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A40 86. � s � The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT , No. �� Date _ -�'�� Owner: -41 A � e r�.� v �► Location: � � � � � � � Contractor: Water Supplp: Private Public T- Sewage Disposal Facilities: No. bedrooms � Disliwasher, Disposal, washing machine, other auto atic appliances Size of tank: Nitriflcation line: � � . Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INS LATION IS COV- ERED AND PUT INTO USE. Date approved: �� Signe Sanitari We� U ,/ • � 5-ewa e �ispo� 1: � Count �, aigned By� � ( er or his representative �E it u01D after 3 Years CezliGcate of Compietion V�---� �-.,�-� � �,, . /�� Date App v d: � ^ � By: � "� ` �� a itarian (OVER) Location of well and sewage disposal facilities sketched on back. �o�- � (,b�,�°�- . ' `i 4 . ! _ ► ,! � 4 �, � l � WELL PERMIT [ Caswe 1-Chatham-Lee-Person Counties DATE SSUE �� TE DR LED: r 1� CO TY: "" �-b�/� OWNER: Qe RO�j��T T: � ADDRE ,,P�RMF�'}(��T�_(�P$ , AR DRILLI G CONTRACTOR: Kk�� VW l 1f4 ��.�- WELL CONSTR[JCTION Distance from earest Property Line Distance from Source of Po��ut�op--�. 6 Total De th• Yield: GPM Static Water Level: Ft. Water Bearing Zones: D�th:��'t. Ft._ Ft/ Ft. Casing: Depth: From �_to L.�t. Dt��6ter: � Inches TYPE: Steel Galvanized Stee1 If Steel, does owner appr Yes No " Weight: Thickness: Height Above Ground: Inches Drive Shoe: Yes: No: Were Problems Encountered in Setting he Casing? Yes_ No If "yes" give reason: Grout: Type: Neat Sap Cement: ��Concrete Annular Space Width � Inches / Water in Annular Space: Yes ��No Method: Pumped �Ssure Poured Depth: From to �� Ft. - Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand�ravel, cuttings) - Ratio: to ID Plates: Yes No Chlorination: Yes No 4 x 4 slab Yes� No �• . • �-. �0 . �- . ��%_T___�' J �, . � . u�-'1 •••i-,r �� G7:�7Rtf.7�ll, Tir �" l�C��'/'• - �� I fiEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRE T AND THAT THIS WELL WAS CONSTROCTED IN ACCORDANC�J TH REGU TIONS ET FORTH BY CASWELL-CHATHAM-LEE-PERSON DIST. A E T Signature of Contra or Date FOR HEALTH DEPARTMENT USE ONLY REASON FOR NO INSPECTION: itarian's Signature Date Sketch well location on reverse si /.� estab 's� reference points. n 1? �� i� E - - 1 Application� Date: 1 �T � �� Amourttlsaid: �� eCE1P��: • . Tax Maa #: � � v frarcE�:#k � �� '�� i' �� _ �� - . � �-��5�' �p M�e ��.m.,.-,. �.��:-�.� �m..�.a� , � � ��NQ�� APPtlCAcTiON FOR� SEFtV�IC�S - SHALL BECOME INVALID. � 1) Permit requested by: (Owner/a entlprospective ownerr: `i G� �� . � G��TR' Home Phone: 33C� 3�F-- I54� Address: � t �`A""f NEa-- G µ. 2� � Business Phane: �� 3C�4-- / S4� _, �k �0,2 0, nSG �,� ? 3 2p (dame and addr�.ss of carrent ovmer. �p G� 1� �•��-� 1 l �A� U i2. � u, D• c�uBo�, ►J�. ��S'Z3 3) 4) Praperty D�escription: Lot size: �� s� Township: FLd7�] ��-Subdivision: Lot# �� Directions to the property (Inciuding road. names and numbers): 60 T u 21-� ,�,ti1 oN So l 5 o ur�l , ru 2 N �� u o� �LAT vF r� c l, 2 .. Ga T�I - M iC.L 5 ous� L T o0o D.o � � a� �r ��T ,el VE1Z GN , ,eo . � Ex�s�' ►� � Proposed Use and Siructure Description: answer each of the f o l l o w i ng q u e s ti o n s: > >�e�� a) Proposed _, Existing ✓ Type of Structure: �FFI G F Width: �a Depth: �a b) Number of 8edroom� Number of occupants or people to be served: / • c) Basemen� Yes _, No _ Wili there be plumbing in the basemenY? C p,UF FM pLDYE�> d) Garbage DisposaL• Yes _, Na _ 5) Water Supp(y'Type: Private ✓(new _ or existing ,✓�, PubiicJ Community _, Spring � Are any welfs on adjaning property? Yes _ No _ If yes, ptease indicate appro�cimate iecation on the site plan. 6) Does the property r.ontatn previously idetrtified jurisdiclionai wetlands? Yes _ No _ PLEASE NOTE TNE FOLLOWING: '➢ A PLAT OF THE PROPE32TY OR SITE PLAN MUST HE SUBMITiED WITH THIS APPUC�1T10N. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. 9 THE PROPOSE� I.00AT10Pi OF ALL STRUCTIJRES MUST BE STI4KED OR FLAGGED. � 9 THE SITE MUST BE READILY ACC�SSiBLE �OR AN EYALUATION BY THE HEALTH DEPAitT11AEAiT STAFF. !