A40 334Application Date: 3� '( � � Z�l ��'1 C� �k .�� r f j��j� ��� Tax Map: ��' �
� 1�� ���• Parcel#: 3 3
Amount Paid: Ov , oC� �w�� �-"' � � ����� . -�
Receipt #: I�S3 �2 IS3`� 1 IE��,aa-,m�,,:�.��.��.Il 7Htms.lL�.l�.
��I bo) �a��
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
�lication for Services
Services Requested
Construction Authorization
(Fee is dependent on the type of
Permit Revision
Repair of E�isting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor tion: � �
Name: �,�,r-r���
Address: �
� � �t l3 mn-t� �, c,
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 33 � s9 � a I a 4
(work/cell):
Phone:
3) Property Description: Lot Size: _L_ Subdivision:d��� RC"�a Lot #: /� 6
Address and/or directions to Property:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes D no Does the site contain any existing wastewater systems?
� yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
� yes ❑ no Is the site subject to approval by any other public agency?
Q yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of 5tructure: ,
❑Residential '
❑ New Single Family Residence Maximum number of bedrooms: oZ- / Occupants:
� Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes � no
�Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats: _
5) Water Supply: ❑ 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 sowces of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative � Alternative O Other ❑ a'►Y
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, t� site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (O�rier/ Legal Representative*)
* Supporting documentation required.
3 , �.. / -/'?
Date
Permits are valid for either 60 months or are non-expiring 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., SuiteC, Roxboro, NC 27573 (336-597-1790)
�1��, ) f ���� �d. �I
� � � ����
�.��s�rn�nar��,*-TM,+¢�aa�am.� �'���s.Il.��a.
Tag Map:��� Parcel• 33
Subdivision �r,'o� • v-e 5
Phase/SectionlLot #
Applicant: �'"t� ��''��r �
AddresslLocation: --
— ------ -----�—`--- a---`�" --�t �i�c Ct.��o,.e ov. L _
Permit Valid for: Five Y�
Type of Facility: Z�te
Number of: Bedrooms 2
Proposed Wastewate Sys�
Proposed Repair: �
Improvement Permit
� Non-expirin
> � New �Addition _
)cqupants /,�mployees / Seats:
Water Supp;y: ��'�
Projected Daily Flow: �o gal(ons/day
Type: Jl�
Type: �
Permit Conditions: �, �<<5 �✓Ot�� L e�'
Authorized State Agent: __ ►^� �%` �"''e-✓ Date: `t —
(X) Owner or Legat Repres tative: -� � Date: �
The issuar_ce af this permit by the Health Department does not guarantee the issuance of other required permits. It is th;, responsibility of
the appticant/property owner to insure that all Person County P3anning and Zoning and Building Inspections requirements are met. This
improvement Permit is subject tu revocation if the site plan, Qlat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in campliance with the provisions of the North Carolina �Laws
aiirl Rules for Sewa�e Treatment and Dicnosal Svstems'(15A NCAC 18A .1900). Neither Perso� County nor the Environmental
Health Specialist warrants that t�e septic system wiil continu� to function satisfacto::iy in thc future, or that the water s�ppiy wiil
remain potable. — __
Authorization to Construct Wastewater Sys#ern
�ee site plan and additional a#achments (�.
x
Propos Wastewater System: �P�" ��t( � V ('�)Typ�� Design Flow ��� gal./day
New � Repair _ EYpansion _ Soil LTA.�: R aS gal./day/ftz
Type of Facility: a'�1� %�2 S� Ba.sement: _ Yes ( P10
(`k) System Types lilb, Ilibg,l V, rrnd V, requireperioriic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank L � d� gal. Pump Tank "' gal. Grease Trap � gal.
Drainfield• Total Area �o�-� sq. ft. Total Length o� �� ft. Max. `french Depth 1� in.
. Trench 1Nidth 3 ft. Min.S�il Cover � in. Min.T�rench Separation � ft.
