A40 400:,
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� 3C'.L'v�� cp ^r^i �^rt^�+ <B 7L=L�.�.:1 � 1i � �i.� �
' �� • �� ����
��z�# �al'ad %r �, �'�ve �
Type of Facility:
# of Oc�uQantS # o:
Praposed Wastewater S em
��o5�a x��: _��
• a�..� � � , .� . • .
���f��o o ��,�o��
�.� ��n� ��
G�� o o � ` _ _-, /��
�pra�e�es��t �?�xmit
sr �, . ,.
ter �aa�pdq �!/���
Owner or Lega1 Regresentative
Autiiorize3 State Agen�
Type; �— q' "
Type:
�!�
. - c.� � . � � � � � ..
1he issu�nca of tiris pes�it liy #i�e Health Departmeat ia does nai gnara,niea the issuanc� of other permib. If is the �spons�biiity of the
aPPli��P�Y owner tn in stae t�at aIl Person County Plaaning and. Zo�g and Bn�mg Zaspections re�ements are me� This
�nprovement $'ermit is snbjecf ta revocatiam if the site pIan; �pl�tt''�i� ti� intend� nse c�anges. '�e ��ovea�e�t �er�it is not �
affe�te� lig a c�angs in owner"s�ip of tlae gnropertp, T9iis permit was iss�aed in c�ffipli:ancE with the provisaons of ti�e Nurth �arolina, .
`LBws aa�d Rules for Sewa�Qe ?iembnent and IDi.mosal Svstems' {�,SA NCAC �13A .1900). P%ither 'Parsan ��un#p.:nor�;t��.`�'�
Envirmnmental �ealth Sgecialist �varr.ints th�t the septic #ank system w�1t canf3nue to fnne�on sa#isfacfosifly ui t�ae futnre�or�#li:i#.
th�water snpply w�l remain potabie. �• . �
' �i�at�aoa�tion to C�mst�uct ��stewate� S�si� �� iur �ati�lmling ��) � �
*. Ses site plan mid additional attar}unents (_). • ' • � . -.
Progosed Wastewater Syst�m: �✓`Q✓t �j �vt.�i �� Ty-pe�4 astewater �low �6 � g.p.d.
New ri�- Re�air Ex�a�sion ' .� Soil L��18: •� O g.�.si.1$ Z .
Type of Fac�ity: � �P � Basement _ Yes 1C No
� ' •��$��P�.$��' S`9'���3'ib �11H3'�331.�31$9 � .
ian� Size: Segrtac ian&t:' l�C�vgad �p Tanic; � gai t�re�se'T�p: gal • ,
l�raim�e�d: Tot� Ar-.,.�: 2o c7 sq fg To#al Length �d �#� ' 1Y%aaiaa� Trenc�t D�pt9n �_ an ��� �.
�r�c�a �id#h � fi �a '�� Soi� �oves: _� i� �aaa�i �`r`rea�c% �ep�on: � �i
�ist�+ibu�on: �3isda�u#non �oa i� Serial ���n�aoaa �'ressure I�ianafoid �
SDC�l�CatlOII9: ' �� Sf ,.� �� � � , � . - .
State Agea�s: _��
Pernsit Fx�iration Date:
Date: Y/ !�/o
The tyoe of syste� per�itte� is �C en� Ac:,�t n A1tPrn�r.ive. I a���t the sperifications of the
P�� l�U
�e�/���.i �z�aa�s�s��€ave: Dafe: �— � '�
rCED rev. 11/10/05._
. , .. : .
y _ .
�.: �� a�oc���- `�� 6� � -
:: c��a�-t���.���-��� ��i� ►���.ir��y
: o�mor� -� - 09- -���
�
Owner_ o a� M.a , c, �' � Groat Log � L�
!� � �� Taa IVtap � Pa�+cei # ( 0
Location: _
subdivisian: �� , r,� w C A� r r S j[.ot #, i n �
• WeII Constrac.fion
Dishance From nearest Prope=ty Line (1Mlinimum 10 eet) I 0
Distance fi�om�itc System (Mmimiun 6o feet) �D ,r
Total Dept�: i��0 ft Yeld: �(� GPM • Static Water LeveL- Z 7 ft
Water Beazing Zane� Depth 12 � ft� ft ft &
Depf�: From�_ to ��i $. Diamet�er: � in
Type: Galwani�ed Steel �V L � �
Weig�.� Thiclmess: 5�'� Z( Height above Ground: � in � ; /
Drive Shoe: Cf Yes No Atty problems encountet�ed w1u7e �tmg casing9 Ycs l� No
If `�es" give reason: ' —
Grou�
. Ne� Sand/C,en�t Ca�+ete Grav.eUCem�ut
- '• Affiu�ar Space Width ' inches Water in Affiular Sp�ac� Yes ' No
Me8�oc1 of Gmu� Pumped Pressure - Pouc+ed Dept� ' to Ft
r�at�ia�s IIsed� -
No. Bags Portland oem�ent " Weight o� 1 Bag � pounds .
