A23 206��' ; ,�f ���� ��
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l.�e na-yn. �z- o �ra�raa� ���.Il IE-� � �.11 �Il-n
Applicant: �k'� �"�`'�0"�
A dress/Location: _
�,, c 1- �--�' —2Dtr'V✓Oc-' r
--.yL(.z,y ��1� — � '� — ��_✓1_� ---.�
�
Improvement Permit
Permit Valid for: Five Years i� Non-expiring
Type of Facility: ►'�j'Z I� S. New � Addition _
Number of: Bedrooms �/ 0 upants / Em loy es / Seats:
Proposed Wastewater System:
Proposed Repair: ; � o �
Permit Gonditions: �°2 Sl� � s�'� � l-.
Taz Map: �3 Parcel: o� �P
Subd:�•ision �wvq, �
Phase/Section/Lot #
VVater Supply: � � �
Projected Daily Flow: � C� o gaIlons/day
Type: �
Type: �4
Autherized State Agent: �+�+ �"re✓ _ Date: .� -'j—1
(X) Owncr or Legal Representative: Date: 3-� i
The issuan�e of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applica�nbpr�perty 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 Improvemeni is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws
and Rules for Sewag� Treatment and Disnnsal Svstems'(15A NCAC 18A .Y9U(i). N�ither Person County nor the Environmental
Health Sp�cialist warrants that �he septic system will c�ntinue to f�nciion satisfactorily in the future, or ihat t�e water supply wiil
remair pota5le.
Authorization to Construct Wastc;�vater System
See site plan and additional attachments (" ✓.
n
Proposed Wastewater System: �� �g�j�� `��(f �(*)Type �� Design Flow �(o O_ gal./day
New � Repair _ Expansion _ � Soil L"Cf1R: � S— gal./day/ft2
Type of Facifir,�: �,2%(,�s- Bssement: � Yes _1`To
('�) System Types Illb, Illbg, IY, and V, require perio�lic sysrem inspections by the Ferson County Health Department.
_�� ��.,...
Wastewater System Requirements
Tank 5ize: Szptic Tank �� � gal. Pump Tank ��� � gal. Grease Trap ^ gal.
Urainfield: Total Area ��a sq. ft. 'fotal Length 3��_ ft. Ma�c. Trench Depth �� in.
Trench Width _� ft. Mici.Soil Cover � in. Min:Trench Separation ( ft.
Distribution: Distribution Box / Serial Distribution__ / Pressure Manifold �
Specifications: ��P �C ��_'ff'���< <ul' �5�� �+-���s�' 6 �� ���io�,� �o�� � �q� �
Authoriz.,d State Agent: `��M l� �f-ev�� Issue Date: 01�'1�('7
Permit Expiration Date: �--?�ZZ
7'he system permitted is: Conventional /Acczpted �_/ Alternative / Innovative . I accept the coitditions
and specifications of this permit.
(X) Owner or Legal Representative: ` Date: �- �f-1 7
Person Counry Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12)
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STTE PLAN
P1ame J v �1 ✓� 4 `Q ►r^�OVI • 'r� �P # �23 r cel # � 'f'
. Sub ' ' 'on $ection/Lot#
° �,� z-�,�,�
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S,ysrem compoaeats tepieveas appro�mate rnamurs only. 23e roaCactormrucr ilag the system pavr ro beo nni tq rhe iasrallation m
iasurr t6stpmpergn�de is n�tataed
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Tax Map: Parcel #: Datz: 3 8 D �
I.ine Tap �ap (a�c�a) �aa� �o�v Li�ae �,e�� ��w / #�m�
# Da���e�(�} ( �aj �:. rt)
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3 D S� 0� 68"
4 � s. S" 0 0 6
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3�� ft of line x 65 gal. per 100 ft =2�t7�"'� ; 100 =�� gal
75% x� ga1= ? S g� per d�� �_ gal per minute (gpm) = Flow Iiate
�a�icicon �ea€1
I.oss: ��ft per 100 ft o supply line x~ 3S'a ft of supply.line =100 =�•'� ft
ft x.1.2 = ft of frictian head
1Via�ai� ��e: �_„ �orrx IViai� �iae: '� " PVC
'�o�l Dytt�eic �ead =�ft of Eleva.tion hea.d + ft of Pressure head +�ft of
Friction Fiead = ��TDH
�ffip flZeaea$a�naent: �� GPM C�_ ft of Head
Drawdo�n: � ger dose � 21 gal per inch =_� inch drawdown per dose
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1JEMA 4X Simplex Contml Panel
. � �1
, 4" }a 4" Pre.mre Treated Post �
Sloped To Shed Watez 12" Separation
. � Electxical Con�it —
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4" SCH 40 PVC Pipe '�' '
. . Check .�.N,ylon
. Valve Rope
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(6" Sepuatiox�
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. ' Pxecast Coxicx�te Tank 4° Conczete -
� � Iv4aterial Strex�yth }3500 PSI) Block '
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+"•i•-,•••. �
Tluea�ed Gate Valve •
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Ties 1
Concrete Riser
6" Separation
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Line ••
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Float Wues ' .