Distribution: Distrihution Box �/ Serial Distribution / Pressure Manifold �_
.�1 �-� � I • � � f( _ „ _ _�n..D
Specifications:
Authorized State Agent: ►�^ ''�� [ssue Date: ���Q'��
Permi� Expiration Date: ��� — Z Z
The system permitted is: Conventional / cepted �i Alternati�e / Innovative . I accept the conditions
and specifications of this permit. ,
(R) Owner or Legal Representative: �` Date:7 oZ�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
�� ) f �����1 � Name:-- Q�
�.�•� Subdivison: (%
� cC��J�T�°�Y �
lE���m�ffi���.�Il ]I�emIl�4a
t
r� �b I � v�e5
>�
�
System Type• i � • �C/
Septic Tank: �� � gallons
Pump Tank: � gallons
Total Linear Feet: Z`��
Max.Trench Depth: � Z "
� u�►s
5�
sa; l
Site Plar.
'? >Address:
y''P S Lot: ��
EHS: ;
Date:
1
'ZB
���
�'
� �. L.7 I �
t
Tax Map: �
Parcel: 33
—/Y�l
�c �
Scale: � = �
Noie: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person Cou� ty Envir,p nmental /Health� with any questions (3�36,,;� 5/� 7-1750. _n
A��ition�l C
omments: � q�u' '�, v�4, ( Sp� "� vt-Q�P o�v-C c�V�*' CXrQi� �i,'ei� ',
�
���.sf ���.���
� � � ����
I���a���.,,-�.-n ����.Il IFZL��.IL�I�
Tax l�iap �� Parcel # 33
Subdivision �G `
Phase/Section/Lot # �(p
# of Bedrooms 2
Operation Permit
System Type (From Table Va); 11 i
Type V& VI Expiration Date:
Product (IIIg): ��-`
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.
; "'
�r
( orized Agent)
� �'�,�� ��.�h5
(Licensed Contractor)
�y'
Scale P
PCHI�, rev
\�4
�1-5-t�
(Date)
Line Len
1 `1
2 SZ
3 S2
Total 2y 2'
T�x �1a�: � Par�el #: 33�
��
Septic Tank System Checklist (Type II-I� System Type: �_
Se tic Tank InitiaUDate
State ID & Date: _ 2 � S _
�'-2 - � �
Ca acity: � . �
Tee and filter ✓
Baffle ,�
Vent �
Riser o s
Outlet boot ,/
Perm. Marker
Distribution
D-box (levels set)
Serial _ �
Pressure Manifold
LPP
Notes:
-�.
Pump System Checklist
Pum Tank InitiaUDate
Sta D & Date:
Ca acity:
Riser (6" min.
NEMA 4X Box
Model:
Pi y back lu
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:
���.sf ���.���
- � � ����
1E�ra�n�r�aa�rnn.o�rad�.Il 1HCo m�L ¢]La
WE�PERMIT
(New Repair_ )
Tax Map: �� Parcel: 33
Subdivision: � ►-; 0� �e
Applicant's Name: ��'zM �, �R W jC �'�
Mailing Address:
Phone Numbers:
Lot: ��
Location of Property: �u �t ►�DE'� '� �.�/� � ��C �Q �C � • � �� '� � � � I �1
Gu - �e�s�e
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry 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: ✓�-� �
�Tew Well:
EHS/Date
�an5 ��
S�el�r���a
�.- �j'l 1
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Certificate of Completion
Date: �� � � � l
Ol,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date: _
Method/Materials:
Well Driller: �(/\�C�'2 License #:
Pump Installer: ' ` 'T License #:
Approved by: vs�---. Date: - -(
Additional Comments:
Date Sample Collected: \-�� Date Results Mailed:
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
Aug 2517 03:03p Barnette Well Drillinglnc
WELL CONSTRUCTIQN RECORD (G
1_ We! Contractor Information:
�ON�r�� � � �i�(�- cT_ <
Wcll Centractor Name
33 �d -�
NC Wctl Can�actorCcrtificaeon Numlur
1,��3R�e.-f-i�.e t ue.t ! A2 .I,
Compnoy Name
2. Wdl Consmucfion Permit d:
i.r.*! al! appltca5lc well c»r.rlrrrainr. permir� (Y.r.
