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A32 21Application Date: � S' � �Ktt i8g� �� S q _ Amount Paid: � �� (50, o� `� � �•� f �� Receipt#: i77117 S� 33s� �' �� ]Effi��r��¢�.11 ]H[�mIl� �-� � g3 � A lication for Services _ 5ervices Requested 8'Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building . $150.00 (if site visit required) ❑ Well Permit (l�iew/Replacement/Repair) $300.00/$200.00/$75.00 Tax Map: /�32 Parcel#: 21 Ca 11 �o nn ee� 0 ConstructionAuthorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: M►eNA�.� �t't�.►�S SNE►iaa.� I Stwc,►� Suc�� Address: y�� CHA.r+�S Qowc '�u�aw�d.tr . a� 2�57'Z • 2) Name and address of current owner (if different than applicant): Name: V�[iC�N�A Caa.o�Ya MoaK. Address: 2Z C/'rnnf3��DGE f�2we �k �o Q p. .+.� c. Z'7 �'7 3 Phone (home): 9� 9- g� i-�\ (work/cell): q� y- �,� �-3�o i Phone: w� A 3) Property Description: Lot Size: 7 Subdivision: Lot #: ��. . Address and/or directions to Property: 'Fe�r+� 1-Luao� nn,��s 2carz - Twcr► �qT oaa C'�U�S �LpMO —' 01L � w!!�. '��2 M� lES ' FKLI.G hIWc.J1< SL�y►D � ❑ yes no Does the site contain any jurisdictional wetlands7 'Brr,�� `�o� Go �c¢.oSS �23oG,� ,'Tµ� �� ❑ yes 0 no Does the site contain any existing wastewater systems? `-'�� '3� ov Yo��. �FT. Ta� �S w*i ❑ yes �no Is any wastewater going to be generated on the site other than domestic, sewage7 S�►�E S��"� -£oo�� / � yes C� no Is the site subject to approval by any other pub(ic agency? �o►..tic� 3 ��y �' �� `� ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide, supporting documentation) 4�) oposed Use and Type of Structure: oResidential ' eC�Single Family Residence Maximum number of bedrooms: 3 / Occupants: � � Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes 0 no With plumbing fixtures7 ❑ yes � no ❑Non-Residentia! Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: N? New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground .water restrictions or sources of contamination: 6) If a�plying for `Authorization to Construct', please indicate preferred system type(s): C3'Conventional O Accepted ❑ Innovative ❑ Altemative ❑ Other � Any I certify that the information provided above is complete and correct. I also understand that :f the information provided is inaccurate, the site ' ubs ent�ed, or the intended use changes, all permits and approvals shall be invalid. �.. ,�.....Q �� ,1� l ►� Signature (Owner/ Legal Representative*) . Date * Supporting documentation required. • Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��,s� ��.� �� C��T�� 7.C�e �rn�n. �r � �rn,•-,Y„ � arn ��.Il. IC� � „ffi.Il �I�a Tax Map: i�32 Parcel• 21 Subdivision � � Phase/Section/Lot # / Improvement Permit Permit Valid for: Five Years 1/ Non-expiring Type of Facility: $;,,c,(,� �Q,,,,�� I�w�P((;,b New �Addition Water Supply: J�� ( � Number of Bedro�� / Oc upants�_/ Employees / Seats: Projected Daily Flow:� „b gallons/day Proposed Wastewater System: �1_1,_�s°I. Qv��+',cn-�Sf�,� TYPe� �--- Proposed Repair: ,� �eL Type: � Permit Conditions: �,' � � - �.�f�cn-- a jl-� Authorized State Agent: (X) Owner or Legal Re Date: � 2(�-/? Date: �-2 ( -1'1 The issuance of this permit by the Health Department cioes 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 mtrl Rules fbr SewaFe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system witl continue to functioa satisfactorily in the future, or that the water sapply zvill remain potable. �.. Authorization to Coostruct Wastewater �ystem See site plan and additional attachments (�. Proposed astewater System: ��,,D(!