A40 425'*—'r�ipp7ication Date: G a7-� y
Amount Paid: � O .0
Receipt #: I Q,� 0 8.S'
C'�'-(�
1 O y-y'
g ,ao-►�1
,,� �`,�,s.� .���.���T
'703y�0 ' �:�����
�� �cnwna-anTM* �*+�* oosadan.11 IHIa�,s.]Ld�.
—�j3�
Application for Services
Services
�'Im veme ermit (Site Evaluation)
$Z00.00/$ 00.00 (if> 600 d
� Mo e Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
0 Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
Tax Map: a /�
Parcel#:
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
/1) Applicant Information: / •
Name: Sh � 41 � I� w 1�' i^'-S
Address: � r� �� /-� � R O� F_ j�1 ; L � s /� D,
R G��D,I 6 w� a �s� �
2) Name and address of current owner (if different than applicant):
Name: S 1� w,, F �
Address:
Phone (home): � 3 r 3� y-� S d�-
(work/cell): 3 3 6 S y�- a I a 9
Phone: �
3) Property Description: Lot Size: /, S Subdivision: -- Lot #: —
Address and/or directions to Properly: ,} m�Q� v-►1 �P 7'- �' �f' ��- � R�•
¢_G��s_S (�'o• �"I�r� n� �9 ss H �� D a C M i�.� s��,
❑ yes I�no Does the site contain any jurisdictional wetlands?
❑ yes C�-rlo Does the site contain any existing wastewater systems?
0 yes �o Is any wastewater going to be generated on the site other than domestic sewage?
0 yes @-no Is the site subject to approval by any other public agency?
❑ yes E3 no Are there any easements or right of ways on this properiy?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
New Single Family Residence Maximum number of bedrooms: ✓7
❑ 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: L�New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property7 ❑ yes ❑ no
/�6) If applying for `Authorization to Construct', please indicate preferred system type(s):
O�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
inaccurat or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� � �- ��.-�-� .� -� � -, �
Signature`(bwner/ Legal Representative*)
* Supporting documentation required.
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)
���,s� ������
`�'' �—,� C����T��
)C�s��nu-��� ����.Il IL-���.Il�I�
Tax Map: Parcel• ` � �
�b�-- �—
Subdivision �%
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: '� New � Addition _
Number of Bedrooms �/ Occupant �e / Employees / Seats:
Proposed Wastewater System: o
Proposed Repair:
� ,
Permit Conditions: � r
P���..s._����-__�
Authorized State AgE
(X) Owner or Legal
Water Supply: WP �'
Projected Daily Flow: 3� gallons/day
Type:
Type:
Date:7 ,
Date: 8`
The issuance of this permit by the Health 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 in ownership of the property. This permit was issued in compliance with the provisions of the Piorth Carolina �Laws
a�:rl Rules fbr Sewa�e Treatment and Disnosal Svsiems'(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 supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposecj�tl�astewater System: ��d�251 Qc�u 'o� S�S�m I(*)Type �,L[ � Design Flow �D gal./day
New �� Repair _ Expansio �� Soil LTAR:� �3 t� gal./day/ftz
Type of �acility: � BR P�i �Qi�. �QS; en�P Basement: _ Yes No
(*) System Types IIIb, Illbg, IV, and V, requireperiodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank � d 0O ga(.
Drainfield: Total Area q o� sq. ft.
Purrip Tank ` — gal.
Total Length :� vo ft.
irease Trap - gal.
Max. Trench Depth %(,� in.
Trench Width 3 ft. Min.Soil Cover �g_ in. Min.Trench Separation �_ ft.
Distribution: Distribution Box v/ Serial Distribution ✓/ Pressure Manifold
Specifications:
..
Authorized State Agent;�� /� ��`-� Issue Date: �- / 7-%�%
Permit Expiration Date: '�-�]-/g
--�—
The system permitted is: Conventiona( /Accepted ►� / Alternative / Innovative . I accept the conditions
and specific,�tions 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)
Name
Subdi ' 'on
A thorized State gent
���, sf ��I�.� ��
—= � � ����
I���aa-�������.11 1F33I��.Il�]�
SITE PLAN � � �
Tax Map #� Parcel # �
Section/Lot#
7-�-,
Date
System components represent approximate contours only. The contractor must,Jlag the systemprior to beginning the
installation to insure that proper grade is maintained �v ► _ � � � • _ _ � i t�t _ t D ^ ... _ , , I _ _ _I
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Applicant: �wM�.ua ►-ea6
Lacation: �-1uv.�� t�.►v�,s (� � oJ, -a�►s; ?
