A40 37113365975822
10:54:11 10-31-2017 1/1
OCT-31-201T 10:58Af,�1 FRO�- T-0�5 P.�01/001 F-545
Applic�uon Uate: �� �.I 5 t� �� S � !� 1e1�V��� '1'sx Map: �,+ �
�mount Paid: � . C G� �CLS. � ��.. Parce!#: •'i 7 �
Receipt #: � a.� s f 19 � 3 ��� '� � � �� � �
-- `i�� .•3ro�sazos�i..n • —
v�� '�'��L A lication for Services ^�
Services Re uested
Impro.�emeus Permh (Site EvaIuation) : Coastrucrion Authurlrgtion
S��4 fl0�S3Q4 00 C`> fi00 �pd) � (Fee is dependent on the e of tern erraiaed
�loblle Home Replacemeat or Buildsng Additiou � Permit Itev'csinn '
S i�D.Od (if sice �Lsic requ
WeIE Permit (1ew/Replacem
5 0�.0 �i �04.Q41573.00
pair of Eustiag Septia Syst�m
Appllcarian: No Charge/ CA $150.00 or $300.�D
1) Applicant �nfo�ation: / .
\�me: �GL�- d.-���
.�.ddress: cr.�-��c'-' '� �
i �---'{' r � -
3) ti�me and uddress of current o�vner (if different than applicant):
1ame:
�ddress:
Phoae (home): � � � '� .� � �-
(wotklcell);
Phane:
+ ��� -
3) Property De�CriptIon: Lot Size: � A`" Subdivision: D� ��.ot #:
�ddress andlor directions ta Property,
p yas Q no Does [he Site cpntain any JuiiSdiciiorIal wedands7
- ❑ ye5 ❑ np Do�s the sice concain any exis�ing wascewa�cr systems?
Q yes � ao ls any wascewa�cr gofng to be gcn�raced on thc site other �har► domestic sewage?
O yes G] no 1s siie si�c subject to 8pproval by any other public egen�y?
0 yes ❑ nv Are chexe any easemenu or rIght af ways on this prapQrry? �
('sf `yes' [s checked, pleasc providc suppardng documcntadon)
�) Proposed Use aad Type of Structure: ,,] i b/3 �/� �
QR.esidential
rJ �eu• 5ia�Ie Farailv Residentc Maximum numbcr of 6edrooms: /� / Ocxupants:
� Fxpansion af Existing System If expansion: Current numBer of bedraams:
� R�nair to `ialfi:nctionina System Will th�r� Ue a basrment? � yes � no Wlth plumbing fixtures? C� yes ❑ no
�l�'on-Residencie[
?•� of business: _ '1 ocal Squnre footage of Buildirtg:
�riax'smum aum6cr of �mployees: _ Maximum number of seats:
�} . Water Supply: 0��etv well Q Existing Well ❑ Community Weli 0 Public Water C7 Sprin�
.'�re there any exisr.iag wells, springv, or exisung waurlines on �his property? O yes 0 nn
Please note any kaown ground watzr remiccions or saurcas af contaminatloa:
6) If applying far `_�utiiori7stion to Construct', ptcase indicate preferred system tyge(s):
� Conventional ❑ Accepted I7lanovaiive � Alternadve CI Ocher Q Ar►y
! rerrify that the rnformation pruvided above is cnmplete and corrert. I also understmtd thcu ifthe tnfarmatian provided is
inucctrrat j the sire is .s�hsequently alrered, or rhe f�tender� use chan�es, a!! permfts and approvcls shalt be imalid.
iY� •J�3 �a^3���J
�� . �`"` -. .
Si�natur '� wner/ Legal Representative' Date �
)
;' Suppurt�ng daeumenW[iop tequired. �,�f-� �y,.Y—� / j� .- � j �" � �
Pecmits are valld for either 60 manths �r are on-expiiin� when aeeompanie� by aa apprnvr.ci piat.
A completed 'Lot PreparurioR' form must uccompaay any apPlication reqntring s site cvuluuuon.
� � nt � � i APrSnn C�nuntv F.nviCoiuri�tt� Health, 32S S. ylar�an S�. Suite C. �toxboro, NC 27573 (336-597-1790)
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I.E�e arnwa �r- ��rnaa-a ��rn��.Il IL� a�.�, Il �IL-n
Applicant: 5n w
Address/Location:
�.