• hereb� make application to the Person County Health Department for. a si� evaivation for the on-siie sewage disposa! system for the above-descnbed property. f agree that the corrterrts of this application are true and represe� the mabmum faalities to be p on the property. I understand ifi the siie is aitered or the intended use changes, the permit shail become invali . . /� � _ ��-� � /� er or Legal Representative � � D� �o, ►��. im�7ro� ��n.�n��nn�xnc��n��.� ��.��n. �� T February 7, 2002 Ms. Jackie Gentry 2611 Flat River Church Road Roxboro, NC 27573 Re: Home Occupation of a Design Stitch Patterns and House Plans Dear Ms. Gentry: The Person County Environmental Health Department approves of your in home occupation and recommends to Person County Planning and Zoning Department to approve your in-home occupation application for an in-home office. If the septic system serving the residence at Tax Map # A40, Parcel # 86 malfunctions at anytime, the business must cease operation until repairs are made to the septic system. If I may be of further assistance, please contact me at 336-597-1790. Sincerely, ,�,,� Q . C.�c��`��P�-(� Ja et O. Clayton,•MPH, RS Environmental Health Supervisor Person County Health Department r phone 336.597.1790 fax 336.597.7808 20-B Court Street, Roxboro, NC 27573 Application Date: �'�5/"' � 2 Amount Paid: 7 ,0 U Receipt #: � a i o 6 7 �� ,5�� 3 Aa� ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $ I50.00 (if site visit re uired) ell Permit (New/Rep �nt/Repair) $300.00/$200.00 75.00 ) l `-.,�„� ) f ��.��<l � �� Jf"�.�rno-nn•anv.n.v.xaa�.2a.d.s.Il ).L'II�mII�:ia ►lication for Services Services Re uested ❑ Construction Authorization 1) Applicant Information: Name: ��Vi S �3drnef� Address: 611 13 ai��t I i �u c� � Z Tax Map: � 4 G Parcel#: �� 1 N e.1� (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 Phone (home): 33 C— S y S�0 a 1,5� (work/cell): 2) Name and address of current owner (if different than applicant): Name: �G%i � �.cr�Ffc,/ Phone: � `�/ -�1 S4 Z Address: Z� j I I4 �}- t�• 2� � rGh 1ZZ 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Lot #: ❑�'es �no Does the site contain any jurisdictional wetlands? 0 yes ❑ no Does the site contain any existing wastewater systems? ❑ yes f� no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �o 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: �ffesidential ❑ New Single Family Residence Maximum number of bedrooms: ❑ 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 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ 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 inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. �� G2 %��i Signature (Owner/ Legal Representative*) * Supporting documentation required. ��Z S"'1 Z 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. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��, ; � �� ...�, .� �' � � � � � � 1�a�.�a� � �a-�. � ��.�.11 I�3L � �.11 �.1�. W�I�i, PERMIT (New Tag Map: L�,� Parcel• �G� Subdivision: Applicant's Name: �t�i� Gc�v`r',�l Mailing Address: Z/// �'� ��/� , �n • Phone Numbers: Location of Property: �tepair� Lot: I'ermit C'onditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks appdy.� 3) Permits expire S years ft-om the date of issue. Other Conditions/Comments: - Pe�mit issued by: I�ate: /�� /7i CER'i'�+'�CATE OF C�1d�LE'TIOI�T New Well Inspection: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: � Yi Depth: la ° . Grout: �.,�fdfl,✓��.