A40 409Qo
. . 3 �� � � �
A�nlication Date: ,t�—��_l�s � ,Q � � �b Tax Man #:
Amount Paid: � . 1 '
Recai t: 1 y 3 Parcal :
� �'--�.�`?��� �J.L��� ��
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��.���.�,..,.....���.m.a ��.�.��.
APPLlCATIOM FOR SERVIC�S �
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT. FALSIFlED,
CHAiVGED OR THE SfTE IS ALTERED THEN THE IMPROVEMENT PERMIT AiVD AUTHORIZ,4TION TO
COIVSTRUCT SHALL BECOME INVALID. • �
1) Pertnit requested by: (Owmer/agentlprospective owner): �A ►J� U�cr/�S�S
Home Phone: 3'� � q'� `�`1�� Address: , J�
Business Phone: �,?� ��_ �� G �Z�,Y N< < � s7 �(
` 2) YVame and address of curret�t ownee ��/e S%�� � L
. �$-:wY: � 2� � ��� ��a �� � � c � �673
�> ,
3) Property Description: Lot size: ./ vl �Township:
Directions to the properly (Includin�road names and
���--
,e .�:c>SQ�
4) proposed Use and Structure Description: answer each of the foilowing questians:
a) Proposed ! Existing , Type of Structure: ,�,�� SC Width: �C1 Depth: �
b) Number of Bedrooms: _�,� Number of occupants or people to be served:
c} Basement Yes� No _ Will these be plumbing in the basement?
d) 6arbage Disposai: Yes , No �'�
, � � .
5) Water Supply Type: Private 1/ (new _ or existing�, Public_,, CommunityJ Spring _
Are any welis on adjoining property7 Yes_ No _ if yes, please indicate approximate locatiori on the
'site pian.
6j Does your properEy contain previously identified jurisdictionai wetlandsT Yes No �
- —,
PLEASE NOTE THE FOLLOWING: .
➢ A PLAT OF THE PROPERTY QR SIT� PLAiV MUST BE SUBMITTED 1N1TH THIS APPLICATIOM.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. •
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAaCED OR FLAGGED.
➢ THE SITE NIUST BE READILY ACCESSIBLE FOR AN E1/ALUATION BY THE�HEALTH DEPARi'NIEAlT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposaf
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the' permit shall
become� invalid.
��.- / � . ��-��= �>�
Owner or Legal Representative Date
. PCtiD, rev. 06127102
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n. � / rv. itc a�'se., �Jt�' � � . .
. / �g'IIDiTeffi� ��I3�P$ , ,
$�CY�11$ �3�i� f0I' `� �'1�@ ��BY'�. �Q �Il"d$�'i0�1 v . ..
Type of Fae�ii�y: �. o �-e�-. ���5?�..' New ✓1�ddition �%�te�' S�PP19 �nva4�
# of Occupants (n MaY # of B�oms 3� � Pmjected Da�y Flow 3��o g p.d.
Propo�ed Waste�rater S�stem: �u.,� � _
Proposed Repair: . . kZ C aS %. � �.�:k-.�,-, ' '
' • � ���.a.
Peanit Conditions: t�l� 8�� �Siu�-�.�.. `fh.a�.�,'1z:r. •
Type: ._u� ,
Type: r_ _ i � �
cl
v, � •
Owner or Legal Re�tes e Si � Date• 3- �' G 7
Authorized Staate Age�t: 12S � � � Dat�• �- tD -os
'I71e isauaace Df ii�ia pe�it by the Hesith De�cnt ia does not gumantea ti�e Issuqaca of other peanita It is t�e �esponsib�ity of the
aPP�P�P�h' owner tn in snre that all Person Couni�► I'lanning and• Zoning and Hwlding Inspections reqniremeats are met. T�iis
Improve�nent Per�o�it 3a sud�ject to revocatian it f�e Afte Phtni, P�at or the i�ttended m9e cIeanges. The Improvesneaet �'erffiit is not a�fecte�
bp a'cLange na ow�mer�hip oi the IsroPerty- �hi.e permit waa issueal no comgliance wit� t[►e jproMsions of the N�rth Caroliaea Zuws and
�,a for Sewa�e Trerrt�eea�t and lDispg�al 5`d�s�teyns' (I5A leTC�iC.18A 1900). Neither gerson �oanty nor the Envi�onmentai Healila
Specialist w�rranf� that tiee septic t�[ system w�71 aontinue to fanc�eon satiafactora'�y m the futm a or that the wa#er �ugsply w�11 aemain
potable. - " � • �
��in�o .�tamn #o C�ns� a��'��s��ater� �p��tea� (�e� ��r �uat� �ermit) .
