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A40 380��g�� . a Application Date: � 8 � o Tax Map: �� / i�7 t..,�,� sf �� Amount Paid: �p6 .OU__ 1�J'%� , _ �,,,.►` ��- � Parcel#: ��_ Receipt#: � �332� I 83�7j ��T1��[°� T�".�cawam�a,TM�,TMM*aes.�n��n.l� l�Ia��.)��l�n. � � C.�'ff�' Services �Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Iiome Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement/Repair) � $300.00/$200.00/$75.00 for Services Construction Authorization (Fee is dependent on the type of system permitted) Permit Revision $75.00 Repair of Egisting Septic System Applicarion: No Charge/ CA $150.00 or $300.00 1) Applicant Information: . Name: ��} !YI M J A w,� ��, S Phone (home): 336 � S9 �—�- � 2 q Address: s�{ �s-� D � � /l�l � «s �D. (work/cell): 1 � 2) Name and address of current owner (if different than applicant): Name• Phone: Address: 3) Property Description: Lot Size: / Subdivision: 0,4 fr /4 � �o �� Lot #: G% � Address and/or directions to Property: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? /��. y❑ yes ❑ no Does the site contain any existing wastewater systems? � yes 0 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 Structure: ,� �i �Resideatial ' �� ❑ New Single Family Residence Maximum number of bedrooms: -�J�" / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: O Repair to Malfunctioning System Will there be a basement7 ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square f�otage of Building: Maximum number of seats: 5) Water Supply: 0 New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring . Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no Please note any laiown ground water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional O Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccur , the site is subsequently alte�ed, or the intended use changes, all permits and approvals shall be invalid. C�'-, �' � �� ,�-- 8 - l7 Signature (�lwner/ Legal Representative*) * Supporting documentation required. Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. ?_ completed `Lot PrPparatio_n' f�rm must accomnany any application reqairing a site eval��ation. (10/15) Person Counry Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �-�`�, ; , �s ��.� �� ` �r � � �� 7.0 ye �n.wn u- � ara�+-+•-� � arn ��.Il IL� �s �.Il �IEn Applicant: SQM� Address/Location: Tax Map: �}y0 Parcel: 380 subdiL:s.�n vaK Qiae �S Phase/Section/Lot # PI,� � �ot 90 / Improvement Permit Permit Valid for: Five Years ✓ Non-expiring Type of Facility: ' I New �Addition _ Water Supply: L�% �� Number of: Bedroo �/ cupants / Employees / Seats: Projected Daily Flow:�� gallons/day Proposed Wastewater System: ��,1(2s�'L R�.1,,,cE;s,,, �,s�e,,,,� Type: � Proposed Repair: �� T Type:� Permit Conditions: � �la,.E R�..�.r �.W�ess1,�.I Pr�rFu Authorized State Agent: (X) Owner or Legal Re Date: 5-2N-l7 Date: ln •_ � G� 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 aze 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 ar:rl Rules for SewaQe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply will remain potable. Authorizatioa to Construct Wastewater System See site plan and additional attachments (�/. Proposed jNastewater System: Acctnir� �2sqo �.