� Y �r�,✓�G�� r Well r�bandonment: EHS/Date Completed: Methori/Material(s): _ Well Driller: _'�/hZn`;/� License #: Pump Installer: License#: �Vell Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 I9ate• � v Date Results Mailed: " Phone: 336-597-1790 Fax: 336-597-7808 3/1/08 North Cazolina Division of Public Health Occupational and Environmental Epidemiology Bravch, Epidenniology Section INORGANIC CHENIICAL ANAL'YSIS REPORT Private well water information and recommendations County: �,%b �_ Name: � Sampla Id Number: % � d�l Locadon: Reviewer ANALYSI5 REPORT �� Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the federal drinldng water standazds. The pH is a measure of the acidity of the water. Drinking water may contairi substances that can occur naturally in water or can be introduced into the water from manmade sources. TE�T PlESULTS AND USE R�CONIlV�-TIDATI�JIYS � Your well water meets federal drinking water standards. Your water can be usad for drinking, cooking, washing, cleaning, bathing, and showering. - The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering, 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. � / � 1Y1i711b'al1GJG � AG1GlLiuul � uu�va ��avwuua � �+a�+v 1 Y" 1 . / , ei The following substance(s) exceeded federal drinking water standards. We recommend that your well water not be used for drinldng 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. Baz:u�a I Cadm:am Re-sa�npling is recommended in months. I��n Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house lnreferably 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. OTHER COle1SIDERATIONS Routine well water sampling for the above substances is recommended every two to three years. Sample your well water when there is a known problem or contamination in your azea, after repairs or replacement of your well, or after a flooding event. Contact your local health department for sampling instructions. For further information please contact your county health department or the Occupational and Environmental Epidemiology Branch at 919-707-5900. Revised January, ZOl l North Carolina State Laboratory of Public Health 06 N. W?m'�ington St. Environmental Sciences Raieigh, NC 27611-8047 htta://siqh. ncau blichealth. com Inorganic Chemistry Phone: 919-733-7834 Fau: 919-733-8695 Certificate of Analysis Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: JACKIE GENTRY 2611 FLAT RIVER RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27573 EIN: 566000331 EH StarLiMS ID: ES022112-0011001 Date Collected: 02/20/12 Time Collected: 1:30 PM Date Received: 02/21/12 Collected By: H. Kelly Sample Type: Raw Sample Source: Ground Sample Description: Comment: A040-086 Sampling Point: Well head Well Permit #: Temp. at Receipt: GPS #: Inorganic Chemical 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 94 mg/L Chloride 29.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 1.60 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 15 mg/L Manganese 0.91 0.05 mg/L pH 7.2 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 17.00 mg/L Sulfate 11.00 250 mg/L Total Alkalinity 262 mg/L Total Hardness 290 mg/L Zinc < 0.05 5.00 mg/L Report Date: 03/05/2012 ��q� � � ��,� l, „-,','� Page 1 of 1 Reported By: �e�ic �Kto� `^�� J■ ` 1 / �ti� , � � � �� n.�v-n��encnc�.uv.tE�.� �""�c��.�.��n. LQIC. � L ' ��? Tax Map: �� Parcel: �_ Address: �� la'� N'�� C�' Re: Bacteriological Water Sample Dear �'� U i�'!�Y Your welI water was sampled on T/�/ �Zand tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). � The results of your water sample are as follows: � No colifortn bacteria were found in your well water and therefore your water can safely be used for drinking, cooking, washing dishes, bathing and showering. _ _ Total coliform bacteria were detected in the sample. _ Fecal coliforrn bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil and fecal coliform bacteria aze associated with animal and/or hurr�an waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well has not been properly disinfected prior to being used; or that contaminated groundwater is entering tke well. The w�ll shoula be properiy disinfected using the enclosed chlorination procedure. A well contractor or plumber can assist you if needed. • Once the chlorinated water has been thoroughly flushed out of the system, the Health llepartment sh.ould �be notified so that the well can be re-sampled. If the well water continues to test positi re for ccliform bact�ria, then there may be a problem with the water source or with well construction. A well contractor or the Health