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A32 189���.� Amotint paid Rece�pt l� ' " .� " �j i 0 `� O � � w U � a W � z d a a�. o� �° �e�- ..� �- 0 �g �!� �-9� '2� � - Date ts Permit.(EstablishedlRecorded Lot) I Reinspection of Existing System (Loan Closing) mt�ovemen[s Permit (Unrecorded Lot) � Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) _. Permit for New Well Improvements Permit (Addition) _ Replace Existing Well t z � � x Y eh y . <s L .ii '. ..A..K " . J F �s ... a z � h �Y �:;�'� s .7�' �,_ �;�y.�� '" = Kx ��� s x� � 2j "' s V�'aEerSariiple {o be' Collecfed �s=�,� x<Y�.,� . �, �. d �. . r,..- s S � �` y . s� �u .,. : � .,. ..,.�.�... �....-%�.,.a>.:. . .<,<. � i:?> ..,..; �, ., R. -� :•.�`.'a ax�,W.:.�-H >,.. .i. r: .:, ,a,.<���.s �...w.R,.:i�x...y'�N. ,:.e>. r.,.� .. Bacteria _ Chemical _ Petroleum _ Pesticide 1. Pe er ros�eC[lve CCSS: . � �) 3 � . � ome Phone #: (��(lq � `�Sy-�l3�01 usiness Phone #: 5�1.`1�' � Name and addre&s of_current owner: Property D Ta Max p#: Parcel#: _ ion: Lot size: 31}c (zES 7. Dimensions or Proposed Structure: �rr�►�( Width: �7/ 5/� � T__�L_ iw\.0 � �� . Directions to property: State Road #& Road ✓y�l15 20 Number of occupants or i d p�� iv! e/� to be served: _ Lead 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility �hat this sewage disposal system is intended to serve? 9. Water supply t}•pe: private � . public ❑ community ❑ spring ❑ Are any wells on adjoining groperty?Yes ❑ No � If so, identify location: 10. Type of structureJfacility: Proposed: C�Existing: Q I Type of dwell' g: � House: Mobile Home: C� Business: ❑ Type of business: �� Number of Employees: �— Number of bedrooms: Garbage Disposal? Yes No � Basement? Yes ❑ No�If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerSOit COL1Ilty �ealth Depal'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree tha[ the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. wi[hin 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. � . \ � Authorized Agent w � • A • t , � .._ _ � Vy d a B 2814 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCAT�ION IMPROVEMENT PERNIIT , Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # A�� Parcel # 1� i Zoning Township s c,[��t V Fo rK Owner/Contractor ci V � q( ��Q V �sr ��'�� � 6.., Date 3-17-9 �i Location/Address 15�5 remQ,;,� nn i�f(�rGY/e rVli/l� f`�C�' �-�055-�C� ,r� V1��5 C�e- S.R.# Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Lot Area �.''� %�G � Size of Tank SFD ✓ Mobile Home Size of Pump Tank U i� Business # of Bedroom� Nitrification Line s�� ��� � _ Max Depth Trenches o?� o?S� `� . SC/� �O �VC 1��-�'�t Permits may be voided if ' e is alter d or ende use chang . Well and Se La out b 'U � _,/ .�•....,...,......,.. p�n► n �Itu �i � 1�11 �!� /, � �i��'I /, I`�iL J Installed by�' � Approved by _,_,� , � A I Well Permit Paid WELL SYSTEM SPECIFICATIONS Individual v Semi-Public Required Slab ,J Public Replacement Air Vent ✓ Site Approved 1/ Required Well Log � llq�� C,�j � Well Head Approved � Well Tag �/ � Grouting Approved � `� (0 �-{05� 6i b ✓ _ Date �'0 Installed by_ ��/Q��,� OApproved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person Cou�ty nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l O.B. 182, P. 489 � MACNETIC ts .,-...,..__ ,-�..., .._.._ � . _ . . _..., . _r�... . � S`�i�. �� � � �2��� .,, STATE OF NORTH CAROLINA . ' COUNTY OF PERSON � " '�` . . � .