�uc�;c„ �vSic»,> (*)Type � Design Flow � gal./day New �� Repair _ Expansion Soil LTAR: .,3 gal./day/ft2 Type of Pacility: — Basement: _ Yes �/No (*) System Types IIIb, Illbg, Iv, and V, require p2riodic system inspections by the Person Counry Health Department. Wastewater SS�stem Requirements Tank Size: Sepiic Tank o0o gal. Pump Tank gal. Drainfield: Total Area I pQ s sq. ft. Toial Length �i0o ft. Trench Width � ft. Min.Soil Cover �_ in. Distribution: Distribution Box / Serial Distribution�/ Pressure Manifolc Specifications: �.. . . . Authorized State Agent: Grease Trap ---- gal. Max. Trench Depth Z],_ in. �,G. Min.Trench Separation � ft. Issue Date: S-2y-l? Permit Expiration Date: S- Zy_ 22, The system permitted is: Conventional /Accepted ✓/ Alternative / Innovative . I accept the conditions and specifications of this permit. •-� (X) Owner or Legal Representative: Date: (o'' '� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �� (� ��q ��T Name: a� ~•"'� 1� Subdivison:0 �� — ]Eaaviro��a�aa��m.Il ]E �c�.��n (f,.�, - - - �-•— Site Plar. Lot:g� � a��,�+�o�s�a�c+H 1��51� � �� Y ,� �, System Type: � Septic Tank: 1, o� gallons Pump Tank: gallons Total Linear Feet: 00� Max.Trench Depth: �(_" Tax Map: Q�iO Parcel: _3ga EHS: ,�� _ Date: 5-25-1'1 ��; , �ei S1�l�o�;� �� r .., : F... � In1Cl1. ,&r� d,rivi loc.a{;ohs ar� �Icx�ble � Be sure �o confacf E� o{��.� bc�cfe rzlocafing eitt,e�. J Scale: `�= SO � Vote: 1) D�ain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person County Environmental Health with any questions (336) 597-1790. 4dditi�nal Comments: Fla+- Ri�er 1,Jakrs%p� �ra. p,rt-t.f ��. sf ��.� �� ' �- C� � t��7�� I��aa-��.��.Il IE� m�.Il�I� Applicant Location: Taz�Map � Parcel # 3�✓O Subdivision Phase/Section/Lot # r 4 �,��G� # of Bedrooms 3 Operation Permit System Type (From Table Va): Product (IIIg): /y��zZ%.� Type V& VI Expiration Date: 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. (A orize nt) /'r�- ,�'�cvi� (Licensed Contractor) Scale �� PCFiD, rev. 12/14/12 ll301 � (Date)T �/ IJ (Date) S%� ii siy.� ��7" �/ % �s' `� p' ,�D�"' �� ovsg h�s • 3/4s/r � '�i'��-6C0 D 5r� - 3� Ci�?�!� Ly Line Length 2 / Q(o tZ 9 �s � � � v i Z �� DD �L Z Z Tntal Tax Mag: � Parcel #: ��d Septic Tank System Checklist (Type II-I� System Type: __�� Se tic Tank InitiallDate State ID & Date: �j - G� y ✓ � l? Capacity: - /�DO Tee and filter Baffle Vent Riser Outlet boot Perm. Marker Distribution D-box (levels set) Serial Pressure Manifold LPP ��_._ . Notes• Pump System Checklist Pum Tank InitiaUDate State ID & Date: Ca acity: Riser (6" min.) NEMA 4X Box Model: Pi gy back plug Hard wired Alarm functioning Mounted on ost Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes• Tank Com onents InitiaUDate Pum model: Block (4") Nylon retrieval ro e Float tree and attachments On/Off float swing: in. Alarm float 6" se aration) Anti-si hon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed A proved and secured riser Sr� 1 Line � � Size and material: in. sch. Length: ft. �` �. ��1i1�� ne department of health end human serviees . . , � ; s � r-, 5•� �., x ;l �, �S � !�� /'� j ��1 � E � � i Q s �^ j,.,`�`� r"'} ,'. ; ° '�"� � � � `p �..� r k � b f 1 P ��i 5 li �` �G �J �� t E i i��% i i I i i...�� E,� i� ( € € �---. . —; ,�;. � e: �.... .� ,� �>-. �--., r-., � : � c,Y c � .,"` l=3 L �� ` � �' � r � : � �i t�� t � �t �"- ± , i= -- C- ; � 1 1 € t G ��,� i I`.., a ,,....�` �� ''iA i; �`/ �.._/' �-f E E e f f��l � S',i i�f f� ( l,? k i�i For lnorganic Chemical Contaminants � County: Sc, Name: rweS Sample ID#: 0 � � Reviewer: v✓-2✓ � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for i�organic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorFanic 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 inorFanic chemica[ results onlv. Arsenic � Barium � Cadmium � Chromium Nitrate/Nihite I Selenium I Silver Fluoride � Lead � Iron Maenesiurn Zinc nH 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 be used for washing, cleaning, bathing, and showering based on the inorPanic chemical results on[v. ❑ 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. 