* See site plan and addittonal c�ttaclunents (�). � .
Proposed Waste�yater
New ✓ air
Typa of Eacility'�
Size: Sepiic T�m�: l�'�. gal
Type �.. Waste�water Flow 3(�. g.p.d.
Sa7 I�TAgt: . �5 g.p.d,l $ 2
� • �Basement �Yes �No �
i��stewater Syst.�an I�eqairements . .
. Paamp �aaa�c —� g�l' Gr�ase Trap: '' gal
fie1d: 'Total Area: � I�] sq $ Tot�l Leng#6� �/ yv ft '�reue3a Dep�a ��
cla ����_ f¢ �ffi Son1 C�aer: ;_[�_ � M'mimum Trencli �epazation: �_ $
IDistr�buta�n: ,� I�istr�`b�tion I3ox Serial Distributian .Pressure Manifold
�peca�'ac,at�ons: i1An.:,-lz:n C�Q\ �kSGC� ,nS�,�.Q� � Gc�n1�x.,r
Aast$eo�ed 3ta�+e Age�t:
P�rmit �xpiratinn Date' �- �-
Date: �7 - � - 05
The type of system permitterl is X Conv�ional Inn.�vative Alternative. I ac��pt #he spe�ifications o�
the peanit ' .
��ezLL�g� ��a�se��re• .. Dat�' �" � � CJ�
. . � PC�7/30I2002
:���. ��- �► � ��► �' �' � �
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Name �.�_�� �u� Tag ysap # /��v Parcel # �'0 �
S division � Se.�tion/Lot# K1
'7 - C. -c�s
Authorize Sta.t t ' . Date .
� System caars�ioraents r�h�esEra� cr�i�ia�xisnate�caratours os�I, y. The contractor saaust', fZag the systeqrt paa�r fo
begimznsng t3ie iasstallati�n to irssux�e that pr+o�iergrade is �rsaintaissed :
C`�
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c+�ko-c..� E ru, 9-�2�
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� 33t� -59?-174C7
Scale: � � �' � SC�'
13N��3
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/��]Q�1Cc�!]� � er
Locaiion: ` ' > h "
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n/3( �ir • cifC
S u,a:dliv�i _ i an
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cr Q( �� r c7 C):Rl.c
� . ��'��1�C� �� 1� .
�� Sysiem Type (In Acr.arda�c.� 1N�h Table Va�: � .
THiS SYSTEi�i i-�S 6E�3►d iI�tST.ALi.Ei3 � IN Ct�MPi.l�4NG� WiTH 1�►PQLl+CABl.F NORT�t �
C'�R�L• l�, G�[i Ei�AL STA'itITE�, RUl.ES Ft�R SE�If�,G� TREAi'�iIE�IT AND DlSPE�SAL; .
AND AL:L � C�I�IDI'TiQNS • OF '� Ti�E �,,,�PRflV�dE�1T PE�fl!!1T �41ND CL)t�dSTRllCT10�{
�►UTHOf��ZA �DN. �" � ' . .
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. � �� • �/_Z�p-i _
o� S� ,�� a�, � o� �
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lnstalle�i Hy: . �ec� � : �v� Dat�: � � —0 7 . .
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t ��.�. �� �.�'�� ������� ����� � ��� ��
� T� �i�p � �i 0 Pa�� # � � 5ys�sn TyQ� (?a�1e �Ia) � •
Owned����icani Sui�divis�on
Add���ian Se�Pft� �ofi � �
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<;�y�':'�.' �m�:�'� .
�•7hT;?'a'.,71:�7!G'!,ati�::�:.�'R71^_'�.,�..;';..,�9�'I�:�,iDi:]L•�'����+',p�A-JL�¢� :
WELL PERMIT � �
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �-� Parcel # y'� � Townslup:
Applicant: C� 1�<,1�;..,, ) [� 3�.��
Subdivision• � Lot # A �
Location: Sa1 8� 1-h.rdl,� Y�..�v 1� -� � d. 'Pc�.►.u., f�� -� I �L
a+► CvJ ^' (/4 vV.�R 4� �ir�.t •
Type of'Water Supply: �Individual _ Community
�ltequirements:
Sita Approved By: _
Grouting Approved
Well Log: _�
Pump Tag: _�
Well Tag: .
Air Vent: �
Hose Bib:
Casing Height: _
Concrete Slab: �
Public
Liner.
