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A40 345• .. s � �r-oo ��«� o�:.�� Am�au�nt�P�t�� 1.�0 . v- ° D �i{° #303� . � �o � � ��U� k �� Perso� CouMv Heaith Deoarbnutt Eaviro�merrt�l Heaitl� 9ection �• : • �• - � �;t� �?; Par+eal #: �.r�-�- # �5'i IF THE INFORMATION IN THE APPUCATION FOR�AN IMPROVEi�ENT PERMIT IS FAL91Fi�. C�IANGED OR THE STTF IS A1 TERED. THEN THE 1MPROVE3111ENT PERMIT AND AUTHORIZA'T10N TO CONSTRUCT StiALL BECOME INVALID 1) Psmtii# roqwatsd by: (Ovmerhga�tlp�sp�tve owne�: �-r, ra,..,�,�, .�c Homs Phon� __ Z � �1- a �. r,� �. � A�ddroas 4 A � , � �d �� ,3 � - r9.s �?,� . Btmi�eas Phot�e: u � o� � i�allt0 i�{� i�[6�i Oi C�lflbflt G1AfIfAf: �c� m v 3) Ptcp�rty D�scrlQtlon: lots� I, (�t� Tawn� � tQ 1�1Q i0iti� iitld flUiilbBfE �! i�i r i-� � n �i_P-t IQGi. �� 1,� ?� 1 c t�� k � n�! `�' 4) Pcoposad Usa and Structur� Doscriptlon: anaw�x esch af the fonawin� qttea�ona: �1 �P�� .'"� 0 b) Stirdc 8u�t Q Modutar C. SLnsie Wfde 0. Da� Wide � cj Number ot sedrooma-�B�,l�� Number ot oca�n�s. o� p�is m bs se�ved: y e) 8ase�nC Yea q No Cd� yes. � of basemart ib�ucex • t� Garba6e Dts�a� Yes o, No �' � Q�r�io�v�.of P,op�d sa�u+o: widlt,: as Daptr � �1 ��Phr � Privacs q(na�r o oc a�datlno �j. Puhic 4 Cocm�u�r o. sp�w a. Ars arry weqa on a�oi�ing popettYt Y� Q No �tf'yes, locatlan � P{as� Indicab D�aind SYstsm 1ype: (syat�na can be rado�d In a�d�r of Y� P�+'�l �Coava�ttlonal liodifled Conv�rttiatiai _ Al�tnativr �nnavatlw Ott� �p�[y): CLEARLY. STAKE ALL CORNERS AND t1NE8 OF THE PiiOP�TY. 3TAKE THE CORNERS OF ALL �tOPOSED STRUCTURES. PLEASE ATTACti SURVEY PU1T OR SRE PtAN TO TH{S APPUCATION ��Y �� ta tt� Person Coucrty Health Daparfi��t ior a s�s a+rak�atlon tor tfie at�si�e sawaqe disposal sya�m tha sbove-deaaibed propecly. l agres that the contenta of thb appllc�on are tn� and rep�eaent the maodrtuun �tiem tp Ptacsd on the propetiy. 1 und�stand if the siCe is altered or the inGended us� ctwtqea. the pe�m$ shaY bemme itntaitd- i unde� tt�t as app6cant� I am rospons�ie tor ida�tifjhng and nmddn9 P�'oP�Y iinea, caners and maidng Utis a�e a� tac personnd of the Pers�t Ccuniy Hesqh Onpartrnesdt to conduct tt�ir avak�aUoc�a. I t�d that t am tespatis�le t� n�9 Hes�h D !f my ��iy �s any weVanda aa de�i�6ed bY the ArmY CorPs oi E�s. � �� '—�-�- � a or 1.�a1 RePce�tative . Da�e , _. - - P�.E.ASi Tax Nlap � _ ZOIUn9 �� . J�Qj11iCi11G � LOq1�00: � Su6diviataa: � P�#�St�N Ct3llfVTY ��1ViRONME�ITAL MEAL-� , �� .�� . . �3 �_ Tnrw��ldw �/�� V L/ • S�dloa Lot S<�/ � Improvement PeRnit � , A buildinct �ermit cannot be issued with aniv an Imarovement Pennit New �Repair Addtion T� ofStrudures�� WaterSuPply �9e�� . # of Occupants �•of gedrooms ��pther . Basemerrt? _„r/,�, 9asemerrt Fodcues?� . rn� � Projeded Da�7y Flov� �, g.p.d. Pertnii VaUd Fcc: f�Five Years ❑ No Expiratton Proposed Wastewater System ij�pe: CG�H v'c�+�'ibna / Pump Required?