0 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 we(I 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, cooki , 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 insta(I a household water treatment system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride � Iron Maneanese Selenium Silver ( pH � Zinc For more informalion regardingyour we!! water results, please cal! the North Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis P.O. Box 28047 4312 District Drive Rafeigh, NC 27611-8047 http://siph.ncpublicheaith.com Phone: 919-733-7308 Fax: 919-715-8611 Report To: ADAM C. SARVER Name of System: PERSON CO ENVIRONMENTAL HEALTH CLAYTON HOMES 325 S MORGAN STREET 84 HENSLEY AVE ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES083017-0028001 Date Collected: 08/29/17 Time Collected: 2:50 PM Date Received: 08/30/17 Collected By: A Sarver Sample Type: Raw Sampling Point: Well head Well Permit #: A40-380 Sample Source: New Well Temp. at Receipt: 2.0 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < �.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead Magne Manga Mercui N itrate ese Selenium Silver �,.a;,,.,, Total Alkalinity Total Hardness Report Date:09/07/2017 < 0.005 1 0.160 < 0.0005 < 1.00 < 0.1 0.015 0.05 0.002 10.00 7.5 N/A < 0.005 0.05 mg/L < 0.05 0.10 mg/L : �� 1Z.U0 76 70 < 0.05 Page 1 of 1 Reported By: Deddie .�lancol' � � , - -., -•. �� : � tij� ��/�- 1�.+.-, � +r�"� � � � �t�� '��' ��Yl6�JRiiJLli�iJltti.r'J�J'L4ir�� 1��+•Y+"�� Date: �/ 2Z' /� Name: C�a 1°ti CI��eS Address: g � KSl ve e � Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel: 3� Your well water was sampled on �/�� /� 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 only. � Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliforrr bacteria are naturally found in the soil. Fecal coliform bacteria arz associated with animnal and/or human waste. Th� 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 inay rot be safe for use. Young children, the elde��ly, and the individuals with compromised immune systems are especiadly vulnerable and their physicians should be notified of the test results. A well that tests positive or total orfecal coliform bacteria should be properlv disinfected 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, c��✓ Environmental Health Specialist Person County Health Department (rev. 4R0/16) ?erson Counry FnvironmeMal NPatth, 3�5 S. Morgan St, Suite C, Roxboro, NC 27573, Phone: 336-579-1790, FaY 336-597-7808 . •�:. 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: ES083017-0066001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: CLAYTON HOMES 84 HENSLEY AVE ROXBORO, NC 27574 Col lected: 08/29/2017 14:50 Received: 08/30/2017 08:19 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 A Sarver Susan Beasley Well Permit Number: A40-380 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present 08/31/2017 E. coli, Colilert Absent 08/31/2017 Report Date: 09/01/2017 Explanations of Coliform Analysis: Reported By: Cindv Price (�.t� ��ce � 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. ��.sf ��.�� --�- � � �� ]E�.�,��,��,��.Il ]HC��Il�I� WELL PERMIT (New�Repair_ ) Tax Map: �� Parcel: 80 Sabdivision: �aK R�dap l�cres Lot: �D Applicant's Name: $�CM,,,1v w�� ns � la�.-�o l�on�es Mailing Address: �- Phone Numbers: 33c - sqst- 2 t 2R Location of > > Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County Yegulations 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 Ot6er Conditions/Comments: �liln�infa►'h all s��,,�Ks Permit issued by: � -,�----,� Certificate of Completion ew Well: E S/Date Location: � / Grouting: ai3'b � � Well Log: ,��z 1�2 � C� t t�C( Well Tag: �_ �G � �� Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: �— ��1�/7 � �— Date: �- 2�[-/ 7 Di.iner: EHS/Date Depth: Grout: DAbandonment: Date: Method/Materials: Well Driller: �n'e?'