� �25� ��cr� �u � (*)Type� .Design Flow �_ ga(./day New Repair _ Ex ansio�i— Soil LTAR: gal./day/ftz Type of �acility: ' ' — Basement: _ Yes _ No (*) System Types Illb, IIIbg, Iv, and V, require p2riodic system inspections by the Person Counry Health Department. Wastewater System Requirements Tank Size: Septic Tank d00 gal. Pump Tank - gal. Grease Trap � gat. Drainfield: Total Arza DO sq. ft. Toial Length OD ft. Max. Trench Depth � in. a•G. . Trench Width ,3 ft. Min.Soil Cover _(� in. Min.Trench Separation � ft. Distribution: Distribution Box ✓/ Serial Distribution ✓/ Pressure Manifold Specifications: �gria i o� iS�nl�u�ion er t�`�bax 6� ; S� �-loox ,,,�� ,;, �a � lt��ri�es Issue Date: �_��(7 Permit Expiration Date: /-24-22 Tlie system permitted is: Conventional /Acce}�ted v/ Alternative / Innovative . I accept the conditions and specifications of this permit. � (X) Owner or Legal Representative: �� ` Date: � Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) � �� .1�� ]E�v�as�---^-��o�.Weo.71' lE'��o.�lt¢]�a SITE PLAN � . �- -`�� Name f vi ��q oi� �t�,�.. Tax Map# f�32 Parcel#1 Z( `�� 11 � Subdivisio Section/Lot# N Pc ��y , /-3a-1 ' J �:Authorize Sta:e Agent �ate �RON G � � . �, w � 08 67 b` System components represenl approximate contours only. The contractor mustJlag the system prior to beginning �he PB �: � `�`- � installalion to insure that proper grade is muintained. . . RECN >, L 12 � Note: An Accepted system may be used in place of a conventional system without permit aulhorization or modifccalion. A- -- _ — _ _ . I � . L13 S 85��a�z�� F lfj0` r_ � . � � '_ - . \ ' Z � r,. • � � ; � ��, , w, , �o � � t � � a , 1 � , . w ', /' �9 . � . �8 �. � , � � �F�a�- R►vtr I�a{tr cd ��rorc�E�►/ ( i�l�le,ll Sik. -�c�b(e, CoKfact� E!f o�ic � �� O CAIL OIANE `PEEO RICH UB 897/804 PB 11/98B RECN 23752 Z w �: � N � � r c„ �n�+� ( Sys� --3�� 3 BR . <a, — 3 00' l� �c�c� �s �4 � 3(�" I �cncl, �o� — ser�al �is{r;%ix{ion ar' 7-box OIC; Z� ��loex r�ta�ti�!'a�,� �c�a� ltnq� �lrteS J � 15'36'34^ E i00.� flfl � 3 ,N � v � o ,� N � � ------------ AMBER LYNN OB 892� PB 12/ RECN 2� � �� N �� - o°------------------ � JOHN D '& R461N f � DB fi5t/� PB 12/8 ^ � RECN 24i n o <c M � � � s�.��, _ � j1` �� t , g�•00' �� 'W �. JOSEPH & PATRICIA EARP 265.57� �`� DB 695/524 �.` PB 12/810 . RECN 24855 DIANE PEED RICH OB 897/804 PB 11/98B RECN 23752 . , . .` � , , . . � . . . ��,s� ��.�� ' �- C� � ��T�� I��n�a��a„-„-„ ��a��.Il IF��.IL�I�n. Tax 1Viap �2 �arcei # 2�_ Subdivision Phase/Section/Lo # ,�l # of Bedrooms 3 Applicant: ' ,, � Location: �► r�P ,� i I is '�I ��! �,��' �s � � Gaf- r� r L` r� �� iv�� n�l[1P Operation Permit System Type (From Table Va): Type V& VI Expiration Date: Product (IIIg): �v� 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 Authorization. �2' � � ( uthorized Agent) C�rv�rcv► (�o��r,P (Licensed Contractor) 1 Scale �_ PCHD, rev. 12/14/12 8'-10-�7 (Date) S'-10-r-t (Date) Line Length va ' 2 /oo' 3 �� Total 3�' Taa Niap: 3Z- Pa�cel #: 2� Septic Tank System Checklist (Type II-I� Notes: & Date: ..r.. �, . Riser (6" NEMA 4X Box Model: Piggy back plug Hard wired Alarm functionir Mounted on post Above grade (12 Conduit sealed System Type: � Pump System Checklist Tank � InitiaUDate Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes: ��.sf ��.�� --�- � � �� lE�.��m��.Il IE3C� a Il�l� WELL�PERMIT (New ✓ Repair_) Tax Map: A32 Parcel: �_ Subdivision: Applicant's Name: -�,�,,;s .� �.� _; o Sl„rr,�. Mailing Address: �{I� hn , �_�. 2 Phone Numbers: Q l - Location of . 7 Lot: � ��L Permit CondiNons: 1.) See attached site plan for proposed well location. Z.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.J Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: ,/L�a,:,�fv�� o!