� Yes X� No Proposed Repaic :�» v'G'sL i n t,,o„Q PelmitCGlld�iOR3: l�vo;> �us N.' S' �vojx �u� �o��n.9 �c��`�%ar. n,u..� `he . �s�i►�� cu�' nrnnQr Qr �W�I@t Of �� Authom.ed State Ager� nlof,� QatB: � -'�` � � oate: /� ct� The issuance of thi.s perrnit by the He�atth Departrnent in nc way guarar�ees the issuance of other p�rmiis. The perrnii holder is respons�'61e for ct�ec:ang with appropriate goveming bodies (n meeflng their requuements. This site is subject to revocatton if the slbe plan, plat, or the itrteoded use cl�anges. The ImQrovemant Permtt shall �at be affected by a change in owne�si�ip cf the site. This pertnit ts subject to camplianca with the provisions of the Laws and Ruies for Sewage Treatrne�t and Oispagai Syst,ems of the North Caroiina Adminlstrative Code. Type cf Wastewater System L`rX�l/P,�Z/� Fadity 1'y� .e. �f ��r. S, �'�. . 8asement? � Yes No Wastewater Svatem Reauirements � ' � Waste�nrater Flcw: ��q,p d. �� Q 3c� Basement Fnfiu�as? 0 Yeaj� No Septic Tank Size• 00 gaqons Pump Tank S1ze: � gaRons Total Trend� Leng�i�-�'Z� � Ma�dmum Trench De� � inct�es AggcegaCe Depth: IZ ir� Ma�amum Sal Cover: � ind�es Trenc� Separation: � Feet on Center Permii Expiratian Date: Authorized State Agent �/19 /oS ��: l� f� o� The type of system permitted � does Q does nct. dif[er from the type specified on the applicatloa. 1 accapt the speciftcations of thls permit OvmedLegal Representattve Signature: "-"�"b Dabe• �� a � ' PCf-ID, rev.11/181'99 . . ___ _._ _.. _ _.... __..._._..._ __. .... .. _ _.. . . ��r��re Caunty 4ieaith. Department ' . � Esavironmeniai Hesith Sec�ion T�c��1Aap �: � �fl . . Parcei �. � Si'i'� S14FTC#� � _ . . _. - - -��i h� - -�- _. w k t hs � a �� '� . � Ap Q Name S bdivisio dioNLct# . ' �� . AuthoriZed State ent � ,Sy�t coaiponet� re�r.esent appraudma�e co�tnraa only. Tha cnrrtractor murt flag tlia systeet, _ � prior to beg�i�n� tl% ins�allation lo inrure lbat pmPerRrade $�alntaiired � SC�B: � �� = .�f � � ; Co n v c:y�,`4" �'a� r� ��(a� � t- i�; t''e.c� Cp V�v e h�-� orw.l SQ P 1 iL ��15+�►� 2�-F �� rvt�X�v►tiu� -��1�-�- de� �- i;,��. �f�� - �; --�--=�,�- 2s' �(co' � �r. � mob�t� }�ar+�. �g� ,o► LL �+ �� k� �� rep+,�c sys�M s ,li�in, mum �n. b6u`�i�inq -��tnc{c�fivn J 5 S' (�o� R,%W E� d �� ` v ' � � � �1./ �� n.�a �- � �aa�a � � ��.11 I�3C � �►. Il. �I�n. Applican Location F •� .'./ � I � �1 •'' �� - i T�x Map P�rcel # • Subcilivision �1. � . Phase � ection Lot # • # of Bed!rooms System Type (In Accordance With Tabie Va): GL THIS SYSTEM HAS BEEN I(VSTALLED 11�1 COMPLI/�NCE WITH APPLICABLE NORTH CAROLlN�► GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IfVIPROVEMENT PERMlT �1iVD CONSTRUCTION AUTHORIZATION. �'7"�� d�J . Authorized tat gent Date ' �2��OS . Installed By:-"�i�mrn�P GJ�I1P_ Date: 0 d 51 �-b P�t- �� ,� `�,�.o _. , ��, �� \a, �� .1- 4. � \o`°� �o'� ►�' -� �`�' 9�P�� ' �� o•'� 5b. � '°� a� �.e� , �. _ ►o•'' � gt� � l��' 5�'-� Q�� 2�' 3�R i�, 5�' du P�L �6' -� P)L PCHD, rev. 07/29/04 Qua�r�e�r�.