Permit Valid for: Five Years
Type of Facility:
Number of: Bedroom � / �
Proposed Wastewater System:
Proposed Repair: ���
Permit Conditions:
_ �.P��Zz�r�Ln�s_
Authorized Sta.te AgE
(X) Owner or Legal
Improvement Permit
Non-expiring
�New �Addition
Employees / Seats:
Taac Map: �� Parcel: 3�_
�u�3±v:sio� DaK� R;�
Phase/Section/Lot # g
Water Supply: 1n/� � �
Projected Daily Flow: 3(�� gallons/day
Type:
Type: �
Date: � � _j(� _ f:.
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met T6is
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
a�rd Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Persoa County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply svill
remain potable.
Authorization to Construct Wastewater S stem
See site plan and additional attachments (✓�. �
Proposed Wastewater System: �cc�„��s� ea,,,��,�„ S„�� ) (*)Type � Design Flow � gal./day
New � Repair _ Expansio�i T Soil LTAR: � 2? gal./day/ft2
Type of Facility: Basement: _ Yes o
(*) System Types Illb, Illbg, IV, and V, require pariodic system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic T�u�k 00 D gal. Pump Tank �--- gal. ^vrease Trap -�al.
Drainfield: Total Arza, ��D sq. ft. Total Length 3o ft. Pdlax. Trench Depth 2� in.
o.�,
. Trench Width _� ft. Min.Soil Cover �� in. Min.Trench Separation �_ ft.
Distribution: Distribution Box ✓/ Serial Distribution ✓/ Pressure Manifold
Specifications: 1� -
Authorized State Agent: Issue Date: �1�L-/�� _(Re��� ll-�a-I��
Permit Expiration Date: J/ /(�- 20��
The system permitted is: Conventional /Accepted i/ / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Site Plar.
Name: �► 4�,,,�i Na�K;nS Address:
Subdivison: lk�K��nn, /�cre5 Lot:��
Tax Map: /-�� 0
Parcel: �-1l
EHS:
Date: I (— lo—f y
L � �T
System Type:
Septic Tank: gallons
Pump Tank:—i' gailons
i
Total Linear Feet: ��
Max.Trench Depth: Z� "
��- {-ahK ov� l,i` l� s�d+� ot" hous�
!� P'Y I�nes MU�T b� nnarK�ec� 6� Ct Sur� a Pn'c� �'o ��sfal(a{��or�
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Scale: � - (�v
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2j Ccniact Pers�� Count� Env��o��m�nta
I y�alt�t vrith �ny �,uest�ons (336) 507-1;9�. �.
Additional Comments:
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�ua.�va�ramaa�ra-n.o�radam.�. ��ce�Il�Ila
WELL�PERMIT
(New� Repair_)
Tax Map: �Q Parcel: �
Subdivision:
Applicant's Name:
MailingAddress: �t�c;� ,,.� � �I�(;[�S J�,�.1.
Phone Numbers: _ .�(, — 25P2
Location of Property:
Permit Conditions:
Lot: �_
1.) See attached site plan for proposed well location.
2.J 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:
Permit issued by: � `
1�Tew Well:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
EHS/Date
c/ s S
[�ZI-17
�
- Zf-[�t
Date: ��-ICa-ls
Certificate of Completion
Di.iner:
EHS/Date
Well Driller: pari,�
Pump Installer: �` " -
Approved by: �„�' __
�
Additional Comrnents:
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: /j-2�-11
Date Sample Collected: ��3 m'�`� Date Results Mailed:
EHS: �SS
Person Caunty Environmental Health
325 S. Mo�gan St.,Suite C
Dnvl.nrn �If 77C7]
Phone:336-597-1790 Fax:336-597-7808
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WELL CONSTRUCTION RECORD (GW-1)
l. Wetl Contractor InCormadon:
�t9lts'f�/�C' �.l •��''��
weu co�ao� x�e
.3.� �6 �,�}
NC Well Coatractor Certificarion Number
Barnette Well Drilling, Inc.
Company Name
2. Welt Construction Permit #: � T�
List a/l applicable well construction permu�('ce. UIC. Cowity. State, ['arimrce. etc.)
