 151 mg/I 5/6/2009 Arsenic <0.005 mg/I 5/6/2009 Barium <0.1 mg/I 5/6/2009 Calcium 30.1 mg/I 5/6/2009 Cadmium <0.001 mg/I 5/6/2009 Chloride IC 8 mg/l 5/6/2009 Chromium <0.01 mg/l 5/6/2009 Copper <0.05 . mg/I 5/6/2009 Fluoride 0.68' ` mg/I 5/6/2009 Iron <0.10 ' mg/I 5/6/2009 Hardness as CaCO3 (Ca,Mg) 101 mg/I 5/�/2009 Mercury <0.0005 ' mg/I 5/6/2009 Magnesium "' 6.2 mg/I 5/6/2009 Manganese 0.08 mg/I 5/6/2009 Sodium 32 mg/I 5/6/2009 Nitrite as N <0.10 mg/I 5/6/2009 Nitrate as N <1.0 mg/I 5/6/2009 Lead <0.005 mg/I 5/6/2009 pH 7.3 Std. units 5/6/2009 Selenium <0.005 mg/I 5/6/2009 Sulfate 7 mg/I 5/6/2009 Zinc 0.08 mg/I 5/6/2009 Date Received: 5/6/2009 Today's Date: 5/19/2009 Report Date: 5/19/2009 Ref: 6278 Login Batch: Reported By: �-1,L�i1:' """ """ '` Sample Number: AB88995 Explanations Coliform Analysis: , If coliform bacteria aze Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Section BIOLOGICAL ANALYSIS REPORT Prlvate well water information and recommendations /J .� County: �� Name: � ��4` _Sample IdNumber: � �S�J Location: � Reviewer ��%� Your well water was tested for biological contaminants (total coliform and fecal coliform bacteria). The results were ev�luated using the federal drinking water standards. Drinking water may contai.n substances that can occur naturally in water or can be introduced into water from man-made sources. Total coliform bacteria are found in soil and fecal coliform bacteria aze found in �nimal and human waste. Total coliform or fecal coliform bacteria in well water indicate that the well may have structural problems or that the well was not properly disinfected. BIOLOGICAL ANALYSIS RESULTS AND RECOMMENDATIONS FOR USES OF YOUR P ATE WELL WATER (These recommendations are based on biological analysis onl . No coliform bacteria were found in your�well water. Your water can be used for drinking, cooking, washing dishes, bathing and showering. Total coliform and/or fecal coliform bacteria were detected in the sample which indicates that hatmful bacteria from human or animal waste could enter the well. Do not use the water for drinking, cooking, washing dishes, bathing or showering unless you boil it for at least one minute. If you have been drinking the well water and are pregnant, nursing, have a child in the household under 5 years of age, or immunocompromised (such as an individual with AIDS, cancer, hepatitis, dialysis or surgical procedures) inform your physician of these results at your next visit. There may be a problem with the construction of the well, the groundwater source, or operation of the well. The well needs to be inspected by the local health department or a local well contractor to determine the problem with the well and to give guidance on how to correct the problem. You should re-sample your water after proper well inspection and disinfection to malce sure that the problem does not continue. If the contamination continues, you should investigate the possibility of drilling a new well or installing a point-of-entry disinfecfion unit which can use chlorine, ultraviolet light, or ozone. Contact your local health department for more information or go to httn://www.epi.state.nc/epiJoii/hsfactsheet.html. Aiarch 10, 2009 Report To: North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH �'. 325 S MORGAN STREET ROXBORO, NC 27573 Name of System: 88 Harvest Rd P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 htta: //siph. state. nc. us Phone: 919-733-7834 Fax: 919-733-8695 StarLiMS Sample ID: ES050609-0014001 Collected: 05/05/2009 15:50 J Smith IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ` Received: 05/06/2009 08:35 Angela Heybroek ES Microbiology ID: 4545 Sample Source: � New Well; ! Well Permit Number: GPS Number: Sampling Point: ,, Well head �. A31-138 Sample Description: `� Comment: Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert �- Analyte Test Result Analyst Date Total Coliform, Colilert Absent Benjamin Saavedra 05/07/2009 E. coli, Colilert Absent , Benjamin Saavedra 05/07/2009 Report Date: 05/07/2009 Reported By: Joy Hayes Page 1�of 1 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. 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. ,� Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mg/1 No established limits 0 Iron L-ead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 Z��fo 4 �� C,�- C�- �- ��,t/�� l � 3��i��, � �. �_ c� � �,.�,-c� .� ��•�k� �-L, � �`; v�� 5�� VIS(�" ��'o `r'Ct�� -?. ��Z Q� ��I'y��(C� s, /\ Y C-'a%',�P�' t- �ji�`�"j,� Orl °�p c4t'` c%r�+J+� r'1r�;(c.:d� 1�'"►r�'y�o' �!� �'� %� �f��1C�5 /� �;c�rCr�� / ' �. �'' � 1 ' -�� ' c� ��? � � ( I r'l � 1 r �� ,�`'� '��' ( � . .-��-'--'�- _.--'--� . rti1�1�F ��/�___`1 ---�_�_..- � � � � "__" -ir�c�� _,___�___ ��_