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A40 394� �/3��f.�. q1��1�� n5 ��-�,��, \�a�'► Application Date: 3�-3 17 a p �� ) f ��,� �1. �y Amount Paid: , ,�OG , 00 �i�� ,►`� � Receipt#: 1�'302`� I 183N�`� �'�� , 'n � 3��C .�. ��E�daa-�a.��.�m.Il 7HI��,ll�;1ln. l� � Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 tion for Services Services � y�.,ns� .� Tax Map: � � Parcel#: ��`� Construction Authorization (Fee is dependent on the type of Permit Revision U s�,►�e ��/ Repair of Esisting Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: . Name: S'�9-JYi M y %�� uJ �� v 5 . Address: �'+s-�' N v R�� e/11;,- � s ,�c' �. _ �46X QoRa �, �. 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 3 3 6—S9 �— a i� 9 (work/cell): Phone: 3) Property Description: Lot Size: A-� Subdivision: �f}l� �i� �7� G��"°�I-ot #: �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 systems7 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? 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: . �Residential ' ❑ New Single Family Residence Maxiinum 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 fixtures7 ❑ 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 Please note any known ground water restrictions or sources of contamination: 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 inaccu�a�e, the site is subsequer,[�y altered, or the intended use changes, all permits and approvals shall be invalid. Signatui wner/ Legal Representative*) * Supporting documentation required. 3��'�� 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 e.valuation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��,.�� `_'= �'� c� � ��T°�� lC�+e��a�� .Il 1L��.Il�I�. Applicant: Address/L Permit Valid for: Five Years � Type of Facility: 12 � -P . Number of: Bedrooms 3 / Oc u� Proposed Wastewate System: Proposed Repair: k� Improvement Permit Non-expiring New � Addition �, Employees / Seats: Tax Map: � Pa cel• q Su'udivis��il i� Phase/Section/Lot # Water Supply: �� Projected Daily Flow: 3 6o gallons/day Type: � , q Type: � Permit Conditions: '�0� S� �� I�tQ'"� � Authorized State Agent: r� �`�� Date: `i— (X) Owner or Legal Rep esentative: -� Date: � The issuance of this permit by the Health Uepartment does not guarantee the issuance of other required permits. It is the responsibility of the applicant/property 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 in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws n�rd Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). 1�leither Person County nor the Enviranmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain ota6te. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �p�— �S� ,�/ (*)Type �_ Design Flow 3 6 D gal./day New� Repair _ Expansion � Soil LTAR: �'3 O gal./day/ftz Type of Facility: �✓.�� P S. Basement: _ Yes � No (*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person Counry Health DePartment. Wastewater System Requirements Tank Sizz: Septic Tar►k l��c gai. "' Pump Tank '— gal. Grease Trap'� gal. Drainfeld• Total Area �� 0 sq. ft. Total Length 3D a ft. Max. Trench Depth � in. • Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft. Distribution: Distribution Box �/ Serial Distribution� / Pressure Manifold Specifications: Authorized State Agent: b6X � s ��. "��c ( � 7�` /��,e Issue Date: �— Zn ` �7 % � �� Permit Expiration Date: �{—zo� Z The system permitted is: Conventional Accepted �/ Alternative / Innovative . I accept the conditions and specifications of this permit. , (X) Owner or Legal Representativ Date: � � t � �. :_ Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-179'� (rev 5/12) `� )f �1l��l � Name: � ~.�'� Subdivison: � �� lE��-��ffi��¢m.Il IE�emIl�fln =- .�� System Type ��—��'r SepticTank: ��do gallons Pump Tank: '-' gallons Total Linear Feet: �� Max.Trench Depth: �" Site �lar. dress: . Lot:� EHS:, Date: '�" YELLI��T��P DRIVE ;- � � '. ��' RfV� Tax Map: � Parcel: 3 Q —2D�-( � r — � /' Scale: � — S Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2j Contaci Ferson County E�viroiimenfal Hea�th wiih any questiors (336j 597-179C. . Additional Comments: � ) rlSf ��''��S ��, ; , �f �� _ � � �� I��.