The URL can be used to link to this page

A40 426JAN-30-2015 04:16PId FROM- , ' Applicasion Date: i / y� A.monnt Faid: 200 Receipt T: 713S1� � �o��o� !'�,9.t � �/ �Z �Je.i.�r. �t� S"� . � � ..�\� S f /� �� Jl°��'�l.y��TT� ; � ��•�•rA� V � V �� i � � 1 � ][�aawan•aasaa�aoY�d.A� ��+L1d�iA (Sne E��aluatiott) t'�' 1'�. (if � 6a0 gpol �ent or BuiIdiug :�ddition S I � 0.04 (if site �isit rcqvirtd} «'eil Penau (1ew�lRepIacemenNtepair) S.ib0.0U,'5200.00rS7�.00 T-528 P.U01/003 F-219 Tax Map: .� Parcel#: � (�ury�i•�y dv� n- ! /fr.cc �lication for Services Sen'ices R uested Coastrucdon Au:horization � (Fac is depetsdeni on the Npe of system pem�itted} ^ Permit Revision I 575.4fl I itepair of ErictiAg Septic System j Application: `o Charge/ CA Si50.00 ar �3oo.oa /G�Zily'�. � �'[��- i�l,�Lcl�z� 1) �ipplirant Inforrnation: ,0/L�G� �o gE¢f 1/i�, f' ��e. Phone (home): addre�s• Q_ (worlJcall): � — ?) \�cue and address urrent o� r(if dif�renc [haa applicant): 1atn2' K Phone• L' S address: 3} Propertti� Description: Lot Size: __��(►,Subdivision: f Lot �: �ddress and/or ciirc:cuons to Properry: __ D�(' �" i p' fY � C� f� , � �.�l�Q,(-_ p vCs no Boes thc sitc contain any jurisdictional wttlartds? Q�•es p no Does the site contain any existing tvastcwater systems? Q}es ❑ no Is any wastcwater going co be gcncrattd on dte site othcr than domestic sewagc? � y�es � no IS che site subject to approval by any othcr pubIie agency? p yes ❑ no Are zhere any ca5cmcnv or ri�,ht of ways on this properry� . (if 'yes' is chacked, please providr suppotsing documentation) �}�Propased Use and Ty�e of Structure: dentia! ,'ew SingIe Family Rzsidz�ica Maximum �umber of bcdrooms: � p��pansion of Gxis�in^a System if cxpansion: C.urrcnt number of bedro ms ❑ i2epair to �lalfunctioning Sysjem t�'ill thera be a bascmcnt? ❑ yzs ❑ no With pIumbing fixtures? � ycs ❑ no ❑`on-R�cidendal T}-pe oi business: , . Total 5quare faotage of Building: �ia�cimurrc number of cmpinyccs: ,_ Marimum number of srau: ' Zi'ater Supply: C�7he«� ��cll ❑ E?:isting Wcll ❑ Commuaity Well ❑ Fublic Waur 0 Spring :�re thcrc any cxisting wa!]s, springs, or existing waterlines on this praperly? ❑ yes � 6) If apph�ing for �Anthorization to Gonstruct', please indicatc preferred system type(s): �jlCom'�rional � acccpted O Innovauvc ❑ A{ternative ❑ 0[her 0 p►nY 1 czr:ij}• ti:ac �Jra infor�nu�ion prpvidad ahvve i� com�le�a a�rd correCt. I af.co understr�nd Iha! 1f the �nformalion provided is ;,,�,-�-:�r�,rr_ or if1h�� sf�e is suhseau2ntly �lt�red, ur tha irtte.nded icse changes, all permils �d approvals shall 6e invalid � � ��C.i . tii aatu� (0��•ner/ L�gal Represzntative°} Suppunin� documentation rcc�uirzd. b ate . Yermiis are valid far either 60 months or are non-expirin4 when accompanied by an appraved plaG . A eompleted 'l,pr Preparation' fvrm must accompany any spptiration requiring a site evaluation. t lU•l ?) Person Count�• Environmental Hz�1Lh, 3Z� S. �for�,an St., Suite C, Roxboro, NC; ?7573 (336-597-1790) ��, s� ��..� �� ]Eys��u-��.