If mndt�re {sand, gravel, �) - Ratio bo
ID plabe� _ Yes _ No 4 x 4 slab Yes No
Liaer.
- .�.
�h: Dat,e InstaIled:
Driiling Log
Grot� 7nstalled by: -
Location Drawiug
FY-om To Ror�a
2 P v� v.< �
- - . : f ` � .
, -
_ �
�� C�I � f�1C BbORC' II�E� 1S (:dIICCL 8Dd ��115 WCu �V�S C�S$'� ID��VI�1 I�t1�1�115 � f0�i
by ti�e Person Co�mtyH� Departra�xit. : .
�atnre a#Con�o� /�� - ID # 3 � Daic . ' I -� Z ' (J .p _
p�P�
Pump Inslallation Cantractoi: � n,p�� �,✓ c'. State Registratioa NumUet: � 2�� �
�P �P� � $ S't�ttic Wates Level: $ l
'am�p Make & ModeL- [ 'Sr� r. l: �l� Pamp Size a�d Ratm�- ��2 hp t� gpm
j��Y �Y �� P�P was � an,d ti� well I�d �couipldsd ac�rd'mg �o the Persan Camiy Well Rnles ia effert
xi this dabe and thaf a capy of this record has beeu p�+ovided bo-tl�e well owner_ .
�P �' �� �� ' . • Dat� l -% Z - �� FCHll rev O1f27104
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S�,T'E SSETCH
Name ��M ��STas Map i�� � Pascel #� �
sub ' io �n secdon/I.ot# l D
hrv � � a
Authorized State Agent a�
Synem components repnnsent approxi�nate rnntotds only. The rnntractor must flag tbe
systr�rt priorto beRinninArbe installation to insure tbat proper�¢r'ade is maintain.ed.
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i�ELL PERNIIT .
PLEA�E SEE ATTAC�D �LAN �OR V�LL SITE LAYOUT
� L.
Tax Map �
Applicant: _
Subdivision:
Location:
� �/
Type of �Vate� �upply: � Individual _ Community
Requirements:
Site Approved By: �
Grouting Approv d By:
Well Log: �
Pump Tag: "� �J - `I o �
Well Tag:
Air Vent: � - o q 1 b
Hose Bib:
Casing Heig�t: � �
Concrete Slab: � . c.� - ��or�
Public
Liner:
�Installed by:
Depth set: _
Grouted: _
Date:
Water Sample:
�n
Well Driller: �� �
Well Approved by: Date: `� / /'�f ��
****See Attached Site Sketch****
Wells must be 10 feet from praperty lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev O1/27/04
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c��1�B�' g80Gt7 �a r�id �P �G /Y's'
pl�ol�o��o� � � ot� �l o
��o�o 00 �
Applicant: `�`"" ^.. Qu' �' ^ S
Location: o�- I���� Rd, 74kP ����,�- o�.t� w�1J ��t a��, i-� ��.,� o-,y-�>
. Q.�or^�Pr-�P47'P , /�� �P�(-,i ��ia �011�-,w�J-, � �i'�� G oi' �-, /�'�P�-, �
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:::
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C� Q,`.L.�P r
Syst�em Type (ln Accardanc� Wifih Table Va}: ��
?HIS S�S?��ii 9-�AS �EE�! iNSTALLEi3 if4! COMPL]A�C� UVtiH 14PPL1CA�L� . NORTH
Ci4R�Ll�� GE�E€Z�L STAT�lTES, r�dJ�.�ES F�R S�ii1tAGE TREAT1�IEi�T AND DISPOSAL,
A�ID AL.L �Oti��ITi�NS �r THE IIVIPROWE�E�1T �Ei�I�ll'i" AiVD CONS � RUGTiON
AllTi-(OFZ1�4Z10N. .
. ��9-: ' O � � la �a� .
