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A40 391�/�� -w�� - �s-o � � � i3 Application Date: � ��"l1 �� S� �� Taz Map: �� D Amount Paid: 2�ccs.od G "13 .r.., "� Parcel#: �� S Receipt #: � 1 �1 W a �. � �� lG��.a��¢�,Il 7H[��.Il,� Aaplication for Services Services Cs7�mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mo6ile Home Replacement or Building . $150.00 (if site visit required) ❑ Weil Permit (New/Replacement/Repair) $3 0 0.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision 0 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Infor ation: � Name: Address: � �f n �d'• ,� b � 6; 0/i� n � /V � _ �i J � � 2) Name and address of c rru ent wner (if different than applicant): Name: Address: Phone (home): ' (work/cell): 3 3 6 S�� a ,--� Phone: 3) Property Description: Lot Size: ��' � Subdivision: � Lot #: d� 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? 0 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 properiy? (if `yes' is checked, please provide supporting documentation) 4) P oposed Use and Type of Structure: �idential ' � ew Single Family Residence Maximum number of bedrooms: �/ Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? O yes ❑ no ❑Non-Residential Type of business: Maximum numbei of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: CI'1Vew well 0 Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? O yes 0 no Please note any known ground .water restrictions or sources of contamination: 6) If agpl-ying for `Author' ation to Construct', please indicate preferred system type(s): O�Conventional Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any 1 certify th the information provided above is complete and correct. I also understand that if the information provided is inaccurat he site is subsequentl altered, or the intended use changes, all permits and approvals shall be invalid. a ��Q,�� _ , , - �'7 ��- „ Signature�wner/ Legal Representative*) * Supporting documentation required. Date • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved ptat. • A completed `Lot Preparation' form must accompany any application reQuiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �� v �� Tax Map: �Q_ Parcel:�_ �.� � Subdivision � • _ _ ..•< — � � � � � � � Phase/Section/Lot # 101 )E�s�rawna-�irn�-r-+� ��rn��,� ��am.�.�Ila Permit Valid for: Five Years Type of Facility: � Number of Bedroom � / Proposed Wastewater System; Proposed Repair: �� Improvement Permit Non-expiring �� n New �ddition _ �/ Employees / Seats: Permit Conditions: �� '��S Authorized State AgE (X) Owner or Legal Water Supply: � ( � Projected Daily Flow:�� gallons/day Type: / Type: Uate: 7_ t 3-l'1 Date: (o/7p/� -� --�� The issuance of this permit by the Heaith 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. 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 ia ownership of the property. This permit was issued in compliance with the provisions of the PTorth Carolina �Laws a�rrl Rules for SewaFe 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 �vill remain potable. Authorization to Coastruct Wastewater�ystem See site plan and additional attachments (�. Propose Wastewater System: ,_,_,.