�a��n„-„ ��.IL IFZL��.Il�I� Applicant Location: iax iVIap ��Q Farcel # 3R Subdivision Da K<<�1 � � Phase/Section/Lot # # of Bedrooms 3 Operation Permit . System Type (From Table Va): �l � Type V& VI Expiration Date: Product (IIIg): �r� Type V& VI Renewal Date: j.l �{ �' 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. Scale PCFiT�, �-I$-l7 (Date) �j -18-i� (Date) _ � . ��II • •. � � a� Map: �� ParcEl #: 3�_ Septic Tank System Checklist (Type II-I� Se tic Tank InitiaUDate State ID & Date: S _ 2 �_�g—� f Ca acity: � 8 p f Tee and filter ,/ Baffle Vent Riser �,c p Outlet boot Perm. Marker Distribution D-box (levels set) Serial Pressure Manifold LPP Notes: <------ System Type: � Nitrification Lines InitiaVDate Trench Width: ft. �s q_�g_ Trench De th: Z in. Total Length: ft. ,/ Minimum s acing: ft. o� �, � Rock depth/quality � p�- Dams/stepdowns � Grade (< .25" in 10') Cover (6" minimum Setbacks From wells Jz _�g Pro erty lines � Foundations/basements ,/ SurfaceWater � Other: Pump System Checklist Pum Tank InitiaUDate te ID & Date: Ca ac' Riser (6' in.) NEMA 4X Bo Model: Piggy back lu Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of ta s: Size and sch: � Contracted Certified Operator (Type IV Systems): Notes: t, Tank Com onents InitiaUDate Puimp model: Block�4") Nylon retrieval ro e Float tree anc�attachments On/Off float s 'ng: in. Alarm float (6" separation) Anti-si hon hole �'�� Check valve �� Threaded union �� Gate valve `�, Conduit sealed Outlet sealed A roved and secured riser Su 1 Line Size and material: in. sch. Length: ft. (,v� f l �WC �,��, sf ��.� �� . � � �� lE ��a,� ��,� m,� ��.Il IHC � m ll�l� WE� PERNIIT (New Repair_) Tax Map: �� Parcel: � � Subdivision: n vQ . Applicant's Name: __ ��►'Yi/'?c, �'�Q-W �Ci�c � Mailing Address: � Phone Numbers: Location of Property: . --� i,,,,�loC Lot: ( 0 < �li �r�✓'��(� --� y�r�'"`1 �� 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: � Certificate of Completion �ew Well: � � EHS/Date Location: f�q-I �� Grouting: � 4-t --�-�Well Log: '�� Well Tag: /�l�, Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Wetl Driller: �l',r� �� Purap Installer: Approved by: � Additional Comments: Date Sample Collected: �-1 � � `� EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Date: � � o �� U �-�-� � QLiner: EHS/Date Depth: Grout: DAbandonment: Date: MethodlMaterials: License #: � License #: Date: 2 � � Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 Sep 20 1710:59a Barnette Well Drillinglnc 'I�Ei,L COI�TSTRUCTiON RECORD ihis ftxm caa h� ascd Far s�sie� mu�Uipl� srctis 1. Wei[ Cond-actor Lafornwlion: a �u,v `C' � �%� u : if' wa� c�� N� 3 � 76 ��J NC WcJ1 Ccnrsaaar CasiFcatoa Numbcr Bame�te Wel! Dri!ling, fnc. C�acy t�ame y V�rdf Co�tstruction Permit#: Yarrmx� ery L�sr ulf apppeabii wafl coreurnaion �crndu fu CaarrN. S��S a. wa� u� {��atn ��: OAgriculwrat OivleinicipaUPublic- ac,�oc�� (x��c�� sun�rl 0'�des�ul Wfficr SuPP1Y (uDP��) Qr�usuiaVcoa�mcrcial �[%siaaxHa� water SnpPty C�) Ci►d4 QAQUI�Cf$CC17J[P.0 Q�iiODlldtil8ftl�tlflC�Yd�l00 Qi�11[fiG $[�'d9rC Si[� QaY1VCR' a$8[NtN 82STEGf QAquifcH'rst ��'�� DE�aeaiatnlTcclmoto&Y C]Sx�SidrnaeCoyum! QCrtuthetrnal (Qosed Loop) OTiaar �.��u�»P�� 9�l�'!7a►larn� � �v �9.w� r.o�aoTM - 336-598-9275 p.1 �arr� uRflr�r.v � n a- iS�f{ / tb" �u'� !� oz�/ :Oi}TERC�.S'II'iG �r-�lots:e�xe3ls �%�.II11ER d [Ohf '�O DYAR7E17�R 7�[� N � n ,�d tc �y � �- SUigz t � ;.=n�Rci�ssrvG.v��vsul� � � r ;o� -ro awe+er�x ft � 'a' R �- 'n' 715CR�N" . � . . . COM 'ro DIAMIIER SLOTS[7S '�[Ci[SVE iL tt ��. � {y '°' �CRAII't� • .- - ffitP ��ao1d TO -. . RL�Tf�uA]- C� � LC �` j O�c rc f� R � [4. SAIYQ1GEu°CVEI:TiIGK d ' Gai6Te -... •. �,- . 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YouaiayaLso suach nd�ioianal �agcs �fn�'- Fareac�e ��flr naec+eoternq�7Y w�'t OIYLY�di l�aaC �.Y� °�' $�1Bd1�7TAi,31�.SilJCfIONS � one�Cirac ; + f�-t> «c) �a. � wn w� s�c d� t� w� ao aays aeoo,a� ofx-uc a. �o�l � depth r�ow (aud snH� �on L��fdt� �brnmf� iaras littaff deArhs jf� C� ��•°0��qp� A'itis+'ou of Wa�ec'Qaalii�.7nCarma�oa t'�'oa�inS Uaic, i� se�,�cer�a aaoW �p o€ � 2� t�) asi7�s�x c�, �ag�,r�ez��-z�7 �,�r:Rrg� � � -j` 7 L Serr'.boic dia�netet: � i� ?.4#i. For falec6on WdL� irt ��a raidai8 ttte form. ro ihe addtc.s ia 2Aa abos� aLso snbm� a aopp of qtis Lonn aalkia 30 days oY oomple� of'well + l�,i 0� �Df��, `�� m�e�ouuo� 12WeI1eaastntcRont�e�od-_ II andfpJxlicluCeu�olFrogr�. [i� au8ci r�. �Is d'v�a p�b, ezc) �iYis�Oa of Watu Q�t9� ��'Gr" I636 D� Servioe Ceic�xa �ob+NC Z7699-Ib36 Fdlt Wd'IER SIJE'Pf.Y R'Ei.IS Orii.Y: . ' �j �___ ��a�o� B[ownzo m�n 3Ac Forti'ater. � Sub�wit a� cv¢y of dus foxm wit� 30 days of I3a.Ytcl� {gpm} the a8d�ss(es} abat'r. romP�ction o£ wc'� �m ta tt�e crna�iS' �8i �'�°1rnt of thc toun�Y 13b.Di�fcCi�ioatvP� HTH p�O� 7� �P - athueooasadcte�- ' Di+eioo� of Wa�eeQ+a��Y RevisedJan_ Z033 FormGW i NoahCmoTmaD�eoeafF�vii°°a�aodN:rmalRcsame�s- -^---•! .._..._ . _ _..