Department can assist you in identifying the problem and fmding a solution. If coliform bacleria are present in your water sample, then the water may not, be safe.to use. Young children, the elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should be. notified of the results. Water can be disinfected by boiling for one minute. ' you nee er in orma ion p ease ee ee o con ac our o ice a - - . e are open wee ays om 8:30 am to 5:00 pm. Sinc ' , Environmental Health Specialist Person County Health Department Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790 Revised (I 1/13/08) �� T PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant CiC � �1 P� Y Address Z� 1( ��1�- �;(;v�Q ��'�,. �'�el •_ County -erSo Collected By �� _ Date Collected �� 2 Time Collected ��• 5� Source: I�Well ❑ Spring ❑ Other Location: � House Tap �Well Tap ❑ Other ❑ No Charge ��Cha :g : ■�/i �� . % ................................ � ............... �f��Q V *********************************�************************************** Results Present Abse¢t Total Coliform ❑ �� FecaUE. Coli ❑ � --� Reported By ' Date Reported � �� I �� Z Application Date: �/— / � Amount Paid: Receipt #: ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Buitding Addit:on $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 .��.SS �� Tax Map: .-. � � ��.� Parcel#: IL-"u.�rav-an-�cna.nnxata=n�d,�..11 ]L1[�o.�..11.�]l�,. tion for Services Services ❑ Construction Authorization (Fee is dependent on the type of system permitted) � P�rrnit Resision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: C c� r,� ,/ 1,�� i{ i S Addres� � r /-1 RnX b/o �� . (�- '��57 � 2) Name and address of current owner (if different than applicant): Name: �aC K' -%-� Address: �6 f / �'/c,-i- � J-�i C' ,�. ,� ., Q �x �Ob�� vl -C- Phone (home): .�3� -S �`� - 5� �'S (work/cel l): 3 3�- 50 3— 7 3�� Phone: � � `-/— /Sy� 3j Property Description: Lot Size: Subdir•ision: Lot .#: Address and/or directions to Property: �� I/ �(�, ; �„� ��, �c R c�__ _ ❑ yes no Does the site contain any jurisdictional wetlands? es �❑ n�o Does the site contain any existing wastewater systems? ' � yes C�f-t% Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �io s the site subject to approval by any other public agency? ❑ yes �Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Pro osed Use and Type of Structure: esidential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: � Repair to ndalfunctioning System Vl�ill :here be a bzsement? ❑ yes � With pl�:mbing fixtures? ❑ yes � CJNon-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well Ly'Existing Well � Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? es ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is coinplete and correct. I also understand that if the information provided is inaccurate, or ifthe site is subsequentlY altered. or the intended use changes, all permits and anprovals shall be invalid. Signature (Ow�er/ Legal Represer �` Supporting do umentation required. � - i �---��_ 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. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � � � i � �r, s � � � �J � � � �n�n.�n�^��nn�rn,c�na��u.�. �ce�.��n Building Additions/ Mobile Home Replacements .� �. ;� ' +, � •�� /� i ' -• i„' i ,..�: � � Approval Requested for: Applicant Name: Address: Phone #'s: . Mobile Home Replacement —� Building Addition �c �,. _, .• _ � Permit Located: ✓ Yes No Installation Date: / 9�7 Design flow: �, D(gpd) Current Contract with Certified Operator on file (if required): � Water Supply: �/ Well Public or Community s`�- 7 Wastewater system shows no visual evidence of failure on: �ya, �� (date) (Applicant's signature ir site visit is not required) � - � .� .: �_. , �� ..i �� ✓ � . .�. _� .. Addition/Replacement Approved Envirorunental ea Specialist /> / D e Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www_personcount .y net zo ,�� ip �' �'1��C%�' Wr�� '�/� , � � � �G� � : 3a ��`!¢� �� ' c r�� ' ' �° ��,� �� , �'v� ��' 7' f��ct �✓sh�+l9 �� . ��,�o� 0 �� a��q