��¢�.Il IE��.Il�I� Applicant: Address/Lc Tax Map: � Parcel: �i2� Subdivision Phase/Section/Lot Improvement Permit Permit Valid for: Five Years � Non-expiring � /' Type of Facility:�i,r �%��,�(u ��.��n0 New � Addition Water Supply: W�� Number of: Bedroo�hs �/ ccu0 pants �Employees / Seats: Projected Daily Flow: 3�d ga�s/day Proposed Wastewater System: Type: Proposed Repair: Type: Permit Conditions: ��s;, � [( sPf%Ks Authorized State Agent: (X) Owner or Legal Re Date: /Z - 22 -/S Date: (-Z7-Z�li� The issuance of this permit by the Health Department does not guarantee tt►e 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. T6is permit was issued in compliance with the provisions of the l�iorth Carolina °Laws mrrl Rules for Sewage 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 yvill remain potable. Authorization to Construct Wastewater S�stem See site plan and additional attachments (� Proposed yVastewater System:��/rd�?f� Qe�u�-�on �T__� ('�)TYPe� Design Flow 3l�o gal./day New �� Repair Expans� Soil LTAR: ,� gal./day/ft2 Type of Faci(ity: �;„�� M'l�( 'n - (Z Basement: _ Yes ,/No --�— — (*) System Types Illb, Illbg, Iv, and i�, require�eriodic system inspeclions by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank I+DDO gal. Purnp Tank �—�gal. irease Trap'�--"'—"gal. Drainfield: Total Arza DO sq. ft. Total Length � ft. Max. Trench Depth � in. o , c. Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation 9 ft. Distribution: Distribution Box �/ Serial Distribution / Pressure Manifold Specifications: 3 �,�„pa, �� ►oo� Authorized State Agent: The system permitted is: Conventional /Accepted ✓/ Alternative / Innovative . I accept the conditions and specifications of this permit. / (X) Owner or Legal Representative: -( � Date: �- 27� zc� l[� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/l2) ��-,�, f I�'1�I�.�� ]Eaawas�o�� .�.Il ]H[�a�u�7�. ...... .... . .. SITE PLAN ' � Name Tax Map# Parcel# ��v Subdivisi ►J f-�— " Section/Lot# � � [2�- -!S Authorized State Agent � Date System components represent approximate contours only. The conlraclor mus�J/ag the systemprior to beginning the installotion to insure that proper grade is mairrtained. Note: An Accepted system may be used in place of a convenlional system wichou� permit aulhorization or modification. �n�{-,a( . ��.ss ��.�� r � � �� n.wn��n,r-,r,. ��n��.� ��.��a Applicant: Location: System Type (From Table Va): � Type V& VI Expiration Date: O�eration Perrnit Tax Map �D Parcel # y2� Subdivision Phase/Section/Lot # N # of Bedrooms `� Product (IIIg): � � Type V& VI Renewal Date: f� 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. A \�� 1 e�L (Licensed Contractor) Scale PCHD, rev. 1 /14/12 �=1�- ��,. Chur�/� � 3-��r-r� (Date) 3' 1 u-I (� (Date) ., ��■ .. .. ',�c�� ., � , r,� Tax Map: � Parcel #: � 2� Septic Tank System Checklist (Type II-I� System Type: �( EZ) �.