� • . ,. - � . I, ����A_�✓���� _, REVIEi� OFFICt�R 4F PERSON COUNTY. CERTIFY THAT THE MAP - OR PUT TO wHICH THIS CERTIFICATE IS_ AFFIXED A�EETS ALL STATUTORY REQUIREMEN'rS ,'� FOR RECORDING. `' �` 'p� , ��i�•SlS �� � � � . / � . . REVIEW OFFICE1�����---- -A-- �� - TE , � e-� � �" � �1�I� _ . 0 � �� ��\ -� � 3 \ S?��69,35� ��\ ` ` � 39 �35"ly � � � IS 31.93' � f` � �� �� � , � N� _ � : � � . �, ��' , :; � NS 4 ��2' J3 „E �--- - - ____�'� �_`l== �. • 1 ' ````---- N�.�. . . .._...._..��._.� �.�-.�wi.�+www. .�, �...J,..�......... . .. ... _.. . .-. ..-..�.�. ... .-;.p....--.���-w. 4T�aMunai;rs:3iYM:�'Y :qy!�RMCe1Y1�� . � 0 D.B. 182. P. 489 � MACNETIC IS S�3 � �, - � .�� ,��„ , J 2 �.� COUNTY OF PE � � S �,x :a��, . i r� . � � �V � �����_�✓�, .,� ��� j� �, e x� Of PERSON COUNTY. -CERTIFY 1��.�� � �7 ' OR PLAT TO IMHICH TNIS CERTIFIC ,�"7;�� AFFIXED �IEETS ALl STATUTORY REQUI � � :;. FOR RECORDING. � � / � _�� . �S _� /�� y' Yt `v _l__�__ — — r �r. '`����C ATE -.�;� REVIEW OFFICER . , .; 1• � ��► . •. 1.� � � � � � ' . IS ` \ . '�� —. � � ` 1 \ ` S?� 39 / 3S\ ` � \��35Nw \`� 31.93' ,• \ IS � i" j�' « =�, F,; " � � � / �- , � : .; � ,s , i ; t, ,{ . N' 1 �-� . . i „ + y �> 'r ; j , ��w � � �`_ 4•Q� � 13�E �._., t..�+ :'' � ��s9 91' , , . ,... �. �..r.:t.,�, ' -'' � "�NS �'`�* r;`` N � � / ; ':y; . , ,f.�„�r �r,,,.�: ;',�., . ::;•. . } • f�` +.ww.s�+�e�1P� ' , __.— __, _—__.........,.+..-- — --- -- _ __ .. _....���ri• ,.. , . ..:... ... � . . �.�i:r,:-.c,r� cuu�v•r�- i:NVl.ltONP;::rt•t•�►i. tu;nt,rt� . . . ":�• . • a.F� . ��� � . . � � I��i���. I����� � Date:.��-l:s '� `^ . • Owne;r: �-_�>.:y . C ;- � -r�,� fti I.ocation/Du-ecti�ris: __._.��./,-�-� /� rn: //,s .. ._�._...__--------� S�#�� .. . . ��1._ . .............._.� . ----..... �U�,_'!visiOn Nairic: ..._ _._ - • ------.. � ,ri11�n� Con t�-acto.r• .�✓ . s � �J ..�I.._... � . . ... . = Lot �� � ...^ , .. - �L.l__��-c !� � � ._._.�- r? C._ - --.�. ..... . �::t.?.� ........ C. � ' Distance � 1'�.f ;1.[ ..C:(:7Nti_I'IZ_UC1'i(�N . � . from Nearesc 1'ro��c,-�y 1.,u�c:.__..__..��._ • /u.� '�• . . Pollution .�, d� u�- �. -� ll�,,�,111�� lrom Source o,f ' Total �D�p.th:. �� �• , � . Water $�earing �Gones: De; [t1i 1` ���--`�-v--- �- �'�'M .�t�llic Water Leve] : P _�-...-.-._.....1'r. (��� � �F Casing: Dep�i: Fro:i�_ .��: _tc> . � .,..____.._'1 �'�_Ft.��t. . TXPE: Steel . ��'�" ��:.I��. Ui.�mctcr: d � ,.�iches Z.f Steel d --_._.G,liv.�ni�cxl Stcc] v�— , , .: , oes owncr a��pj-ov�:: a'c:� No . . ' Weig�it:�_'I'liickncs�•: ��,� • --' � � ' � � -Ic�ghc� Gro , � ' .1�rive Shoe: Xes_ �/ N _ ��'0V� ��:--___�____rnches� . � . . Werc Problcros Liicvuntcrc 1 � �Sctti � . .. .. � ., „ c�rt ttt; �}tc C,,S�1� �'� Xes --- �f ycs bive rc.iso�i: � b ___ No �:. •. Grout: .Type: Neat � � S,i,ul/Ccment �� . �. A.iuiular•Spacc Wieltl� ------.Coricre[e ' • '���%�� ._._:3...... �f�►chcs `.f;t� Water in Anni�l•u- Sp:�cc: % . . N � . • ~"�. Mc[t• ` � c:;... _.__. .___._, o_____ �/" . . . iod: Pw�ilx:c��� I ., llCPC}]: 1"IOill,r_`_�__. . .. �j��'::::►11'l:.___-. ___-. � �t11.(CC:��__. `� � .. . . ' �'f .r, ._... !tr � �'l. . ••, MateriaLi Usccl: No. ,C3,i �.� , . - ��..__�._ • �, � c�r�l:lliCl CCI1lC11[` yV , ���������� .; ;t Z�Fmix[ui-c (slild, �ravc�]; cutliri��ti) �Z • _...._ c.�ghtofl�bag,,,,�—�--==1b ;. .�� ��tic�:______.� �• ,. Plates: Xc� �� " — to •.�„'� � ..____.--__ N<�_ _ . .. . _ : • • -. � x �� ::lab �'c� � No____...___ __ .. .