3. Weil Use (check well use):
Water Supply Well:
Agricultura( QMunicipaUPublic
Geothermai (I-Ieating/Cooling Supply) x�Residential Water Suppty (single)
IndustriaUCommercial �Residential Water Supply (shared)
Irri ation
Noa-Water Supply Well:
Monitoring QRecovery
Injectiou Well:
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery �Salinity Barrier
Aquifer Test • �Stomiwater Drainage
Euperimental Technology �Subsidence Control
Geothermal (Closed Loop) �Tracer
Geothertnal (Heating/Cooling Retum) Other (ex lain under #21 Remarks)
4. Date Well(s) Completed: /�"�� '�% Well ID#
Sa. Well Location:
�l�i�,az+a/ R�k l��S tvy-!� J
Facility/Owner ame FaciGty ID# (ifapplicable)
(�.,i�1i OQi 7�m� C ,iL(�.5 GD�g>
Physical Address, City, d Zip
� IQ.S Ore.l � % f
County Pa,icel Ldentification No. (PII�
Sb. Latitude and longitude in degrees/mioutes/sernnds or decimai degrees:
(if well field, one ladlong is sufficient) .�
� F> •:3.�6 5�� x ZQ-n L Z-'�f� w
6. Is(arc) the weil(s)��rmanent or �Temporary
7. Is this a repair to an existing well: �Yes or ��
Ijrhis is a repair, fil! out known we!! construe�ion informatinn mid esplain �he na[ure ojthe
repair under k21 remarks section o� on the back of this form.
8: For Geoprobe/DPT or Closed-Loop Geotherma! Wells having the same
construction, only 1 GW-1 is needed. Ipdicate TOTAL NUMBER of wells
14. WATER ZONES
e�oni �ro nesc�rcor
f� j � �o �I
1 i�v n• �3�� "' /.5 '
15. OUTER CASING tor malti-cased weDs OR LINER if a liable
FROM TO DIAME[ER � THICIQYESS MATERIAL
tJ f�- �Q Z� 61/8 'a U�, ZI ��
16. iNNER CASING OR TUBING thermal closed-loo
FROM TO DIAMETER TEQC[IN6SS MATEItIAL
ft. tt ia
fG ft �a
17. SCREEN
FROM TO D4�METER SLOT SIZE TFIICIINESS 6fATERtAL
Q tt k. in.
r�. rc �a
18. GROUT
FROM TO MATERIAL Eh[PIACEMENTl1fETHOD&AMOUNT
� Z�j �- Gravellcement poured
tG [t
fG f�
19. SANDlGRAYEL PACK da iabk
FROM TO MA'CERIAL EMPIACEMEIVT DOTHOD
ft. ft
ft ft.
Z0. DRILLING 1.OG attach additional sheefs if necesss '
FROM TO DESCRIPTION rnlor, Aardew, w�l/�Je in sae, etc.
d I�. �- t�- D c1`e 2 b u. �.
� fc. r�. v�S� ,
30 �- �`Z '� �" � a� � �.�
1 % f�' Z �f�' �
�
f4 f�
ft. ft.
rr. ra
Zi. uEManxs
22. Certiiica6on:
�f�.;�?—�-�� �, /"�u.�� � ^ l� 1 %
Signature of Certified WeU Contractor Date
By signing this form, I hereby cerlify tha� 1he we!!(sJ was (were) constructed in accordance
wr� ISA NCAC 01C.0/00 or /SA NCAC 02C.0200 Wel1 Constructrort Stmuiards and that a
copy of this record has been provided [o the we!l owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessazy.
SUBNiITTAL INStRUCTIONS
9. Total weil dept6 below land surface: `�- � � (f�) 24a. For All Wells: Submit this fomt within 30 days of completion of well
For mnitiple we!!s list aU depths ijdifferen[ (example- 3Qa 100' an4 Z(a�/00� ���ction to the following:
10. Static water level below top of casing: 25 (ft) Divisioa of Water Rcsources, [nformation Praccssing Unit,
- If waterleve! is above casing, ure "+'• 1617 Mail Service Center, R&leigh� NC 27699-1617
11. Borehole diameter. a (in.) 24b. For Iniection Welis: In addition to sending the fortn to the �dress in 24a
� Air rotary above, also submit one copy of this form within 30 days of completion af well
12. Well consvucdon meffiod: construction to the following:
(i.e. augu, rotazy, pble, dueci push, etc.)
Divisio¢ of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
�
13s. Yield (gpm) �f Method of test• BIOW� ZO Mln. ZqG For Water Sunplv & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this foim within 30 days of
13b. Disinfec6on typc• CI1IOnf16 Amo�r 1/4 Cup completion of wep conswction to the county health departrnent of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Qualiry - Division oF Water Resources Revised 2-22-2016
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Applicant:
Location:
o�� J� arco ---� Ly— � vr oh c��
Operation Perrnit
Tax Map � Parcel # 3��
Subdivision < �
Phase/Section/Lot # 8 I
# of Bedrooms 3
System Type (From Table Va): Product (IIIg): �r�.