� Se tic Tank InitiaUDate State ID & Date: S�3i - 32 _ Ca acity: S- o0 Tee and filter ,/ Baffle Vent ,/ Riser ,/ Outlet boot �/ Perm. Marker Distribution D-box (levels set) _ _ Serial Pressure Manifold LPP Notes: Pump System Checklist Pum Tank InitiaUDate Stat D & Date: Ca acity: Riser 6" mi NEMA 4X Box 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: Tank Com onents InitiaUDate P model: Block 4") Nylon re 'eval ro e Float tree attachments On/Off float s 'ng: in. Alarm float (6" s aration) 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. Date: � �� :� y � ,,� 'ti,r•, ,�,* /7"".�.+/"' �.� � �:?L `� �.1. � �tw;s]CI�'S�'It�'4Ch7[h:illi;'1.� tl�?��s7,.�� J� �le�-�tlk,.fl'�:=��11 Name: �r Lr 2 Address: s�p " � C • � • Re: Bacteriological Test Results Dear Well Owner: Tax Map: �fl Parcel: �2� Your well water w�s sampled on �/��/�1� , and tested for both total an� fecal coliform bacteria. Your water sample test results are noted below: � No coliform bacteria were detected in tne sample. Your weli 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 col�orm bacteria are na�urally found i� the soil. Fecal col�orr,� bacteria are associatEd with animnal and/or human waste. The presence of either total or fecal coiiform oacteria in weli 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 m�y f:ot be safe for use. Y�ung children, the elderly, and the individuals with comFromised immune systems are especially vulnerable and their physicians should be notifred of the !est results. A well that tests positive or 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. Gnce 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, �v�✓ Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmerrt2l Health, ?25 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-59?-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: ES061516-0077001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: DANTE DAYE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 httq://slph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 2300 FLAT RIVER CH RD ROXBORO, NC 27574 Collected: 06/14/2016 14:30 Received: 06/15/2016 08:23 Sample Source: New Well Sampling Point: Well head A Sarver Angela Heybroek Well Permit Number: A40-426 � Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 06/16/2016 E. coli, Colilert Absent Susan Beasley 06/16/2016 Report Date: 06/17/2016 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. 's, '� �_. ` f� j � � ( ,�- ` � s• �t�� 'c 1 '-.-5 � !�i ` � �� ` � f� ' T•S �'� t °�j �S ; � ; • :�"� 1 � k � � ^ � 1 J �_I_,� 5 � `�� ! r L J � 4 � E ! � �.� ; ! < i L�a = f `• i 4 - �--�; q � ( � �---. , k�� —�. �. �. �:--�,� w r.f �, . ,�. " j F~� f•a r ;:s. 1�� L'-'-� ��= v j � f� i J�, R � � ��{` i, � i"�� (^. iI_ � � � .,..�` �� t: � �� ''�. �� E [ e � � � _. � I �; _�' !� � ��' E � � , . �+% � . , - � � �'��L+iTi� For Inorganic Chemical Confaminants ii►,.� '�1►• � TEST RESULTS AND USE RECOMMENDATIONS 1. L, Your well water r:meets federel drinking water standards for ino�ganic che,n�cals. 1'our 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 aze 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 ci:cled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inoreanic chemical results onlv. 3. � a. Sodium levels excee3 the U.S. Envircnmental Protectian �,gency's�(USEPA) Health Advisory level for sodium of 20 mg/l. 