Authorized State Agent Date
Installed Sy: l � � � Date: � Q �� G � �� •
TaT�� = 3�0 '
d
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Z
H
J
0 7/08/68
pTs-�a��
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- ���'�'�G '��a,`�� �Rl����'���� ��E��9S'� �'�y�e �� - ��� --->C�' G "� �J' Pr
Tax Ma� ��¢� i�arc�l # o c� Sysie€�n Type (Tabie Va) ��
O w n e r l A p p i i c a n t S Q' MM y Fta�,.� r;.� s _ S u b d i v i s i o n ��t r; d Sp �� cs
Address/Location �'e llr-,�f�., h2J. _ Se�/Phase Lot # L a t 1�o
State�IDldate STB-3a�/ 07-0�
Gapaciiy 1�� v .gal.
Tee and Fiiter �
Baffte �
Seaiant
Riser (ifi appli�able)
Tank Outlet Seai
Perrnanent Marlcer
Pum� �'�n�
/Se�lant
Riser
Water Tight
P�mp
ChecSc ValvelGate Valve
�Alarm (visable and audible)
Electrical Components
Rate (gpm)
Approved Pump lViode!
Blocic Under Pump
Pump Removal RopelChain
. � Dis�ribu�a�n. System
Serial Distribution
Pressure �lan� o
�ow Fressure Pipe
A�pr. Pipe I�iateriai and Grade
SO w% d�j -
�aara�oca��ra ?�r�e�
Trenct� Width 3 ft.
Trenct� Depth ��+ in.
T.renci� Len4th 3 o v ft.
Trench Grade �
Trencf� Spacing
Rock Depth and Qua�i
Dams/S#epdo�ms �te.
Pressure Laterals
Hofe S�acina �
Sie�ve
��quie�d� Set�ac��
From� We!(s �'Q1� ��
From Pronertv iines
� Surface W�ters
- Public 1Nater Su lies
Verticai Cuts >2 ft.
Water Lines
Ve�iicle�T'raffic �
r�u�a�.�� u vya�c� � �a
� Eas�nients/Ri hq t of W
Oi9�er
5 �3� a9 �6/o Easements Re�orded
� ert� te erator on
iri-Partaie A resrne�t
Co�rarnen� . �
N
'oq_[o -0�
l�
��illn�
T��,.� � vf -��'��
�c:�d rev. 311�/C1
Apalication Date: �'' 3 D�
Amount Paid: �
RecEipt #• '
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Q(�� � [ � � o D �x Mao �: .3/`'�
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� Parcel �: � �`
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— ���T���� �
���a�-��,-,--� .e���.71. 7F�L��.31.��. !
i
APPLlCATION FOR SERVIC�S �
IF THE INFORMATION IN THE APPLlCATION FOR AN IMPROVEMEI�T PERMIT IS INCORRECT, FALSIFlED,
CHAiVGED OR THE SITE IS ALTERED. THEiiI THE IMPROVEMENT PERMIT E1f�ID AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by (Owner/agent/prospective owner): �--� '
Home Phone: � 3�4 x.f6 �- Address: s" �f S� �.4
Business Phone: s'9 d' a-� .� ��t�� 11 �' ,� s� 5�
2) Name and address of current owner. ��`-='
S �.
h<< ��51�
3) Property Description: Lot size: I,od� � Township: �
Directions to the prope� (�I�nclud�g� d n�nes ar�d numbers): _
�Gt' �.4.��1 na'- .>-„ :�
� p,y' G _ Lot # //o
4) P�roposed Use and Structure Description: answer each of the following questions:
a) Proposed j! Existing . Type of Structure: �?��' S� �� Width: � Depth:
b) Number of Bedrooms: �3 Number of occupants or people to be served:
c) Basement: Yes , No � Will there be plumbing in the basement? i►/�
d) 6arbage Disposal: Yes . No �
�
�--
5) Water Supply Type: Private ✓(new _ or existing�, Public_, Community !Spring _
Are any wells on adjoining property? Yes �/ No _ If yes, please indicate approximate location on the
''. site plan.
6) Does your property contain previousiy ide�tified jurisdictional wetlands? Yes_ Wo �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEf�TY OR SITE PLAN MUST BE SUBMITTEfl WITH THIS APPUCATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE NEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is aitered or the intended use changes, the pennit shall
became inva' .