3. Weli Use fcheck wcl] ose):
Water Sunplv Wetl:
Geothcrmai Q-Ienting�Cooling Supply)
In3ustri�l/Commercia3
Noo-R'ater Supply Well:
variancc, e1c.)
R'ater Supply {single)
4Vata SuFP1Y �shared)
lnjecrioq 1i'cll:
�Aquifer Recharge �GroundwatI Reroediation
]IAquifer Storage and Recovery �Salinity Batrier
�Aquifcr'Cest �Stormwat Drainage
�EYperimental Technotow QSub7dence ontroJ
�Geotherma( (Closed Loop) �Tracer
�Gzothermal(Heating/Coo]in�Retum) �Other(expl �nunder#21 R
4. Date Well(s) Compltted:, � Z� �� Wdl [DfF �
Sa. Wcll Loration: �
,Ss�mrn�.y� �'
Faciluy/pwtter Name Fac�7iry II�R (ifnpplicablr)
Physi l Addmss, ity, �d 7,ip
���SB�
County P,irrt�
Sb. Latitudc and loagitudc in degrces/minuteslsceonds
{if woll fidd, one L•atrlong is suft'icient)
��. .�J 7�d h � Z,
6. Is(nrc) the �vcil(a) ermanent or �I'einporai
7. Is tAis a rcpair tn an exisrin� �rtifl: QYes or �
Ifrhi,r is a rrpn'v,_frllvm�nox•n Kel! coaswcrion informofion a�d
reFair ynder r.`1I r�marks saction or on tlre back oj�his forr.i
: 8. For Geopro6e/DPI' or Closed-Laop Ccothermai S
construction, only I GW-1, is needed. Indicata TUTAL
drrlled:
9. Tota1 ne[I depth below land surCace:
!%or nnr/�iple xells /irr a!/ deplhr Ifdi�e�rrt (example-
10. SG�tic �sater levcl bdflw tnp of easing: �
IJ�rarrr lcvcl ir alwvC urring. uxr ••.� •• .
I1. Barehole diamctcr: � (in.)
12. Welt coostruction method: A� Q�1
(i.e. au�er, rotary, cabie, dircct push, ac,)
tification No. (PIt�)
decirnal degrees:
76 ,
0
olain the nomre of the
having the same
1BER of �vells
FOR R'ATER SUPPLY LVELLS ONLY:
13s. Yielel (gpm) � � �fethod oftest: �
I3b. DisiniecHon typr. f{�J�j„ Amount: I'���
Form GW-1
North Carolina
336-598-9275 p.1
Print Form
22 Certificadon:
Sig tuceofCrni�� � ta�� Date ~
H}• .rigning thls jurnv, I i�ereby cerrify rhar rhe relf�s) wa.r (wemJ coratr.rcred in accormnce
wllh !3A A('�1C O2C.0!00 or ! cA NGtC 07C: .02D0 Well Cnrr.�hvct�avt StryLlarrl.c artd rftm p
eopy oj�lris recard kv.c hren prorideJ w the we!! ormer.
23. Sitc diAgram or additionx[ well dcta�ls;
You mey use the back of this page to provide additional well site details or �vel l
cons�ruction dctails. You may also atfach addiuooal pages if necr.ssary.
SUSMITTAL Ti�STRLCf1QVS
24a. For All Wclls: Suhmit lhis form wilhin 3U days of completion of well
cons�uciion to the 1'ollowing:
.._���) Division of WalerResourtes, [nformation Procpsing Unit,
1G17 Afal Serviee Crnter, Ralcigh, NC 27699-1617
24b. For lejretion �tidls: in additio.n to sending the torm to the address en 24a
above, also s�bmif one copy of this 2'ortn within 3fl day5 of completian of wel]
consiiu�tion to the follow�ing:
Divlsion of Wattr Resourccs, Undrrground Infeetion Controt Program,
] b36 Mail Servicc Ceeter, Iialeigh, VC 27699-] 636
24c. For R'atcr Sonnlv & lrtiection Welts: In addition tn sendin� the Corm to
Yhe address(es) above, also submit one mpy of this foam within 3a days of
completion of well construclion to thc county hea]th depautmrnt of the county
where conswcted.