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 h�ed on the inoreanic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic probtems such as bad taste, odor, staining of porce(ain, etc. 4. 0 Re-sampling is recomm�ncied 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 fo((owing 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 Frob!ems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment sysiem to address aesthetic problems. Barium f Cadmium � Chromium � Fluoride � Iron Ma esium Man�anese Selenium Silver pH Zinc For more informalion regarding your we!! wafer resu![s, please call the North Carolina Division of Public Health at 919-701-5900. North Carolina State Laboratory of Public Health 3012 Distnct�Drve Environmental Sciences Raleigh, NC 27611-8047 htta://slph.ncaublichealth.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 Name of System: DANTE DAYE 2300 FLAT RIVER CH RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES061516-0042001 Date Collected: 06/14/16 Date Received: 06/15/16 Sample Type: Raw Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 5.5 Time Collected: 2:30 PM Collected By: A Sarver Well Permit #: A40-426 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Cadmium < 0.00 < 0.1 < 0.00 46 6.40 2.00 0.005 250 Chromium < 0.01 0.10 oride < 0.20 4.00 Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 11 m /L Manganese 0.200 p 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 m /L Nitrite < 0.1 1.00 mg/L Selenium Silver Sodium 8.2 < 0.005 < 0.05 13.00 0.05 0.10 5ultate 5.00 250 m /L Total Alkalinity 165 m /L Total Hardness 160 mg/L Zinc < 0.05 5.00 mg/L Report Date:06/29/2016 Page 1 of 1 Reported By: Deddie .�tonco�' ��.sf ��.�� = � � �� IE��n� ��.m��.Il IE�� Il �]F� WELIt PERMIT (New�/ Repair_) Tax Map: � Parcel: �2(Q Subdivision: �/�- Lot: � Applicant's Name: Mailing Address: �(� r u S Phone Numbers: �3� - 583 - 8 37 LocationofProperty: pws�l� 23yn F�a� R��r ��u�c� 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 w�ter supply Ot6er Conditions/Commeats: �Arn �� S�t��S r Permit issued b• � Date: _ j 2- Z�-�,� Tew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: 3- Certificate of Completion Di.iner: EHS/Date Depth: �� Grout: DAbandonment: Date: _ Method/1Vlaterials: Well Driller: L�j� rn�� License #: Pump Installer: � ~ License #: Approved by: Date: ��/ �[� Date Sample Collected: ��`�'� �° Date Results Mailed: �_ ((Q � EHS: —�T— Person County Environmental Health 325 5. Morgan St.,Suite C � Phone: 336-597-1790 Fax: 336-597-7808 Rnxhnm NC 97573 t �/��H � Mar 171610:04a Barnette Well Drillinglnc 336-598-9275 } � c,u� �` %o►� wELL cotvsxRvcr�o�T x�co�n Tfia Cormun bo �sod Fors�e or mullipla w�its l. We0 Contractor Lnfo�j ation: _� ��n✓�� f nur w�t c��a N„a� --��— 33�?� % Kc ur� c�� c��F�� r+��« Bar�net#e Well Dri�ling, lnc. c� n� Z.lv�lt.Constractian Pcrraitlt: "[V' Ltsr a1f applicabtc �«eUcwas+rouian permits jte. !'.+wnry�. 