��,�,�, �� � �- �-��
Legal Representative
Date
PCND, rev. 06127/02
' ' .�° ' t � '� i � i � E ' F�
�5.� �" 4 iS � �S 4 /�i / t F („=, 2 E 1' � j ��, � ��'�i`� �i �'�' �� !/`c
f �
�' � a E 1P tI� s l� �' �i LJ� � � � ! t .,S � � i � �1a t � `� i F
¢ � M Y(.._..� 5 �
��; �--1 �,� � ,r-.� � ;�� ,-. � �,f,� 3:"`.,1 �'� � r-.� �--., .� , �.,
{i�ij i I l_ a S ....d3 �...�`' 'L � Z ��r l� f s { ` � � � it/1 :� �` # 5 1 f N� �V
E E� � f `/ I f,. E\, i�l
For Inorganic Chemica! Confaminants
County: .PrSa � Name: � p
Sample ID #: 0� a� Reviewer: . Y-Ne,�
' TEST RESULTS AND USE RECOMMENDATIONS
1. � Your well water meets federal drinking water standards for inorganic che�nicals. 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. The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
le e s. The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, unless you instalI a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inoreanic chemical resu[ts onlv.
Barium � Cadmium � Chromium � Copper � Fluoride � Lead Iron
Mercury � Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH
3. � a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Hea(th Advisory level for sodium of
20 mg/1. The North Carolina Division of Public Health recommends that onty 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 inorFanic chemical results onlv.
❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, 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 itrst draw, 5 minute and a 15 minute sample at the well head to determine the source of the
lead and/or copper.
6�he following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inorganic 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 � Chromium � Fluoride '}�on.
Maneanese Selenium Silver pH Zinc
For more informaiion regarding your wel! wate� results, pfease call ihe North Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health
Report To: ADAM C. SARVER
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
RANDY LLOYD
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
84 YELLINGTON LN
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES052616-0056001 Date Collected: 05/25/16
Date Received: 05/26/16
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Well Temp. at Receipt: 7.0
Time Collected: 2:30 PM
Collected By: A Sarver
Well Permit #: A40-400
GPS #:
Sample Description:
Comment:
New Well 1(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 38 mg/L
Chloride
Chromium
Copper
Fluoride
Iron
Lead
5.40
< 0.01
< 0.05
< 0.20
1.20
< n nn�
0.10
1.3
4.00
0.30
0.015
Manganese 0.320 �' 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Selenium
Silver
Sodium
Sulfate
< 0.1
7.9
< O.00
< 0.0;
6.50
�. i �
1.00
0.05
0.10
Total Alkalinity 91 mg/L
Total Hardness 100 mg/L
Zinc 0.28 5.00 mg/L
Report Date:06/13/2016
Page 1 of 1
Reported By: Deddie .Moncol�
�� �
� y, a �� ,,�/^
,r• *t+ .. � �� � �1./ .� .iJ�. J�r
��.',�aa�u:cd�ar�una�n�t��t.�� ��""'� �t: �n.`��S��i�
Date: `�' / � � / 1 �P
Name: �� � �� �
Address: -}-� �, .
c � S�
Re: Bacteriological Test Results
Dear Well Owner:
Tax Map: �� Parcel: 'C � U
Your well water was sampled on 5 ��s , c�, and tested for both total and fecal coliform bacteria.
Your waier sample iest results are noted below:
No coliform bacteria were deiected in the sample. Your well water is safe to use for drinking,
coo ing, 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 nat-arally fcund in the soil. Fecal colifor�r, bacteria are associated with
animnal and/or human waste. The presence of eiiher 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, tlie water
ntay jtot be saf� for use. Young children, the elderly, and the individuals with compromised immune
systems are especially vulnerable and their physiciar.s shoa:ld be r.otifred of the test results.
A well that tests positive 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,
, �vv-2�
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Pe:son County £nvironmerdal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 33E-579-1790, Fax 336-597-7808
�
North Carolina State Laboratory Public Health
Environmental Sciences
�Viicrobiology
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: ES052616-0066001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
RANDY LLOYD
84 YELLINGTON LN
ROXBORO, NC 27574
Collected: 05/25/2016 14:30
Received: 05/26/2016 08:20
Sample Source: Well
Sampling Point: Outside spigot
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:
A40-400
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Denise Richardson 05/27/2016
E. coli, Colilert
Report Date: 05/31/2016
Absent
Explanations of Coliform Analysis:
Denise Richardson 05/27/2016
Reported By: Susan Beastev
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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.