- •,�.L _:. b�—�---------_..._---.._ - --..1� l� I 1.l .1 iyC. � ( .�X' ' ..._... ...__..._ � _....--- _....__.._._ .______ �'l')II11ZIlOiI i�rcrr; -� ---�?-.1=$_�� . .. . � ` �r.�tL�1 _.:, Z �EREBY CEIZTZFX rI'f-IAT `l'I-IE �.I3(�VL iNFURMt1'1'!ON T�S W,ELL 1�rAS CONS 1'RUC"�'L1� �� .• ZS CO�RECT AS fiORT� BX•TkI� PERSON C:nU.N�'Y (•I1:/1T;I'0����C� WITI-� REGULA'I`Z� .. . �n�, rM�N r. � --, . �.:�� __.,,�.�� : .Si�,�t.iturc c�l'Cot��i,c::tc,r __ �-�,� �� � ' �� � ��� � � `��~ � ��������� �L,�a 7t'11�Y' il II °+C� IC1 TC2Cit d:: e[ a1 �:uG`L !l ��� L sC: �t3L .1 i�: ��'A Date: 5 /�( _/ � � � � �. . .. �. • � � - � r �i . II , . u Re: Bacteriological Test Results Dear Well Owner: Tax Map: 32 Parcel:�_ Your well water was sampled on �/ ZS /�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacterio[ogical results only. ✓ 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. Fecal coliform bacteria aze associated with animnal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If co[iform bacteria are present in your water sample, the water may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positiv�or total or fecal col�orm bacteria should be properlv disinfected and retested prior to resumi� normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, r ���� Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, fax 336-597-7808 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: ESO42617-0069001 � ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ES Microbiology ID: GPS Number: Sample Description: Comment: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Name of System: DAVID � JOY GRIFFITH 9339 HURDLE MILLS RD HURDLE MILLS, NC 27541 Collected: 04/25/2017 14:10 Received: 04/26/2017 08:30 Sample Source: Well Sampling Point: Well head J Smith Susan Beasley Well Permit Number: A32-189 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present 04/27/2017 E. coli, Colilert Absent oa/27/2017 Report Date: 04/28/2017 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. � � �� �y ���� `�` � �= � . % � �� '�� '� i � � y �P 'S" 7� y o��� i � t .. ��� • /"� � �.. �5�,,. "� ����� �'P � ��� � � � � ��� � � � � ��.. � � ' � ' � � ,; � � � � + w,, 3 c�� ���� 5 � � ` �t� � � { h w�.w � ` � *� � x � a. }; t �,:� � � � : ds ..e� � � '� � � � �j n � �►> ,,; x�-p �,,� � a � `�, 'i ���R �.��( ry,'r¢ kroJ � � YytR C., f �Y,}�y�''#,� . � •J f � � � �� �.,�� �. �� �. `.� x��� ; ' F ,�. `h� �`� ,�."�� �� ��. + ��aYr. 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'� � � +� .'��, , �'` � ' � ,�� � , t � ��� �� ��' � n �'�. ^�����4�, �, �� "�� R� . � �x d �6� �. � � , � � � x s R � ��3 �-.�Y�°� �� ��� � �4�� X.D �� n� 3"� '�@ ° q a.� y.. � � �,� '�� � � � �� � �. � ���z. � `� ��'�'�a R��� F�� � � �� 3 r - � ���. � � ���'^Y"� xR 9t��tr',y x�''� � a �'� �'� �?;$:�'�'%a`�,'•t�a�;„� �' ,.«�d �;'� �' r .. 1:9,028 0 0.075 0.15 0.3 mi �—�i ' rT� I i� 0 0.1 0.2 0.4 km Esri, Inc, Person County GIS For Reference Ony -Always referto the original source. ���� lil �f/1 — ne department af heaith and human services County: Sample ID #: ��E:a t g � � F � � k t �T i �� l; r° F' i � ���;���I1�� �.� l�r-��� �� 6i��'� � �����.�..�i�g�� y,,..�.... [� [ ? y,� � iv. �f f--�; "" � /—` 6'•,,i �"! ,--„s �....:� � � � � � � ,��: f•.�1 ��, �'� (��. � � � ] � �� E �� � I � 5 ''a f i � � ` t�"t t ,' �....,.�' �.J' �"��' ti `�`�. i..r ✓` \._/ € i ,'� �� � ` ,� � E � ' For Inorganic Chemical Contaminants Name: '� Reviewer: � � TEST RESULTS AND USE RECOIVIlVIENDATIONS 1. 