5raa. Va�zontc. trc) 3. Well U�(eheck weR «sc): Wata- Sappty R'dt: p}1r�icvtpual ❑M�uniapaUPahlic- OGeothatnai (i�eatingrConiinR�PP�Y) iJiLesidantial.iYatuSuPPlY{siagk) Olndusuial/Co@macial ORssidrntiat Watcr Snpply ts6a�#} E]AqniEa Ra3�arge �GcaindtwAtc Rr.�aiedia6na OAquifcr Stacage and Rccoverr OSaliniiy B�rtirt OAquifcr Tcst DStortnwatulhainagc OF.��xim�ntalTechnalogy ❑SubsidettqeCoc�ot OGcpthe�ia[ (Closod LooP) Oi'raax ❑Other feimlain undex �2t t. Uate`R=c[I(s)Com�ictcd: ✓ J6-��! Wdl.IO# i` ��L� Sa.'Wdl Facation_ S�''a/1�^v�� /�' �/�j'y!i Fac�7itg/QwuiYNacia —! FaiiJit�yfIDC(ifapplrca6lc) �U / - � � � ��.r � � /` �J - Pkqr.tical A�. C'a7� ��P ' j�(�,r j� �1 �f�.10 Co�,utp Pa�c1 [dawiG�oaY�n. fP1N3 Sh Latitadc and Laagiiudcin degreeshniQptesluepuds'er dnimaF degrees: (i#wctl �ci�onp �toa8 issaCficioat) � �!• �� -3� N *� � �� `� � � Cct�tre} �cso'tlt(s): ermaacat. or OTemporai7 . � 7_ Cs tdu s npai�' to:s ccistipg,wcp: C3Xts oc i�4o lf 01It ls o nparr, frlJ ou fxv+rtr wcAmuhsoGio,x (rJ'wma[iaai ouad:es�l6in rhr aat�us offfie repair++hder �2l nreer�[z saaiwi or ar� d�e baet oj� 13 forn_ $.� [+(um[m� of wclls cosutiuctcd: � For au�hipk firlupoa or nou-aetccuy�fy vellr OMLYvirh ihasamc awei�r�a: yog �mr s,dmur orrcJ�n� � 9.'Catal'�vellde�tGbelawlaadsudaez: �� (tt) Forruvl�r� weUa lti�all derxfis Id+&r�it f�rryl�-3Q�o0'c+�d I�Oo� i0. SIa6c �titer kvd be[o�r tap of casieg: �� (�) Ir�a�afer lebr! ir abwe caa,rg, rr.sr "�' 2l. Bonb4lc diamaber_ b ('in.) L2.Wdtcw�strudion.mclbad: �.� 6 V��u �'z� Rrgex iuhq'.esbk,dieedput� dc) FQB WA'iER S[JF'PLl' WEI.LS UM.Y: i3i'Yldd (�m). Mcthad of tts� g�°�0 minute ]36. P+ga[ection typ� HTH �o�� 1�2 Cup For [arrna3 Use Oi+iCY_ p.1 22. Cxnlifiealio5: ' r• � ""� �Gr � �.� -.1� . . . ofC.�fifml w . �� Dau�. ey.Fr��,r�fa.n. r x�ay «��• �m �� i� mrar��d i� a�. viih tS t�XE'�tC OZG _UteO dr t.S,t xcAC oZC.r720U Wd! Cauri,ic�'oa.s[artda+iis anoi rlxira +a?PY4��?+* ne,.rortfbas beev��tmvlded m:1ir w1! o�raer_ X3.5'ite'di�itut Oraddilio+oilwdl dbiaiL� Yon may"ust dic back oC this � fd p�ovide.xdilitio�+al.�well site d�ls or vrd[ eoii�con ddac'ts. Yon max e13o.aCachsdtisioital pa�es:if ocetssary. SUD�iITTALIl�ISTUCTIQ]tiiS Z4a. For Ait Wei�x Submi2 this.futm w`nfiin 30 dxys of ooiapletiou' of vrcll cdnsttuttioa to thc�failowii►g: Divisi:aa oLWatcr Qwiiit}, Infarmatioa Yroc�ssi�tg Uait, k617 i4ia3 5erv,ice Ceuta-, Etaleigh, Iv� Z7694-I617 24h For laFtction= Wdls: Trt addifion W saiding d3e faain Ib thc addrass ia �4a ibove, aLto subWit a topy dE �is fa�m wif5in:30 days of ca�hplcGon oE �11 c�shttctio�S to tht fflllow�ig Ditiuionoi'V�'aterQwlity, r]adergraand.Yateetion Conhd�P�rgram, 1636 i►(ail.3ervic� Center. Rsle�[4 DiC 2769�163G Z4c �ar��ter.5u6vt9 Bc [niectiaa'P9dlr. in additioato setiding ii�e.forin Lo tSti a�ditiss(es) s6a�vc, also 3ubmit one copy of this £oim widun 3U da}rs of wmgldim o£ wcll tdnshtitc�ioa tio thc oduiity hcallii dcpa�imurt of ti�c cauii2y �eo�c�a_ . Fm� C W.t \orth Carolina DraattmeatafEnvimoment ud Alsltacal Itrsom¢s - Dir'sioa of Waler Qiniiry Revixd 7an. ?A13