Quality - Division o E Water Resaurees R evised 2-2Z-201 b
\� �
� y�x �
~"".�. v .�^�' � � �i.� �\� � �
�.srn�n�•��-n��-n��L:.�ti�l �E`3��,,��.:I4Llia
Date: �/ 2� /�
Name:
Address: 3�W;�d ��' �n.
P���,�ro �i� �-r��
Re: Bacteriological Test Results
Dear Well Owner:
Tax Map:�O Parcel: a3
Your well water was sampled on �/_ j___/�, 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 bacteriological results on[y.
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 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 for total or fecal coliform 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,
wi� ��`—�_/�
� .
Environmental Health Specialist
Person County Health Department
(rev. 4/20/l6)
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
Niicrobiology
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: ES110217-0113001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
OAKRIDGE ACRES 46
365 WILD OAK LN.
ROXBORO, NC 27574
Collected: 11 /01 /2017 11:00
Received: 11/02/2017 09:05
Sample Source: New Well
Sampling Point: well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sloh.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8617
A. Sarver
Angela Heybroek
Well Permit Number:
A40-334
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Present 11/03/2017
E. coli, Colilert Absent 11/03/2017
Report Date: 11/03/2017
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.
�•'� i � , � ; ,'�; i >� '� � �`�� � � � � � ��, '"' � ,-� � � t�'� �''�
� � '� � �- t�� �� � � �: , � ��� � �
� � � i; t� : i ._.
i s�. � 'r .�
�_ �
� �..__. � � •
�".� G l•� � � < `` tf�� f� � 3 ("'{ �•F � "�._l � �:.�,.-.�t :�.� � � � S �-'y t f �� yt E �. �
- �1"�c � r ` � '`L � _ �_.... ' i � 4 �._.r e ,� �,; ¢ • ! z `� %
E L... '�....,r" �... • v�' �.._.! .
For Inorganic Chemical Contaminants
County: Name:
Sample ID #: Reviewer:
� TEST RESULTS AND USE RECOMMENDATIONS
1. �our well water meets federal drinking water standards for inorganic chemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may
have other water sampling results that are not taken into account in this report.
2. 0 The following substance(s) exceeded federal 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 water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inor�anic chemical results onlv.
Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron
Man�anese Mercurv � Nitrate/Nitrite � Selenium � Silver � Magnesium � Linc � pH
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 Pub(ic 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 showering based on
the inorPanic chemical results onlv.
❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. 0 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. 0 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 inor�anic chemical resu[ts 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
Man�anese Selenium Silver H Zinc
For more information regarding your wel! water results, p[ease ca!! the North Carolina Division ojPublic Hea[th 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
Name of System:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slqh. ncoublichea Ith. com
Phone: 919-733-7308
Fax: 919-715-8611
OAKRIDGE ACRES 46
365 WILD OAK LN
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES110217-0065001 Date Collected: 11/01/17
Date Received: 11/02/17
Sample Type: Raw Sampling Point: Well head
Sample Source: New Well Temp. at Receipt: 2.0
Sample Description:
Comment:
Time Collected: 11:00 AM
Collected By: A Sarver
Well Permit #: A40-334
GPS #:
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
Cadmium < 0.001 0.005 mg/L
�
<
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 0.21 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 2 mg/L
Manganese < 0.03 0.05 mg/L
Mercui
Nitrate
<
< 1.00
10.00
Nitrite < 0.1 1.00
um < 0.005 0.05 m
Silver < 0.05 0.10 mg/L
Sodium 7.30 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 37 mg/L
Total Hardness 34 mg/L
Zinc < 0.05 5.00 mg/L
Report Date:11/13/2017
Page 1 of 1
Reported By: .xennet`i y'reene