/ sHF�a�rXs Permit issued 6y: �._ �� _`�--�� Certificate of Completion �1ew Wetl: S/Date - Location: � —Z3 - ��( Grouting: -z 3 � � Well Log: �/ � Well Tag. 3 Pump Tag: �/ Air Vent: ��-��' Hose Bib: Casing Height: ,/ Concrete Slab: Well Driller: �� Pump Installer: a Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 5. Morgan St.,Suite C o..,,ti,..., nir ��c�a Date• j � so-� � OLiner: EHS/Date Depth: Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: ��,-'�-� Date Results Mailed: Phone:336-597-1790 Fax:336-597•7808 ,,,,�,,, W tLL I�UNJI l'SUI� I IUN CiCIiUtSU IIIYY'11 1. Well Co ractor Inf tjon: I �" Well Name �� 7� NC W Co�act� CatiScation Nnmber �.m�,J /,�� . r.,��. � b� �� 2) 2 Well Construction Permit #� 1(Jd` �..L � Lista//applicable�va//co�sYroctionparnuts(i.e U/C, Co�arty, t� v riance, at�J 3. Well Use (check well use): QMrmicipai/P�blic (Heating/Cooling Supply) �Residential Watez Sapply (single) m�mercial �Residentiai Water SuPPtY �� Recdiarge �Gioundarater RemediaYi� Storage and Recovery �Salinity Barria Test �Sto[mwaYer DraiIIage �tal Tec6nology �Subsidence Conirol mal (Closed I.00P) �Tracer mal (Heatin¢/Crn1inQ Rehiml �Other (exulain tmder #21 F 4. Date Weli(s) Compteted: �� Weil ID# 5a ell tocation: ` o i�e SG� el'�%O/1 acility/Owna Name Fac7ity IIJf! (�f applicable) ��,�,�� 3� _� I � on �. — r��nxo. t�� 56. Latitude and longifude in degrees/minutes/seconds or decimal degrees: (ifweil field, one IaUlong is sufficieat) w s. Is(are) the well(s) ermanent or �Temporary 7. Is this a repair to an existing wrell: �Yes or � /Ithis Isa repalr, BI/ail�bwwn we//consb�rctial iMarmatfonaRd explain the nature ofthe repalr�nder#21 remarkssedia� oronthebacto/Uris torm. 8. For �eoprobe/DPTor Closed-Loop �eothermal Weilshavingthesame conshudion, only 1 GyV-1 is needed. Indic�te TOTAL NUMBER of wells drilled: / 9. Total well depth below land surface: �,� (ft.) formultiple wel/s /Is1 all depUrs If dille�eM (ezample-3Q2oo' m,d 2@100� 10. Static water level belovr top of casing: �� (ft.) /t►vater /eve/Is above casl�p, use "+" ! 11. Borehole diameter: � ' ` (in.) ' i2: Well const�uction method: ��,.N r D• (i.e. auger, rotazy, cable, d'nect push, etc.) FOR WATER SUPPLY WELLS ONLY� 13a, Yield (gpm) ��/ � Method of test: � 13b. Disinfection rype: � Amount: l� �� rbr tntetvat use Un1y: � 22. Certification: . � �-z.2 � 17 S� Catifi dor Date By slpnir� tl�is tomx / hereby certify Uiat tlre we//(s) wa� (were) cautructed tn accardance with 15A NCAC 02C.Oi00 or f5A NCAC Q2C.OZQD Wel! Con�truction Srdrwdards and thala copyofffiis recoNhasbeen pradded to tlre ws/I owner. 23. Site diagram or additional welt detai(s: You may ose the back of this page to provide additionai weIl site dehails oc well consttudion detaits. You may aLco attach additional pages if necessary. SUBMITTALINSTRUCTIONS 24a. For All Welis: Submit tfiis forca within 30 days of completion of well construdion to the following Divisfon of Water Resources, Information Processing Unit, 16i7 Mail Service Center, Raleigh, NC 27699-1617 246. For Iniection Weils: tn addiGion w sending she form to the address in 24a above� also submit one copy of this form within 30 days of completion of well construdion to the followin� Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Suoulv & Iniection Welis: In addirion to sending the form to the adcicess(es) above, also submit one c�py of this form within 30 days of completion of well wncttucxion to tbe counry health depaRment of the coumy where constcuc�ed. . �� "� � , � � � `--� v "� '�� i � ,[�.�;.��,s-:� :r-.��:�� .� :�, s �,.:1 1[—i[ :�: r:�;l �cilz Date: 3 /�( _/�_ Name: �a�ii � ue .rjbQ��en Tax Map: 32 Parcel: 2�_ Address: 12g� �� p,sc Qd , T.,,�,bzr(aK¢ ►JG 2��3 Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on (/ 30 / 1$ , 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 bacterioing�n/ ro�H.c nn�,v. 