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A40 384�t/�� Application Date: / �! 'J. .� , p a ��`� f ��4 �� Amount Paid: ZOD • OD "� •--.> � � ��r Receipt #: v l S� 3 �' 7 � G'/%P�i� /�P4L �-# �IE��aa•�amm��.Il '7H[��.11�:lln Aonlication for Services Services 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 Construction Authorization (Fee is dependent on the type of Permit Revision Tax Map: Parcel#: Repair of Eaisting Septic System Application: No Charge/ CA $150.00 or $300.00 � 1) Applicant Information: Name: .5�� n, n.i Y �a w k, ni 5 . Address• r 4 t r u r b�- r= /h ��- � s � o �oX,�c �c'c N[, 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 33 � .�y � ' �- � �- �1 (work/cell): �� . ��.t'� � Phone: 3) Property Description: Lot Size: �_ Subdivision: �f ac , . Lot #: �%� Address and/or directions to Property: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes � 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? ❑ 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: ❑Residential ' ❑ New Single Family Residence Maximum number of bedrooms: �' / Occupants: O Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes O no With plumbing fixtures? � yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: LYNew 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 applying for `Authorization to Construct', please indicate preferred system type(s): 0 Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑�►Y 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 altered, or the intended use changes, all permits and approvals shall be invalid. �� /''� ��r/� Signat� (Owner/ Legal Representative*) * Supporting documentation required. Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `LotPreparation' form must accompany any application requiring a site evaluation. (10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� s� ��.� �� _` � � �� ):E�e�.��-�� .�1 IL--��.71�7� Applicant: -'r Improvement Permit Permit Valid for: Five Y ars � Non-expiring Type of Facility: �1� �P � New � Addition Number of: Bedrooms �/ Occ pants-� mployees / Seats: Proposed Wastewat System: Proposed Repair: Taz Map: � Parcel• � Subdivision � Phase/Section/Lot # 4 � Water Supp;y: �� Projected Daily Flow: S� gallons/day Type: �_ Type: � Permit Conditions: 5��2 S� �1� /J �a'� Authorized State Ageni: (X) Owner or Legal Re Date: `� �a �I Date: �- LL - /^ - The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is th;, responsibility of the applicandproperty owner ±o insure that all Person County Planning and Zoning and Buildina Inspections requirements are met. This improvement Permit is subject tu 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 ia compliance with the provisions of the Nort6 Carolina °Laws a�rd Rules %r Sewa�e Treatment and Di.caosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Sgecialist warrants t:�at the septic system wiil cantinu., to function satisfacto:;ty in thc fature, or that the water supply wi[l remain potable. — Authorization to Construct Wastewater System See site plan and additional attachments (�. x Yroposed Wastewater System: , ��'��( • V� (*)Type�� Design Flow �� gal./day New � Repair _ E:cpansion ,/� Soil LTAk: . 3 c7 gal./day/ft2 Type of Facility: `Cigl2% 1��' S. $asement: _ Yes �P:o (") System Types Illh, Ilibg, IV, crnd Y, requireperiodic system inspertions by the Person County Health De�artment. �� Wastewater System Requirements Tank Size: Septic Tank L�� gal Drainfield: 'Total Area �v�0 sq. ft. Trench �Nidth � t�. Pump Tank gal. Total Lengtl� � �_ ft. Min.S�il Cover �P in. Grease Trap —� gal. Max. "french Depth � in. Min.T�rench Separatian ( ft. DistribuHon: Distrihution Box �/ Serial Distribution �/ Pressure Manifold �_ Specifications: SPv-,.� v r- D- bo � t 5 �. K• —..-E 't- �--�01C t.� s� �� -eq ccg� (��t9�� n�s Authorized State Agent: [ssue Date: �'�-P `� Permit Expiration Date: ' The system permitted is: Conventional /Accepted �i Alternative / Innovative . I accept the conditions and specifications af this permit. ,/� , "� (k) Owner or Legal Representative: �� - � Date: �-f -Z(o -�� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) u �� ) f ��1 � Name: � ~.