�,�VeN{1� � (*)Type � Design Flow �$0 gal./day New � Repair_ Expansion Soil LTAR: ' o,� gal./day/ftZ Type of Faci(ity: 5�, F„n,�;l� �wtl ,;y�q=1� (�$ Basement: _ Yes _ No J (*) Systern Types IIIS, Illag, Iv, and V, require p2riodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank DO gal. Pump Tank ---^ gal. irease Trap "'"-' gal. Drainfield: Totat Area �DS sy. ft. Tota( Length ��, ft. Max. Trench Depth 2b in. Trench Width _,L ft. Min.Soil Cove (�z. in. Min.Trench Separation � ft. Distributioa: Distribution Box / Serial Distribution ✓/ Pressure Manifold Authorized State Issue Date: 2- 23-� 7 Permit Expiration Date: Z- Z3-Z2. The system permitted is: Conventional '� /Accepted / lternative / 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) �� 3� �L . .11:e11U.� �.1�� i�� .� JCaaorBsoaamea��.�Il' ]E�C�or�.•ll�IEs �- SITE PLAN ' Name ,�� ,� Tax Map# Parcel# ,�j � - Subdivis' Section/Lo� (� I ` 2- 23 - i � .�.••��"'•r' �:�uthorized Stzie gent �ate System components represent approximate contours only. The con�ractor mustJlag the system prfor to beginning [he installalion to insure tha� propergrade is muintained. . Note: An Accepted systern may be used in place of a conventiona! svstem without perrnit authorization or modifica�ion. Rdp� .� �' � S�2•42' 51 "E �~ _ , ��9•7� � � � i �. �. o �'' � � �, ! � ^ �.',',� � :► " �Jr-�-. Q�N �` �( � .�- �- � N �\ � M � � � � �� ar �� '° � � �-�� — . �� a 3 � Sg�,'42' 51"� � ��- - • �� n,� �, o ' o �wr � r ' r � � � � �� J S'�' _--- �i �'� �$ '�jr�_'T . �� ..�._c4a�;v.+�o;<tms, ir �� ti:�� . ..._ _.'•. .�, .. .. r - ...1 �� rn ;� o �, - � � : o0 _,�`?, )� �� I��.�.a-��.Il IE��.Il�I� Applicant: Location: ��erat�on Permit Taz �`�Zap I�t" �0 Par el # �( Subdivision S Phase/Section/Lot # - I°= # of Bedrooms System Type (From Table Va): � Product (IIIg): C�Q+� �� Type V& VI Expiration Date: �n�0� 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 Autlaorization. H-. l:� �v�✓ ( uthorized Agent) / � (�/W' � (Licensed Contractor� � �� N V J � '�4 ✓i�" scale � PCFiD, re . 2/14/12 ✓ ✓ ✓ �`-�-Fr`r (nate) � �-�-�-�� (Date) l� � ¢v �%- Line � f tli� s��, IS`�1►� Tax Map: Parcel #: Septic Tank System Checklist (Type II-l� System Type: �� C�'�'r''� � l�ate�: Pump System Checktist Contracted Certified Operator (Type IV Systems): 1V�tes: ��.sf ��.�� --�- � � �� IE��.u-��m��.Il IHC� a fl �l� WELL�PERNIIT (1Vew / Repair_) Tax Map: � Parcel: Subdivision: Lot: �b I Applicant'sName:� w t'�aw�e5� Mailing Address: r 0 7 Phone Numbers: �?� - Sa� 2�12� Location of Property: 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: A�� au� a!l S G�'S � Permit issued by Date: Z- 23 -/ 7 ew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Certificate of Completion D[,iner: EHS/Date Well Driller: ��a� Pump Installer: ` Approved by: Additional Comments: Date Sample Collected: r� � - �� EHS: Person County Environmental Health 325 S. Morgan St.,Suite C o..,.ti,..,, nir �7c�a Depth: Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336•597-1790 Fax:336-597-7808 „i,��„ WELL CONSTRIICTI�N RECORD Thaf�naan6c�a1 forsmgkamulriplesed(s 1. Wdi Coatractor Informatioa: R o rtrivi � E, i�.i-z� - wa►co�*+� ��6`� . rrc wa� co�� c��c;ab �� Barnette Well Drilling, Inc. Ca�wy Name Z�irdlConshvc6onPu-rnit#: / � �U [.ttt c(f appllmbic