System Type (From Table Va): �
Type V& VI Expiration Date: �
This system has been installed in c
Sewage Treatanent and IDisposal,
Authorization.
'��P�tJc�. f� . SYtzS1\
(.4utharized Agent) /
'3'i�c�`t ��%�S dr Sp S
{Licensed Contractor�
2��
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y� �1��
M�� S
�
Scale 1�5
PCHD, rev. 12/14/12
Taz Map A'�n Parcel # 4�5
Subdivision i1�
Phase/Section/Lot #
# of Bedrooms �
�(S5�
����°�.�1.011 �G�'i�flt
► � Product (IIIg): �Z. �w�
,�, Type V & �Vi Renewal Date: --
with
�
%6'
.
North �arolina General Statutes, Rules for
e�mnravament P�rmit and C.onstruction
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ate)
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Line Leng
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Taz Map: �� Parcel #: W�5
Septic Tank System Checklist (Type II-I� System Type: �_
Sepiic Tank InitiaVI?ate
State ID & Date; �-�y�. �5 �� �y i4
�b 3-1�}
Capacity: Q�iS-�a�c,
Tee and filter
Baffle
Vent
�Riser
Outlet boot
Perm. Marker
DistributiQn
D-box (Ievels set)
Seria1 s 11 �� ��
Pressure Mani£old
LPP �►
Notes:
Pump �ystem Chec'klisi .
Pum '�ank InitiaUData
State ID & Date: �
Capacity:
Riser (6" min.)
NEMA 4X Box '
Model:
Piggy back plug
Hard wired
Alarm fvnctioning f
Mounted on ost
Above grade (12")
Conduii se�led �
Pres�u�r� Manifold
Number of taps�� ___ _
Size and sch:
Contracted Certified Operator (Type IV Systeffis):
Notes •
�
Tank Co� onemts InitiaUDat�
Pump model:'
Block {4"). % �
Nylon retrie�al rope
Float tree an� attachments
� On/Off tloat swing: in. �
Alazm float (6" separatio�)
Anti-si hon i�o� e
Check val��e
Threaded ur�on
Gate valvz ^ ��
Conduit sealed
Outlet sealed
A roved an� secured riser '
St� 1 � Line f
Size ancl material: in. sch. j
Length: � ft.
���.sf ���.���
- � � ����
��ra�n�c-em�a�rxa��ra�.�.Il ����.Il��a
WELL,PERMIT
(New �/ Repair _ )
Tax Map: L� Parcel: ��' a�
Subdivision: _��� Lot: �
Applicant's Name:
Mailing Address:
Phone Numbers:
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: �q�n���Q �� SZi�a�1�5
Permit issued b •
�Tew Well:
EHS/Date
Location: '�AS �� ��`�
Grouting:
�� � �Well Log: �I fa. ►'�}
Well Tag: ' ►► i ly-
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Date:
Certificate of Completion
DI.iner:
EHS/Date
Well Driller: �A��'�
Pump Installer: ��
Approved by: �fLtcii-A�. Sr►-rr.0
Additional Comments:
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: 1 i
Date Sample Collected: tB i Date Results Mailed: � ZS�c�
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 11/26/13
Barnette Well Drilling
'WELL CONSTRUCTION R�CORD
TFus form caa bc nsad fnc siegle a muU:plc w�l Ic
[. Wdi nlraclor fnformapoa:
D Ou � L'"^. / 1-R- /
w�i con�QOT r;�
J .� �p ,�
NC Wdl ContractorCcrtif ca4on Nwdxr
Bar'rtette Well Drilling, Inc.