�e (�d. ti � ��1C �'A€�G( iP��PE��S�R� ��iE��C�..➢�� (�'Y�e �I - I!i� Tax Map #��{0 Rarce! #�('�� System Type (Table Va) T.�.c� OwnerlApplicant m 0. �►'�S Subdivision O��ri c�no��rP Address/Location 1�7 S Nu� �1 . Sec/Phase Lot # n� =. .. . . . � _ , _ , . , r-�. . State iD/date S�-1�4Z, << Capacity � � gal. Tee and Fiiter Baifle Sealant Riser (if applicabie) Tank Outlet Seal Permanent Marker PumD Tank Ca aci gaL . Wate �roof /Sealant , Riser Water Ti ht Pump Check Valve/Gate Valve Anti-si on o e Fioats/Switches Alarm visable and audible Electrical Com onents � Rate m A roved Pum fVlodel Block Under Pum Pum Removal Ro e/Chain . �Distribution. System � Serial Disiribution � ressure Mani o Low Pressure Pi e Aoor. Pioe Materiai and Grade ✓� ✓ ✓ �ate ��u�v�cat�on �enes in�toa� � l51 rench �dth 3 ft. �I � Trench De th t� in. T,rench Len4th 4�2 ft. ✓ Trenct� Grade Trench Spacing Rock Depth and Quali Dams/Stepdowns etc. Pressure Laterals Hole Spacin4 Pipe. Sieeve` Tum-ups/Protectors Required� Setbac9cs From Wells From Propertv lines Surface Waters Public Water Su lies Vertical Cuts >2 ft. Water Lines r Vehicle Traffic Easements/Righf of W Other Easements Recorded ert e perator on Tri-Partate Aareement Comra�enis ✓ � pct�d rev. 3/13/01 PERSON COUNTY ENVIRONMEiVTAL HEALTH PLEASE SEE ATTACHED PLAN FaR WELL SITE �LAYOUT v � �� 3�-� T�� . T�,p �1 � f �;ver � . ,,� �a�� m,� �'laW�;h s - R �'; I � �.� L�. C..o�c- o h L sub�+rWo� c�� I v s�ctlo� , l,ot S% Tvae of Water Supp1Y: Reauirements: W@II Permit �ndividual Community . Public Site Approved by <''S /'S'S ct -i 2-oS Grouting Ap roved by u�12`� Well Log �S '� a Weli Ta � � Air Ve�t S OS Hose Bib � � Concrete Slab Well Driller. Q- Well Approved By: � � Date: � **S�e �Attached Site Skeich'* Welts must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wetls must be at least 25 feet from any building foundation. Other conditions: � PCHD, rev. 11/29/99 BarnetYe Well Drilling Inc 336 598 9275 05/04105 03:41P P.001 . �� S� �� D� QD � � . .�~�, . . . ° � �7 f�',�o � ��T�T'1I9� ��,��,�,,1� �aa�rA:x�� irn�ca�ar3�c��L:.en..� ��ia.�tC�. L"1Cs1151� L/llll�lll�°J L'� _�� C"� -�,..� Grout Log 0��. �,�,�,. Tax Mapf�� Parcel # ��i Location: Subdivision: ' � � � iL�:a Lot#� We11 Constrnctivn ' Distance k'xom nearest �'roperty Line (1Vlinimum 10 feei) /� r-� �istance from Septic Systezx►. (Minimum b0 feet) ( U�% ��JS�1 y� Total Depth: �� ft Yield: :�,C'. C'xPM Static 'VJ'atcr Lcvcl: � 5 f� �� : Water Be�ing Zones: I7epth ��'7 ii f� ft ft Casing: � �7epth: Fram �_ to �,., ft_ Diameter: � in T�pe: Galvanized Steel �� Weight: Thiclrness: �'_ Height above Ground: l� in Drivc Shoe: ./'Yes No A,z�y pxobiems encountered whiie setting c�sutg'? Ycs /No Yf "yes" give reason• Grout: � Neat: SandlCeme�nt Cancrete Grav�llCcmcnt � . ' . Annulaz Space Width � inehes Water in Annular Space Yes 1�To � Method of Grout: pumpcd �ressure Poured .I Depth _�,'L to �_ �t. Materials Uscd: No. Bags Portland cement i�t�'eight of 1$ag �oux►ds Z,�ner: If mixturc (san vel, cuifings) - Ratio to ]D plates: es � No 4 x 4 slab � Y� w No p�p�; Date Installed: __,___ Grout: Drillin� Log Installed by: T,ocation Drawing Frqm To Foxrnation � . � � � f' s �� Y'- C� I �� fJ ' � �'��. 