Type V& VI E piration Date: Type V& VI Renewal Date: �_
This system as � en installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Tre tment dz�isposal, and all conditions of the Improvement Permit and Construction
A»+hnri�.�lin .� l �Q
\
�
(A thorize Ag nt)
3'ce
.�
(Licensed C tract �� �
3,��,
3�Ja 3��t
3'�°
�,AfGO
Scale j�1 �}-
PCHD, rev. 12 14/12
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S
V
E
f / -- Z�-l7
(Date)
1 I - Zl �-17
(Date)
Line Length
I 7'
� r
Total 33 Z
Tax Map: � Parcel #: 3� i
Septic Tank System Checklist (Type II-I� System Type: �
Notes:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
��
����'�,�1 / 1
ne department
of health and
human serviees
County: I '(..�rSd rn
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E � p t f_ �k
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l., k ��C Lf _ E B Q i' ( �� {� E,� k F�l
l�or Inorganic Chemica/ Con�aminants
. - �'� � " i �:�i'L�'.�-'�_ ;
� TEST RESULTS AND USE RECOMMENDATIONS
1. Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for
drink g, cooking, washing, cleaning, bathing, and showering based on the inar�anic 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 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, anless you install a water treatment system to remove the cir;,led substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorFanic chemica[results onlv.
Arsenic Barium Cadmium Chromium Co per Fluoride Lead Iron
Manganese Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's-(USEPA) Health Advisory level for sodium of
20 mg/l. The North Cazolina 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 inorFanic chemical resulls 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 inorFanic chemicnl 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
Manganese Selenium Silver pH Zinc
For more information regarding your we!! wafer results, please call the North Carolina Division of Public Hea[th at 919-707-5900.
North Carolina State Laboratory of Public Health 3�12 Distnct D �e
Environmental Sciences Raleigh, NC 27611-8047
htta://slph.ncaublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: ADAM C. SARVER Name of System:
PERSON CO ENVIRONMENTAL HEALTH SAMMY HAWKINS
325 S MORGAN STREET
44 MARCO LN
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES013118-0031001 Date Collected: 01/30/18 Time Collected: 2:05 PM
Date Received: 01/31/18 Collected By: ASarver
Sample Type: Raw Sampling Point: Well head Well Permit #: A40-371
Sample Source: New Well Temp. at Receipt: 3.0 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
Cadmium < 0 001 0.005 mg/L
Calcium
Chloride
Chromium
Fluoride
Iron
10
< 5.00
< 0.01
0.11
< 0.20
< 0.10
< 0.005
4.00
0.30
).015
m
m
Magnesium 3 mgi�
Manganese < 0.03 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
6.9
< 0.005
< 0.05
5.90
6.90
44
39
< 0.05
Page 1 of 1
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Reported By: Deddie .�tvnco�'
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��nrn�*n���►nrn�n�;�n�n��t.� 1�°��e•�na�����
Date: � / l /� '
Name: Q �r� �s � �
Address: r L� •
e , C 7 ?
Re: Bacteriological Test Results
Dear Wel! Owner:
Tax Map�.�0 Parcel:�
Your well water was sampled on �/ 3�i'� and tested for both total and fecal coliform� bacteria.
Your water sample test results are noted beIow:
� No coliform bacteria were detected in the sample. Your well waier is safe to use for drinking,
cooking, washing dishes, bathing and sho.wering, based on the bacterialogical resulis only.
Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in t6e sample.
Total coliform bacteria are naturally found in the �oi;. Fecal coliform bacteria arz 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
�nay rot be safe for use. Young children, tl:e elde��ly, and the individuals with compromised immune
systems are especially vulnerable and their physicians should be not�ed of the test results.
A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested
prior to resumin�; normad 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.
Sinc rely,
V��
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person Co�!nry Em�ironmeM�l Health; 325 S Mor,an St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Far 336-597-780R
�
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North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
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: ES013118-0097001
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ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
SAMMY HAWKINS
44 MARCO LN
ROXBORO, NC 27574
Collected: 01 /30/2018 14:05
Received: 01/31/2018 08:27
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slqh.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
A Sarver
Susan Beasley
Well Permit Number:
A40-371
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Absent o2/01/2018
E. coli, Colilert Absent 02/01/2018
Report Date: 02/02/2018
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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