�c License #: Pump Installer: ` License #: Approved by: �"� Date: - z� C Additional Comments: Date Sample Collected: ��"Q"�� Date Results Mailed: EHS: Person County Environmental Health 325 5. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Rnvhnrn Nf�7G73 ttMcf�� O \ ^ O f � y _ Jul 11 17 04:14p Barnette Well Drillinglnc WELL CQ�T�TRU�TIDN RECORD rn� � � t�,�a �:�a� a �v�=.� t_ �'dt Contractor Infnrn�atioc: � ` '� rr�u'.u1 e � �,� , wat c.o� N�t ...�� 6 � NC R�d1 Cou�ewrCur,6rrtion Nvm6cr Barnette Well Drilling, 1nc. C�N�� J� �t'GD Z.1Vs!! Conshvetion Frrmitll:, -- Ltrt a!! apptimb!< Kdt mnstrrukn �r+la f+� ��Y. S�• Yait�er, etG) 3. 4Vdt [ise (eheakweA use): W acer SupPlp �elL• pp�j�p� ClhtanieipaUPublie- QGtothet�s,tal (f�eatin�Cooii�rS �PP�Y) �eatinl Water S�p19 ��8��) ��advsttieUGommQcml OXesMer�al WatcSupPtY �shg� (��j�{ � Q�'.Tt�Ot1�d1Nt1[i'�iGrtCd72t�0�1 ❑AquiCrrSiu�ager.adRa.rovm OSslin�3g8uria ❑AquifQ iI'est QStoimwa0er•Thaina8a pExptaaionmi'Cechnolc�r �SuluidatxConuni �Gmtfiainat (c�osr� [�vp) t3rrica 4 Il�tei 5a Wdl �� Complattd: ^' i� T/vti`di ID# TQ � � Lof 40 r��r��) �So ��, ; Pm�zl [de��iafioRNa.iP1N3 � �titudcmd I.o�ftndein de�s/rn[natrslse�ncisar dednr�l dep�a�s (eFwe11 fidd, ox7alAong u mfEeieut] _��i �3G �S' N Z�� ao.s' w f�"It�arejt6t�tIl(S� �rrnaaaeat or Qr�f T_ b t4ls�a reyit te �a �t[ag�oz�E dXCS Ot SL�o �thlr Fs a jrrpaJr, frl! oarixn.n wrflmetrwxlorrLS%� °��+�et namrrcofdx �pvtrm�der C2t ramor+Ermrloe won d,ebmekofdiisform 8tii�acakcraf�►c�lswrahnctcd: � - � � 336-598-9275 p.1 Faz�tu� ontt.r: � � 3yS `� �, m r� �tcr:as�tG ��sa�as�aa.� .�s.r:n�e� ,r� ro �ui� �� 2 R 6 ��- ��R zr �x ¢,►s3rcc o�}ru�xG .m�Iaos�a-t� Tn o[.u��sEn 'rsnca�a�ss ti, R � � Q in. R !o iO- [c ia �- tOlfr•. - • � = ro �nw,� R d f� �► �l (G CL f� iC tt c� � � � �. � � �c> a � 2Z CarG�atioa: � ��.,�. 7 -1 a - � � s��r,��nr� � gy�{�d�Ior� ►Ir�e6pcarUJi+�Je�'�JIGi) �as (�+�J m�av�c�edhr acoorrlarru_ +cir� f�! 1VGCO�CAl� ar l3e IV['.�4C O7C.d1�D �eII �t�si�oa Straadmrd� acd thar a mpjrtyrilels►eeod Larbedtptorade� Ar dx sndl owne' ?�:. Sih �171Q1 Ot'f1.�d�7II9� tridl dGiA�IL: Yott ataY n� Bs67iadc o£ihis g�e 1� �ao4ide t$ditiaa�al call site deta0s ar weSi cd�trocoon de�'L� Yaa aiayaLsu �mcis �mat pa@csif�ssacy Far� kpx�oQornwemn�err�7Y�reAs OPttiadd, �sesQner 3� ��A1,1flT$iiJG7IONS � 1Q. � t,., nd�E6 beta++riaaa.sv,rac� 7` O p ei�) Z4a. 7�ar !,a weuc �bma rh� iorm v�s 3o clays a�f canpldian af..z�l �.rNsusratl�eyu►a5i��f�-��'�s(�7a0? �►boB�e'faltav� �aferIevdbdavto�o[eas� ({t� Drnisioao�FPsdsrQaa&lr,LoferrmfxoeYroceaingiTnE� is obaae �ta� �"�' i617iYI�iE Servia �� Ra1cE6h.1\�C Z7694-1517 11_ BOrehoie dtatnctrr_ 6 f a.} 7RL. For Isi Wd1x io �dd'dioa to sasd'tn8 the fotw 6o the add� ia 24a abovy also suh�it a eopy aF �ia fo� withm 30 day�s of comp3aQna cf� �ad� 12.wdlcaasfradionm�ihod:,,.., �i�. A/e-y oa�acdmtati�efdta'�*in� (u- ��*Y �� d"`d�'+ `�� Div�iOa bi�CtGd� Q��it9a IIa�e�gmcad I[�teffoa CreaO'n1�Ptngam. �'OR ZYATEEt SIJPPLYtiYELiS U1VI.Y: i6361N�n�i ServiceCrenEer,Rs�legi�,NC29G99�-IG36 � 3�[eth�ed oF tat SIOwt1Z0 f11i �t ForZt'ater. .9� T eerF��vdlc in sdditiat to sa�diag t� fam to I3a.�dd(gpm). {d tite aad�ss(a} a1�o+rS alm d�1i� °� �FY af ttus fa� wit�ua 30 days of �� r � oo�g6aion oF wctl waslm�on w �hc cacdy heaJth dqmrcmeni of tho cacmry �hD�r��cr� HTH 9/2 Cu „��na. , Nonh Cnaim Dcparmome� aedNamolResnm¢s�-Diri$oa o£Wmee Qintlry Ra+:m3 Fan_ 2073 Fara+ QR=2