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 co[iform bacteria are present in your water samp[e, 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 or fecal coliform bacteria should be properly disin%cted and retested prior to resuming 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, G� � w� Environmental Health Specialist Person County Health Department (rev. 4/20/ t 6) 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 il�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: ES013118-0095001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://siph.ncoublicheaith.com Phone: 919-733-7308 Fax: 919-715-8611 Name of System: TRAVIS 8� STACIE SHERRON 1289 GUESS RD TIMBERLAKE, NC 27583 Collected: 01 /30/2018 11:45 Received: 01/31/2018 08:27 Sample Source: New Well Sampling Point: Well head J Smith Susan Beasley Well Permit Number: A32-21 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 02/01/2018 E. coli, Colilert Absent 02/01/2018 Report Date: 02/02/2018 Explanations of Coliform Analysis: Reported By: Susan Beasley � '� 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. F � , � ;r ��^ r_..y .:r t � � � r � "`� �- r-' �'�.^a �^ � 'p' � � S �� ', F ; ; �� f �z � � , � e �� € � � ' � f €I�, � �, �� € � ! 1 �•� � � � � :I:; ! � :�� I� ; �.1� � c ,�_ E � �- , �---� ;-- , - �_.'� ±.- :� � � � „� t�� ?�' ��i r'+• €.E �'' � f j —�a �'� l�� i t ! �� i � t `.i ...,5 _ : ' �•: s t� � � _f E � f € r � I ,; K'_I,� �,. c :,' t t �� _ ,�-, k j �.2 ,,m� �' ��..J E �`�. �..' �1 For Inorganic Chemical Contaminants County: Name: j— Sample ID #: Reviewer: � � TEST RESULTS AND USE RECOMMENDATIONS 1. 0 Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showsring based on the inor�anic chemical resu/ts 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 recammends 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 inorPanic chemical results onlv. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron Man�anese Mercurv Nitrate/Nitrite Selenium Silver Magnesiurn Zinc H 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 bP used for washing, cleaning, bathing, and showering based on the inorFanic 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 samp(e 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 treatrnent system to address aesthetic problems. Bazium Cadmium Chromium Fluoride Iron Man�anese Selenium � Silver _ � pH � Zinc For more injormation regarding your well water results, please cal! the North Carolina Division of Public Health at 919-707-5900. Report To: North Carolina State Laboratory of Public Health 43012 Distnc�Drve Environmental Sciences Raleigh, NC 27611-8047 http://slah. ncpublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: TRAVIS 8� STACIE SHERRON 1289 GUESS RD ROXBORO, NC 27573 Courier # 02-33-15 TIMBERLAKE, NC 27583 EIN: 566000331 EH StarLiMS ID: ES013118-0029001 Date Collected: 01/30/18 Time Collected: 11:45 AM Date Received: 01/31/18 Collected By: J Smith Sample Type: Raw Sampling Point: Well head Well Permit #: A32-21 Sample Source: New Well Temp. at Receipt: 2.0 GPS #: Sample Description: Comment: 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 um Calcium Chloride Chromium Copper Fluoride Iron < 0.001 26 5.60 < 0.01 < 0.05 < 0.20 0.11 < 0.005 0.005 250 0.10 1.3 4.00 0.30 0.015 Magnesium 6 mgr� Q Manganese 0.290 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date:02/12/2018 < 0.1 7.1 < 0.00; < 0.05 11.00 5.90 110 91 < 0.05 Page 1 of 1 1.00 m n 0.05 m 0.10 m m 250 m m m 5.00 m Reported By: Deddie .�toncol