3 . � �. r� . r �f�, � , • � h,�ui�'�� I t�ereby certify thai the �bove information is correct and that this wcII w�s constructed in accordar�ce wy.th regulations set forth by tb.e Person County �icalth Deparpnent n Signaturc of Co� cto�r/� i'o t �;. lt,�� L '� ID # =��1L �ate � {( ' �� ' �'� Pum� Installment pump inst�l�tipn Con�actor: � �Q_ State Registration Number. �C��o � Pump Depth: /� ft Static Water Lcvel: � S it � l�ump IV.[�lce & Model: Pump Size and Ratin�: /vZ ._ hp �U Spm I hereby certify that this pump was installcd and thc weli head completed according to the Person County Well Ru1es in cffcct on this date and that a co � s been pr vided to the wcil owner. . I'umo Ynstaller Si�natnre� ��'1- ��`� Datc: %_/ ��5.- PCtID rev d1/27104 ; �� l � �.. � �`• �^ �l./ � �.J l V � � I -C�ndn�-on�anvcn��a��.Il IHI��.II�IIEa Date: �/�/ / !'•v Name: S � t Tax Map:�t� Parcel:�� Address: � �.�.�u� G �.� �� .�lcz�a2c��G ?�1�✓7� Re: Bacteriological Test Results Dear Well Owner: `four well water was sampled on �/�2/�l�, and tested tor both total and xecal 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 only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. 'lotal coliform bacteria are nzturally found in the soil. Fecal coliform bacteria �re xsse�iated �=.ith animnal and/or human waste. The presence of eithe: total or fecal coliforr,z bacteria in we�l 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 thcrt tests positive for tatal or f�cal colifor.m bacteria should be�roperlv disinfected asid 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 flus�ed out of the system, please coniact the Iiealth 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, �� Enviromm �tal Health Specialist Person Coant�� Health Depa�ment (rev. 4/20/l6) Perscn Counb� Enviror.men;zi Health, 325 S. P.4orgar St., Suite C, Roxboro, NC 27573, Fhone: 336-579-1i90, Fax 336-597-7RG8 North Carolina State Laboratory Public Health Environmental Sciences N1icrobiology 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: ES072816-0069001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: SHARON PALMIERI P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slqh.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 147 QUARTERGATE RD ROXBORO, NC 27574 Collected: 07/27/2016 14:30 Received: 07/28/2016 08:29 Sample Source: Well Sampling Point: Outside tap H Kelly Angela Heybroek Well Permit Number: A40-345 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Denise Richardson 07/29/2016 E. coli, Colilert Report Date: 08/01/2016 Absent Explanations of Coliform Analysis: Denise Richardson 07/29/2016 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. �� nc department of health and human services � `Y n;€�> � ..ip � � §as" � ��. � 4� � ��s4 � � � 3.g„{.., � � �� s ��a R�K q "v€ ��s. w(nn � yz�y,� l Y qi .3 t �q �, . y" � x .. ,.