�-� N�: r� �a
Z. Wdl Coostructian Permit tJ: _
Lis� a!! aoplina6fe wc!! cortsfrycilon �iermitr (l.s. Cn:m y, Swre, Yarioncc, uc f
3. 'Wr�I Use (check .rell use):
4V afcr Sapply V4'eU:
DAgiailhual �Mtuiicipal/Ptibtic -
C1Gcottia�nal (Heating/Cooling SuPP�Y) �esiaen4al Water SuPP�Y i�+�BI�)
Olndvstriat�Commaoial Q[t�sidcntist WatvSupply (sharodj
❑Monitoring
OAquifer Reci�arge OCitnundwater Rcdodia[ion
IIAqwfirStocageandRxovay p��i�yg��
O Aquifu Test ❑Storn:water Lh ainage
C]E�erimm�al'Techrsolo�Y ❑Sub�idcnceCoturol
❑C.eotheYmal (Clnttd LaoPi C'Cracec
L�Gcothamallfieatine/CoelinoRPn,n,� nna...r......i,r�....a_..�r., o
4.1}ate R'cl](s) ComplUed: `,�LI —! � �/d! m# /Y �
Sa }V il Lpcatioa:
�a..n� e lr1 � orL� �
Fatiliry(Uw�� Naroe Facility i(]a$ (ifdpplicatile]
� es l�-� u. ls- �°.� S�-.S-.S� �
Plrysi lAddiu;�Cire,aodT�p
�Q � S �s�-' � � �-<S�
�104+ Pa�oeJ tdentifiutionNo. CPIti)
5b. L.atiludo aad Loagifude ia de�oetslminates/utpods or deeineat dc�ceeS:
(�wc It 6dc� onc Ixt9ong is safi',c;uK) -�
3 q-- ��' -- �� N_� -- O �-- 2_ 5'� R.
6.7s(uaythexdl(s): L�t a�i a�t. or C]Tcmporup
7. Lt tkPs�a repa�r to a�t e�clstin& well: p`Fes ae �Aj'd
If thla Is �a repoir, fiU auTmorn we!! rau�rvcyron IrrformoUon wrd�crpldih rhe eapt�re�ojdie
rrpafr undrr �21 rewarkcseerio.r ur.,., ilre back of ih/rjoiae,
E._Kamberof�vcLLsconstrue[ed: �
For mxbip!e irrjecrton nr rwir-warr s��,fy wdLs ONGYwiih +hesrrae w�ucYtan.You a�
swbmR onefortn
9.Totaitivclldepth bclowlandserCaee; � z. Q rtk)
1'or�+dry�e .�sl/sli.rr at�dephr �d-�re�t (��r:►ilc- 3�1zW' a�7�1o0')
3365989275 p.1
For Intemal. Use OYLY:
�L a_ ��-- rr. $r�
z '�- q„f- r� ro_4
��� f° I 6`� � I SaRzt
rc. rL � �
ft R, ia.
fc tk
[c [t
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rx rc
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ft R
n r�
ft � fC � Lp �p b
n �o r'- . �� ` Q
Fc: '" .R. J iq'��5 7'G
�- /2o f�- Goe.�
� t�
(t ft
« �
2Z Cert[fcatton: ��
� �
! C • ..��" l/ 1/-lr�,
s��az.uC.oe c�n;Gea w�p-co:na�or p��-
QY s�%+�5�%. f hsroby oer[tfy Aaa the xelt(sJ weu �ircraJ cvnrrrvered tn rcoorslana
�.i/!i IS.[ NG4C 02C .OfilO.w 1.f� NG4C OZG -0200 li'e!! Cortstru�ioa S�aedorzCr add thar o
copyaftbft reaomflw+�been provlded ea� fhe wr1! owrter
23. Site' diabrsm or additional wcL dctails:
You tnay tuc die back af. this pan� ta providc addi[iaral w�el� site details ac wdl
oonstnsction dcbFls. You mayatso.attath edditioaai p ocs ifnccessa:y-
SilIIl�i[7TAL iIYS]'UCT] dNS
24a. Far A11 Wellx SubmiL tfiis fotm vn�ihin 30 days of polnpldion af wdi
�on to tbe fdtawing:
IA. Static water levd below top ofc�sieg; 2-'s~ ��� Dirisioa ofSVater Qna6lp, Inforautivs Praerssiceg tini4
IfMnlcrlevl! ti aGwe casing 7esa "+- 161T Mail $etvio� Csrcter,Italefcgh, NC Z76J4-IG37
11. Borebiale drametcr: �a) 24b,. For Ihiec[iae Wdts: In additien to sendicrg the fp'm to the addrrss in 24a
y� Q ,p above, also ssibmie a copy of Elus fond wiltun 30 da}s of mmpl�ion of we11