0 Your well water meets federal drinking water standazds for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor,eanic 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 orthe 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 water treatment system to remove the circled substance(s). However, 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 Manrsanese Mercurv Nitrate/Nitrite Selenium Silver Magnes►um � Zmc � pH 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 (ow sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inor�anic 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 15 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 inorganic 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 Iro Man�anese Selenium Silver H Zinc For more information regarding your wel! water results, please cal[ the North Carolina Division of Public Health at 919-707-5900. 0 North Carolina State Laboratory of Public Health 43012 D�st�ct�Drive Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncpublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH DAVID & JOY GRIFFITH 325 S MORGAN STREET 9339 HURDLE MILLS RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ESO42617-0037001 Date Collected: 04/25/17 Time Collected: 2:10 PM Date Received: 04/26/17 Collected By: J Smith Sample Type: Raw Sampling Point: Well head Well Permit #: A32-189 Sample Source: Well Temp. at Receipt: 0.5 GPS #: Sample Description: Comment: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L o....:.,..,. � n 4 � nm m�/I Cadmium Calcium Chloride Chromium Copper Fluoride 5 Iron Lead < �.0�� 25 6.60 < 0.01 < 0.05 < 0.20 0.70 < 0.00� 5 < 0.03 < 0.000 Nitrate < 1.00 0.005 m m 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m m 0.05 m 0.002 m Nitrite < 0.1 1.00 mg/L p H 7.4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date:05/04/2017 11.00 7.00 0.05 Page 1 of 1 m 250 Reported By: .�Cennet�i Greene Date: � / g �� � �'""� � , � ,� ��� � ����T��� � ;����x-����:n��.�ti� zE �t�.:���►5�:�� /�_ Name: Qav, �{- Jev Y< i�ri�_ Address: q� �r��C /�r��s �ral�C N�; IiS.TA/G 2��! Re: Bacteriological Test Results Dear Well Owner: Tax Map:�� Parcel:�_ Your well water was sampled on �e / 5/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: I/ No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. 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. Fecal coliform bacteria are associated with animnal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the water may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive or total o�ecal coliform bacteria should be properlv disinfected and retested prior to resumin� normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmentat health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, u� , Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant �a��d ��ou �1r1-�� � Address q�R r � �l/�S {�.�_ County � Collected By \ 5 Date Collected [n- 5-("1 Time Collected 2: oa Source: � ❑ Spring ❑ Other Location: ❑ House Tap �V1�11 Tap o Other ❑ No Charge ��iarge (�e-Sax�cp(� / ..............................................................................� *****�********************************************************************** Total Coliform Results Present ❑� Fecal/E. Coli ❑ Reported By Date Reported �' � � � , Report Calied a YES ❑ NO Called To (�"�T�"` Absent