�'� Subdivison: . '�- �C��.T�T��Y ]E��-m��mIl lE��mIl¢Iln � �«s �,/a�--e�s��P System Type: ��p Septic Tank: l0 v O gallons Pump Tank: "— gallons Total Linear Feet: �{D � Max.Trench Depth: �" Site Plar. Lot: EHS:. Date: ..... .�a.��c��w�.�..... :�aSa�f�. �1i�. � _ ar�, � 15s'� Tax Map: Parcel: 3� c(— Z�, �( �l� ` `7G� l,`=s�' Scale: Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person Cour�ty Envir r�mentai Health with any questions (335) 597-1790. `�� ..-_ Additional Comments: �Da r �� \ �. �—��, ; ,�f �� _ � � �� na�na^�s�TM� ��n.��.� ��.��n. Applicant Location: Tax 1�1a� ,Q4o Parcel # �_ SubdiVision OuK�:�oe ,�creS Phase/Section/Lot # # of Bedrooms r;a Operation Permit System Type (From Table Va): Product (IIIg): T►,�, Type V& VI Expiration Date: N R Type V& VI Renewal Date: NIT 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 thorized Agent) �- 1�Ke L�.��S (Licensed Contractor) Scale ►S% PCHD, rev. _2/14/12 5-18-I� (Date) S- Ig-l`t (Date) Line Len 4 2 13 3 2 iOt� Tax �a�: Au� Parcel �: 3g Septic Tank System Checklist (Type II-I� System Type: � Notes: Pump System Checklist Pum Tank InitiaVDate te ID & Date: Ca aci : Riser (6" in.) NEMA 4X Bo Model: Pi gy back lug Hard wired Alarm functioning Mounted on ost Above rade (12") Conduit sealed Pressure Manifold � Number of ta s: Size and sch: Contracted Certified Operator (Type IV Systems): Notes: r ��.sf ��.�� - � � �� IE�ra�n�roaairncmm�a��.lL IC-��amll�llEa WEL�, PERNIIT (New� Repair_) Tax Map: `� o Parcel: `� � Su6division: 9,�rtC� � Applicant's Name: �rr�.r,." � �Ci �c-� Mailing Address: Phone Numbers: Location of Property: Lot: � �c� � 1QoQ� -� I��` �� D 4 k� Qu0.,��%�e� sa �--� �s� ll-'� Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County 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: r"` � �ew Well: � �� EHS/Date Location: s. 3�� Grouting: � Well Log: Well Tag: ____�� -t7 Pump Tag: Air Vent: Hose Bib: Casing Height: V Concrete Slab: Date: �' � �� Certificate of Completion QLiner: EHS/Date .� Depth: Grout: DAbandonment: Date: Method/Materials: Well Driller: Q License #: Pump Installer: License #: Approved by: Date: �— Z— l Additional Comments: Date Sample Collected: '� I ( 7 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 31/26/13 Report To: H. KELLY North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: JENNIFER SNEED 99 LASALLE AVE ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: Sample Type: Sample Source ES080217-0034001 Raw Well Sampie Description: Comment: Date Collected: 08/01/17 Date Received: 08/02f17 Sampling Point: Well head Temp. at Receipt: 4.0 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sloh. ncpubl ichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Time Collected: 11:00 AM Collected By: H Kelly Well Permit #: A40-384 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 Calcium 50 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.33 4.00 mg/L Iron 0.25 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 3 mg/L Manganese 0.320 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 8.1 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 16.00 mg/L Sulfate 25.00 250 mg/L Total Alkaliniry 140 mg/L Total Hardness 140 mg/L Zinc < 0.05 5.00 mp/L Report Date: 08/10/2017 Page 1 of 1 Reported By: De66ie.r�fvnco! North Carolina State Laboratory Public Health Environmental Sciences Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Microbiology Certificate of Analysis ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES080217-0069001 I I�� II�� I �� I�II� ��I�� I��I �I�� I��II ��III �� I�� I�I ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JENNIFER SNEED 99 LASALLE AVE ROXBORO, NC 27574 Col lected: 08/01 /2017 11:00 Received: 08/02/2017 08:22 Sample Source: Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sloh. ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Susan Beasley Well Permit Number: A40-384 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 08/03/2017 E. coli, Colilert Absent os/o3/2017 Report Date: 08/04/2017 Explanations of Coliform Analysis: Reported By: Susan Beaslev / r 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. Jun 01 1709:59a Barnette Well Drillinglnc , W�LL CONSTRIICri�N RECf) t�D ileis facsa aa 6emed fars�le a m�pieme4s 3�� ric w�i c��c�� N�- Ba�ette Well Drilling, lnG. 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