. .Installed by:
Depth set: _
Gmuted: _
Date:
Water Sample: �
Well Driller: G V �h.S �1�,�� �� -
Well Approved by: _Ti���� � �
****See Attached 5ite Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions: 4�-c�i l�� �� 5�-��
Date: z S
PCHD rev O1/27/04
�----.`�`� ��..�"- �-�'.�.�..�'� ��� t� �� � �.� � .
�"��� � � � � � � �`'''�{,�'" � �'�r - � �. �,-�
���,�...;:Y-��.�.��-..�.�.� ��.�..n�,�� D� (�� :;�.._ � �—� ��
Owncr: ._��� j=�%
Locat�en: ._� q-��
Sui�diviaio;�:
IGrPOUt LOe
T.,,,_ Tax Map/�,,,�d Perccl #_ 7�J�.
__._____.._, Lot � �`
W�11 Couatructlor�
I"�i5tar,cc : rom ncurcat Properry Linc (M�nimum� !U fcct) ��
Diytxricc from Scptic 5ystcr�i {Minimt�m 6Q fcet) _� '�
T��tal I]epth: ,,�rft Yizld: ,L� �iPM Static Vd'ater Levei: _�� it
1�aur Hcaring Zoncs: Dcpth _j_(� ft �� ft �J�,,� ft ft
Cs�aing:
Pcgth: From __��. tA ----�.� a.e_ tt. Dinrn;,ter: .�1L_ in
'I'ypc: Galv�nixcd SGcel ✓ 'I--
waignc: 13 : Th,�kr�cbs: ��Y b'� Height above Grouncl: .,,� ?� in
L"iri��e 5hoc: __ �Yes No Atry pro�lema encouryttrr.ci whil+c sctii»g casi:�Q? �__Yes No
Ef "ycs" ��c rcascm: � _.__.� __....._._...---..--.�.��._----- ------------------ -- - �.__
tyrout:
Ncat: Sa,�tc;JCetn�t f C'orcr�tc t'iraveUCtmr.nt
Annuiar Spucc 1�Vidih 3 ui�t�z,z Waur in Anr.ulnr Spac�: ____
F✓Icchoci of C3rau:: i'urnpad ------ Prc�aure � ei�c;ut�d Ucp:i� �
1WIa�t4rSs►�s Ua�i: ____
Na. Ba�s i'ortlnnd 4cmcnt �,..� '+Nai�ht of 1 Beg 1'c::nds
If mixturc (s�nd, gxavct, cui=:ngs;�Xatio tn
ID pIAtCS: __� YG9 _.` NU d x 4�lab .�'cu t�to
l.�dl£7': � .._...
�iC))�il: _.._.. ____��._.._ U1iC Yl'IBf.��iCtl: �� i�]1'OUt:
iJ�liiia� Lo�
� 7� rorn.��1'0 � _� _ ._� V For
� �-% ..___. _�_._'� _ ,.�
��
t---�---t—� •.-•- -..c� c� Z-
� .._._�_...♦_�- — ---._ �. �_ _. _
u
�46 _ ��U
to Ft.
_ lnctailcd by: ._.____�_._.___..._... ..
l.uc�tivU Urxwtrm,�
�.__.._._..�_ . .._�__._�.._ ,__ I
,�r
�c.w'1'il � � % !
I hcreby cenify tl:at the above info►:netion is cotrer.t nnd that this v�ell wAs const� uw:�d in ucc.�rd�nce with rrgufacior�b �ec fc��J
by thc l=c:son Couaty Ficalth Dcpariznent, ,
Signaturt G[ C:ontractor ,
• — - - ._ ---__.__ Il? ,F ._,,,� o�..� ll�tr _�...s ��� � .
Puiu� it�ataLirct�nt _r.
F'ump l��yi�llatiun Contrac:tor
Purnp De�th: �
Purnp Ma�;c & I'v1ad�1:
:itxi�c Rs�i�xat�an Numbcr:
f; Static Vdxtcr Levc�: �'� � ft
---__._...`...____...r�. _.! Fur,�p Sizc and Ratin�: ..
_ __ . hP __---_� 8t�rr�
i hcrc,lzy cCRify tl�at �his pi,t:,p was ir�atallea r,nd tt�c well hea� �uin��lctrd secording to ti:e I'ers�n Counry i�'J�e.11 �ules ir, r:fie.r.t
on :his dste and that a copy of thtS 1'CCOI'd f18� i1GCti �K6Y1t�Cd 2Q i11C l�•ell owner.