____.�_ -._...r_._ - -- --'--'— - .'_'_-•- -- - �� ...�\ y . � � 1 \,�, v~ � � � `1../ �� .:,1 ri�i1 �a� ix ii''t� ai'�13. i:z:�i± �cY: ��.i i1.;IL�. s� �� u., ,lrii. i v4 �{ +`f. Date:1� /�/�_ Name: Address: P.�xbo�o A� 2�s�y Re: Bacteriological Test Results Dear Well Owner: Tax Map:�� Parcel:� Your well water was sampled on �/�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: V 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 coliform bacteria are naturally found in the soil. Fecal coliform bacteria are 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 may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests�ositive for total or ecal 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, � Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmental Heaith, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences IVlicrobiology 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: ES110217-0114001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: CLAYTON HOMES 53 YELLINGTON LN. ROXBORO, NC 27574 Collected: 11 /01 /2017 10:50 Received: 11/02/2017 09:05 Sample Source: New Well Sampling Point: well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 httq://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 A. Sarver Angela Heybroek Well Permit Number: A40-394 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 11/03/2017 E. coli, Colilert Absent 11/03/2017 Report Date: 11/03/2017 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. ��` ��i��l'/1 v ne department af health and human services r---,. • � t �t k � ; � � � ..�,-.; .�- � �� `�� { � � '_.� .°.. �� t f �� i { ,.' � F �v { � ' � `�• � € ; � ` �� ` ;,.J. : � t t •r � � � t �.�� ,. � s._ � � , � ,.__-�., � -�y �f �,.9 � � 4 � :,".4 (�� • � .-•� ,�`�3 }� �--y g.—�,`.^� _�� 6{lb{ .�- t �� 1.. �rti` F �..� �� ! f ,R ^�...,� �.J� ��...,.y � `t. `._.l ��i �',• F�'N i � f 4 �.../ Y t �/y i�� ,., � .l � F L.+ For Inorganic Chemical Contaminants County: Name: Sample ID #: Reviewer: � 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 inorganic 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 orthe 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 inor�anic chemical results onlv. Arsenic Barium � Cadmium � Chromium � Copper _ � Fluoride � Lead � Iron Man�anese Mercurv Nitrate/Nitrite Selenium Silver Magnesium � Zinc � pH 3. 0 a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. The North Cazolina Division of Pubtic 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 inor�anic chemical results 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 inoreanic chemical results on[v, 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. Bazium Cadmium � Chromium � Fluoride � Iron Maneanese Selenium Silver pH � Zinc For more information regarding your well water results, please ca!! the North Carolina Division of Public Nealth at 919-707-5900. North Carolina State Laboratory of Public Health 3° Distnc�Drive Environmental Sciences Raleigh, Nc Z�s„-$oa� http://slph. ncpublichealth. 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 CLAYTON HOMES 325 S MORGAN STREET 53 YELLINGTON LN ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES110217-0066001 Date Collected: 11/01/17 Time Collected: 10:50 AM Date Received: 11/02/17 Collected By: ASarver Sample Type: Raw Sampling Point: Well head Well Permit #: A40-394 Sample Source: New Well Temp. at Receipt: 2.0 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Quali�er(s) Arsenic < 0.005 0 010 mg/L Barium < 0.1 _ _ 2.00 mg/L t;aamium Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate Nitrite pH Selenium < 0.001 4 < 5.00 < 0.01 0.005 250 0.10 0.08 1.3 < U.ZO < 0.10 0.30 < 0.005 0.015 m 1 < 0.03 < 0.000 < 1.00 < 0.1 6.4 < 0.00; �nver < 0.05 0.10 m /L Sodium 4.20 m /L Sulfate < 5.00 250 ma/L fotal Alkaliniry fotal Hardness 14 cinc < 0.05 5.00 mg/L Report Date:11/13/2017 Reported By: .xennetl�i y'reene Page 1 of 1