12 Wcll caaslraclivu tncthad: _ /�7 r�/�. d�� ! r- � cor�ttiiion t0 i}ie folbsvu�g.
(ie. avy,�er, roLvy,�able, daectpush,�dc,) '7
Divisiou o(Witer QvalitpF Undergmnnd.Injection Contro! Pcogram,
F4R WATER SUPPLY WELIS ONILY: 1636 Ma� Servicc Cmter.IiaYe�h, NC 27699-1pG
[3z Yidd (gsm) �� Meihud oEi,est SIOWr120 fl7ittUt 24� Far Wster SpPAiv'& 7pi�ion R'e115: TP ldditjpn ip Scpdjng t372fpm7 tp
the addtess(es) above. ako suh�nif one mpy of t}iis fom, wilhin 30 days of
136.Dis+iniecaon type_ HTy A'mouwi: �l2 �+ll� �a'Pl�n of wetl cousliuction to the aoun#y heattti dc�arAocnt 6f the eonrrLy
avhere constriicted.
FO^° '�-� No�+Csrolm�Wa�omeuEofFnvimameexrdNamnlRaovees—Dirisimo£WamrQuelity Ravisedlaa1A13
��
� I�,111 /7 —
nc department
of health and
human services
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e :j � a �; .. F s t ; xA a4 �y q t ,m � � �� �;,� � {d � a3 � y'� � �r7g t; � � � �
� � � u ��"., va ��Ar..�r a �; ��.�rSi ,�. � w � �t C �'�' "��` � sk ' 'C�% " � '�
*'� .� s...+
l;
x w �a � � �
Y § � h E ; ' $ � .3 .�'`� „ v �"' - � , 1. r� �� £ 1 p �^` 9�a� F '� ��"�� �' � � '�`^Aa 'Xd � y,.�.'' ; S.:`..� j 3
.��. .. „ �.<<a .� w � i ar � � � � �f r � � w ,� z [ ,"'r � � %i � 'r`��" � '4 #f � � �'�
�
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For Inorganic Chemical Contam�nants
County: -�L,So� Name: �
Sample ID #: ,L� _ z Reviewer: "Z(..
TEST RESULTS AND USE RECOMMENDATIONS
1. �Your wel I water meets federal drinking water standards for inorganic cliemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may
I�ave 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, batl�ing and showering based on the inorQanic c/ieinic�l results onlv.
Arsenic Barium
Mansanese Mercur
Cadmium � Chromium
Nitrate/Nitrite � Selenium I Silver
Fluoride � Lead � Iron
Magnesium Zinc qH
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/I. 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 iiinr,�anic clremical results onlv.
❑ b. Levels over 30 mg/I 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
tlie kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source ofthe
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 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 � Iron � Magnesium
Manganese � Selenium Silver pH Zinc
For nrore iirformation reg�rrding your we!! water results, please call t/1e Nortle Caro[ina Division of Public Health at 919-707-5900.
Report To: H. KELLY
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
f7Ti ii��1S�7:[�3
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slph. ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
5556 HURDLE MILLS RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27573
EIN: 566000331 EH
StarLiMS ID: ES061115-0039001 . Date Collected: 06/10/15
Date Received: 06/11/15
Sample Type: Raw Sampling Point: Outside tap
Sample Source: New Well Temp. at Receipt: 5.0
Sample Description:
Comment:
Time Collected: 11:30 AM
Collected By: H Kelly
Well Permit #: A40-425
GPS #:
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
Calcium 120 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 0.28 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium 3 mg/L
Manganese 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 7.9 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 9.10 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 278 mg/L
Total Hardness 320 mg/L
Zinc 0.15 5.00 mg/L
Report Date: 06/18/2015
Page 1 of 1
Reported By: Arnold Hc►ll
North Carolina State Laboratory Public Health
Environmental Sciences
�ic�obiolog�
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: ES061115-0107001
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ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
PAMELA LONG
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://sloh. ncoublichealth.com
Phone: 919-733-7308
Fau: 919-715-8611
5556 HURDLE MILLS RD
ROXBORO, NC 27573
Col lected: 06/10/2015 11:30
Received: 06/11/2015 08:29
Sample Source: New Well
Sampling Point: Outside tap
H Kelly
Angela Heybroek
Well Permit Number:
A40�25
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Denise Richardson 06/12/2015
E. c01i, Colilert Absent Denise Richardson 06/12/2015
Report Date: 06/12/2015
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.