�;! %y, i � s� �'�m s§ 7 � J a � � � � s� .,� � � ,.� � � � � !; d u G �, r�,.r � � ��>., r� �: �� x � � � � .. ..�' � � � a �� 4a � �� ; � e ,�`� '� .� a �� ,� � r C -.� .s �i 6� irc 3 ^x� �'�4 '�' r >:�.' sa' � � �'°Y3 ,� , � , �� z , � � � :� .� fr.;, � ,� � �, �a��w � a �.< „ n...,, - � •.�'� � ., aa .�.w . � � M � � � � � � '� ��` 3 .' ...a' " „ ��,� a � ? � c °�� c ' �cm�;� �'3 wa � -::�a� ,� ;a �'&:m.'' For lnorganic Chemical Contaminants County: ^ Name: Qp� Sample ID #: — � Reviewer: TEST RESULTS AND USE RECOMMENDATIONS 1. �Your well water meets federal drinking water standards for inorganic c/remicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may I�ave 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 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 cJ:emica[ results onlv. Arsenic � Barium � Cadmium � Chromium NitrateMitrite � Selenium I Silver Fluoride � Lead � Iron Ma�nesium Zinc pH 3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/I. 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 be used for washing, cleaning, bathing, and showering based on the inorganic c/remical results onlv. ❑ b. Levels over 30 mg/I 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 inor�anic 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 Cadmiutn Chromium Fluoride Iron Ma nesium Man anese Selenium Silver H Zinc For ntore i�tformalio�t regarding your wel/ water resu/ts, please ca!! t/re Nort/e Carolina Division of Pub[ic Hen[th at 919-707-5900. Report To: H. KELLY North Carolina State Laboratory of Public Health Environmenfal Sciences Inorganic Chemistry Certificate ofAnalysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: SHARON PALMIERI P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://siph. ncpubl ichealth. com Phone: 919-733-7308 Fax: 919-715-8611 147 QUARTERGATE RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES072816-0036001 Sample Type: Raw Sample Source: Well Date Collected: 07/27/16 Date Received: 07/28/16 Sampling Point: Outside tap Temp. at Receipt: 6.6 Time Collected: 2:30 PM Collected By: H Kelly Well Permit #: A40-345 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 Cadmium < 0.001 0.005 mg/L Calcium 36 mg/L Chloride 8.50 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0 05 1.3 mg/L Fluoride < 0 20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 2 mg/L Manganese 0 042 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.1 1.00 mg/L pH 8 2 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 6.10 mg/L Sulfate 19.00 250 mg/L Total Alkalinity 82 mg/L Total Hardness 96 mg/L Zinc < 0.05 5.00 mp/L Report Date: 08/11/2016 Page 1 of 1 Reported By: Dedd�'e✓'�fonca!