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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
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Bacteria _ Chemical _ Petroleum _ Pesticide
1. Pe
er ros�eC[lve
CCSS: . � �) 3
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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.
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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
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Installed by�' � Approved by
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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
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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�
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Date: 5 /�( _/ � �
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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
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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.
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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 #:
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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