wzf! consaauia+ permtn (tc Crnuu3: StcrG Vario�xa etG) 3. Ndl Uu (c6eck wcA use): Water Suppty R'e�L• 0�� OMuniapaUPublic- OGtOthumal (IieatinglCoolinS SaPP�Y) �da[tia1 Wfficr SuPPt9 (��) QtnduscriaUCommacial ORrsidasaal WaterSupply (shacsd) 4. Datei sawai � � ' Fia'Gpr40 =� . � � c�,ma ib.I.atl C�fwdl fi � 6."Is (a� 7_ Is thl �� 8.Pium For�mU �ta 9 Tot� F'orsc�! IQ. Sta $� 11_ Bo 1Z Wi (� �W FOR� 13a.S 136. I Form 1 ;�g� OGcoandwatetRancdiation age and Remvm OSalinitp Barriu OSwm�+NaoerD�ainage dTcchnotogy ��d�CO1�O� �«� �� OTnca Complcted %'� —�/�1'diiD# � �'7� � tiS �-af lo! ��c�� rp iICR� �� 3 ql �� ►�fi��.t� Far totaml Use OM.Y_ 24:1K!�T6RZUNES- o�p�N rRox T° % �- 2S �`' / 2/U n Z�� Ct` '�i � �.15.01TIERC:ASING focmulu-taud-rallc ��a M 7ERIAL FROM 2'O DL�h1E[ER � i` / O%t` fi �'°' J�'!� z� G ��—� � :�: ,. �� y. � rn� : rv ��==_ �� Q �ana, t � 2 rc R � tD/GRr4GVF.I.�ACK it ' Gcable = .� • � ntnreRtat. � � Tt �- � S� 0 �- %��c� C �.�1 � � �� '� SO -� � %ZA� zba� G 2 0� � R � de and Lo�itnde in degresslmioates/sxondsar da3unf deEreex 2Z. CetiGaBo� �oneladloosiss�am� � p�Gcli� % — 2 �7 �� 33 �"t� 2 H . � `i � c� z 6�0 �w � �� .� - n�- me�en(s}: o�ermaeac or Orimrarar� srs�d+rst�eev,e§r��ru�.�Wr�h��'�. �e�G 1SdXGCO�CAI� or /SI NGlCDIC.0200 �i!! Ca� � md t6ata � �!'gf+�•eooraaasbem p+o.ldad to rGe,ren ora� i rtpair w an ecist[ug wei� OYes oc SPIo epotr:l�loar�a.ar�avua+o�a�rt�+��"'he'oam`oJth` Z3,Site,S,gcamoraaditionr�lRendeml� �CZ[ re�trsarwn oron d�c6xk�ddsform. You m a Y uu the badc of 4ds pagae Uo pmvide a8ditianal �eil site duaals or wdl ' �ion dda�7s. Youaiay also attach a d d i r i o n a l Paga i f�'- x of mUs wrssirnctcd: !� Iekyeat000rnaamurrnqy�7YreUsONLYx+�bdxs�meoua�xffaa.S'�� AL�TSNCTIONS J� af oompletiaa af vetll �! dePt6 be[ow tand mrfaec 24a. �� s £osm w�im 30 days Z 6� (ik) te,Kusuuoaa�h*U�l�+��°'�I�°� �011�i$�efallowiu� Division otWatcrQ+rali�i,Luformation Processingilni� e�vatv Md bdow bop of as�� -��'� 1&17Mai! Serv,ta Ce�L �b•1�C 27699-1617 ret ts aboas ou� � -+' ?Ab. For Ime�oiam WeU� Tn � to sadin� du fam W du addtrss � holediameter: � �-� aboey afso a�bm� a copY of �a fam v�rithin 30 days of oomP� °�. /i2% /� ��.a-P ✓ �tothefdlaa� constradion �od: C,entrdPraE[�ID. :�Y. � aaeapad�, e+�) Divisioa oiWatec Qas��9� IIo�d ��0° 1636 Maa Saria Ceaw,Ra�.� 27�9-1i36 AT6R 5UF'PLYR'SLLS OTiI.Y . ,� Met4od of tes� BIOWn20 id11 Z4c For�ater Snootv� in� �� ain withia 0 da}5 f �d (gpm) _ the ��) �0°�' holch depa�uad of the oountY HTH 112 Cup �n� �,� �� m � � anraaono�rC - nmoanc ,�c�ad. Natl� GtoGns D� � aod Namral R�—Divama a� W�uu Qual+�y xev� Jan. Zo13 �.�� ' � ` � � � E r t �, Y.� , �,_. � l�.k �_ r._� :_,� !I 4 { 2 t � � �.�-�;�� r—., > ,.-�. 5 � � S 3�,,_�1 j f �� f 6•s n j f j i i '� € b E �P �I� i �i 4' �� LJ �1 � � � ; � �.i i � [ � i..�� :, � �• E F � $ " �__.�t p . � s-<< % �-�, �+` a �: ^�:., � � s'.! � !—•� �'. � j ��y s � :s, �� ;'� r�� { � �`t "� , r � J��k � , a 1'- ; , � � �� t.� - - £�--I�� g E \_ a ...,.d` �.�� i... i �'�. `.1 �.�' l�� t € e P � i _/ e ^ � �,i =�� _ i :,? � � i Far Inorqanic Chemical Confaminants County: Name: a - p � (o ( Sample ID#: 0- 3 4 Reviewer: ��Ne,/ � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic 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, nnless 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 inor,eanic chemical resulis onlv. Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron Manganese � Mercury l 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/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 onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic probtems 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 I S minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the we(1 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 � Cadmium � Chromiu� Fluoride 1�Ian�ane Selenium Silver pH For more information regarding your we!! water results, please ca!! the North Carolina Division ojPublic Health at 919-707-5900. North Carolina State Laboratory of Public Health 31�2 D�stnc Drve Environmental Sciences Raleigh, NC 27611-8047 http://slqh. ncqublichealth. com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES092617-0027001 Date Collected: 09/25/17 Date Received: 09/26/17 Name of System: CLAYTON HOMES 58 LASALLE AVE ROXBORO, NC 27574 Time Collected: 11:30 AM Collected By: A Sarver Sample Type: Raw Sampling Point: Well head Well Permit #: A40-391 Sample Source: New Well Temp. at Receipt: 3.5 GPS #: Sample Description: Comment: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium Cadmium Calcium Chloride Chromium Copper Fluoride I ron Lead Magnesium Manga Mercui Nitrate ese < 0.1 < 0.001 14 < 5.00 < 0.01 < 0.05 < 0.20 0.58 v < 0.005 3 0.140 � < 0.0005 < 1.00 < 0.1 2.00 0.005 250 0.10 1.3 4.00 0.30 0.015 0.05 0.002 10.00 N/A Selenium < 0.005 0.05 Silver < 0.05 0.10 mg/L Sodium 7.60 mg/L Sulfate 8.60 250 mg/L Total Alkaliniry 50 mg/L Total Hardness 47 mg/L Zinc < 0.05 5.00 mg/L Report Date:10/10/2017 Reported By: .�Cennetl�i y'reene , Page 1 of 1 � ....�.��. .. . � y„� �� +� � �..-.. Y* ,,�"'� � � �� lt ��n�n��►arnar��irnt�a�.� ��..��.�� Date: �/�/� Name: � 4' �r C� „e Lv{- lo ( Address:5� � S V2 o ,L�r c r?�t Re: Bacteriological Test Results Dear Well Owner: Tax Map:�� Parcel:� Your well water was sampled on l/ a5 /� 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 bacterialogical results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform 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 �nay rot be safe for use. Young children, the elderly, 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 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, ...Z V V V�l / . V Environmental Health Specialist Person County Health Department (rev. 4/ZO/16) ?erse� Ccunty Em�ironmPrRal Health, 325 S. Morgan St., Suite C; Roxboro, NC 27573, Phone: 336-579-1790. Far 336-597-7R08 � . .�:. 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: ES092617-0078001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: CLAYTON HOMES 58 LASALLE AVE ROXBORO, NC 27574 Col lected: 09/25/2017 11:30 Received: 09/26/2017 08:47 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slah.ncqublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 A Sarver Susan Beasley Well Permit Number: A40-391 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 09/27/2017 E. coli, Colilert Absent 09/27/2017 Report Date: 09/29/2017 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.