Purn� :nntatl�r $iQm�rure Ub��: PC:'iit? rev 01ly%'U�:
�
nc department
of health and
human services
County:
Sample ID #:
, � ,
�� ¢� � i � �� � � �;��`� ! �'� � � � � i ��# �r � � � �:� � � �� ��
/f�'� k^ � i E # ��` Y((�� s� �'i( � �."; 1•"�.-� �:",,p,"'� f�� Et ��� � �( � ��� �� �.�
1�=,, f � ,� E'n....f' �..J� '.�/ � �`i_ �".• ° i l.� $ E i R I i �_ . � F \,, {�i l. F •J � � �.i
r
For lnorganic Chemical Contaminants
Name: S ' s
Reviewer: �
� � TEST RESULTS AND USE RECOMMENDATIONS
1. � Your well water meets federal drinking water standards jor 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. ❑ 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, 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 inorQanic chemical results onlv.
Arsenic Barium Cadmium Chromium � Copper � Fluoride Lead Uon
Man�anese Mercurv Nitrate/Nitrite Selenium Silver Magnesium Zinc pH
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 problems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5. 0 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 well head to determine the source of the
lead andlor 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 inorFanic 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 �
Man�anese Selenium Si(ver pH � Zinc
For more information regarding your wel[ water results, please cal[ the North Carolina Division of Public Health at 919-707-5900.
.
North Carolina State Laboratory of Public Health 3�12 Distnct Drve
Environmental Sciences Raleigh, NC 27611-8047
http://slph.ncpublicheaith.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: Name of System:
PERSON CO ENVIRONMENTAL HEALTH JESSICA WILSON
325 S MORGAN STREET
ROXBORO, NC 27573 Courier # 02-33-15
EIN: 566000331 EH
StarLiMS ID: ES062917-0072001 Date Collected: 06/28/17
Date Received: 06/29/17
Sample Type: Raw Sampling Point: Well head Well Permit #: A40-409
Sample Source: Well Temp. at Receipt: 2.5 GPS #:
Sample Description:
Comment: '
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
1101 PAYNES TAVERN RD
ROXBORO, NC 27574
Time Collected: 2:10 PM
Collected By: J Smith
m
Chloride < 5.00 250 m
Chromium < 0.01 0.10 m
�
Lead
Nitrate
Selenium
Silver
�,.,�;, ,..,
<C
m
< 0.20 4.00 m
0.39
< 0.005
2
< 0.03
< 0.0005
< 1.00
< 0.1
7.1
< 0.005
< 0.05
7.20
< 5.00
m
m
m
m
m
m
m
n
m
m
m
Total Alkaliniry 36 mg/L
Total Hardness 28 mg/L
Zinc 3.10 5.00 mg/L
Report Date:07/12/2017 Reported By: Deddie .�lvncol
Page 1 of 1
� 1 !
� �. � �
•�.� i�•�' ��./ � ��. V ��
I -C�a�nso�anvcna3�a��,Il 1HI�m.Il�ll�a
Date: 7 / /3 /�
Name: Q�_ Tax Map:i�'� Parcel: �D�
Address: ! ,Qp_
�1�
Re: Bacteriological Test Results
Dear Well Owner:
Your well water was sampled on lt /�/�, and tested for both total and fecal colifarm 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 bacterio[ogical 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 asso�iated w:th
animnal and/or human wasie. 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 positive for total or fecal coliform bacteria shozsld 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 ealth Specialist
Person County Health Department
(rev. 4/20i I6)
Person Counry F.nvirnnmental Health, 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
f�licrobiology
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: ES062917-0092001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
JESSICA WILSON
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htt�://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
1101 PAYNES TAVERN RD.
ROXBORO, NC 27574
Col lected: 06/28/2017 14:10
Received: 06/29/2017 09:02
Sample Source: Well
Sampling Point: Well head
J. Smith
Darneice Owens
Well Permit Number:
�40-409
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Present O6/30/2017
E. coli, Colilert Absent 06/30/2017
Report Date: 07/03/2017
Explanations of Coliform Analysis:
Reported By: Susan Beasley
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.
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant ��S!'a �=�<'eq
�j
Address � � County �
Coilected By �
Date Collected 7-�'��( Time Collected %/�`�`�!
Source: ell ❑ Spring ❑ Other
Location: o House Tap ��/ell Tap ❑ Other
❑ No Charge �arge �� SQ j�
�
..............................................................................�
********************�*******************************************************
Total Coliform
Fecai/E. Coli
Results
Present
❑
0
Reported By l��(`�� l�,
Date Reported `� - a 1- 1�
Report Called p�YES ❑ NO
Called To l� %'1-Q�1u
Absent
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r
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