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�'az i�Tap: ��3 ar el• Z� o
Subd;visi�n• � �� �QO/ I,ct:
Applicant's l`Tame: � ��, V (Oa-�-o.-�
1dlailing Addr�ss:
Phone Nuanbers:
Locaiion of
Permit ConditiQn�: ' �
1) ilee uttached site plan for prolvosed well location. •
2) All applicable State and Coun� regulations gaverning constructivn and�s�tbacks ap�ly. �
3) Permits expire S years from the date of issue. �
c�ther C'onditiorrs/Comments:
Permit issued b�:
Ne�v Well Inspect�on:
Locaiion:
Grouting:
Well Log:
Well Tag:
Pump Tag:
A�r V�nt:
Hose Bib:
Casing Height:
Concrete Slab:
IDate: � /
��+ i��`�+'��CA��'�+ ��' CdI' .V��,E'T��I�I
-�7
WeIl I)riller: � � ,�_�� •t-f �'_
P-�:mp Install�r: c �
Wel! A.ppro�ed by; '"'� � C�''"'�
Date Sample Collected: �� �-� �� �
Person County Fnvironmenial Health
325 S. Morgan St., Suite C
Roxboro, NC 2757�
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Weli �ilbandonment:
EH�/Date
Completed:
Method/Material(s):
Lficense #: __`� �'
License#: �
Da#e: �—Zz��
Date Resul±s M�il�d:
Phone: 336-597-1790 Fax: 336-597-7808
8I1/08
WELL CONSTRIIGTFON RECORD
n,�r�►�u��a ����+�.� ,
L Wdpl Coauador Informa6ou: �J I
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wai c�N�
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xc w� co�c���+N�� j
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l;ttt oll appUmblc uell consuuaton 1�a (►�
3. Ndl Uu (check weA osej:
Water Snpplg R'e1L '
pAgricultival OMtmicipaUPublic- �
❑Geothemml (Iia►tiagl�°� SnPP�Y) �i cndsl Water SnpPIY {smglo)
aTrtdusuiaVCancna�a! QRcsid�maiwaterSu�ppltY(st�d)
u
olmeation �
Non-WaterSnpply�i%dL• �
. no.�..�wrcr i
���Q�ereterRanediati�
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pFspr�nien�ITeciuwtogy ��CO°�0� '
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For Inorqanic Chemical Confaminants �
County: ' rSo Name: a o r �,
Sample ID#: � 0�, Reviewer: Qw-�r-
� TEST RESULTS AND USE RECOMMENDATIONS
1. � Your well water meets federal drinking water standards for inorganic cher�sicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inoreanic 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 Pubiic Health recommends that your well water not be used for drinking and
cooking, nnless you install a water treatment system to remove the cir�led substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorFanic chemical results onlv.
Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Uon
Manganese Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH
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 inorganic chemical results on[v.
❑ 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 possib(e a frst draw, 5 minute and a 15 minute sample at the wetl 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,
cookin , washing, cleaning, bathing, and showering based on the inor�anic 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.
Cadmium � Chromium �_Fluoride � Iron
Selenium Silver pH Zinc
For more information regarding your well water results, please ca!! the North Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health 3012 Dist�ct D ve
Environmental Sciences Raleigh, NC 27611-8047
htta://slph.ncaublichealth.com
Inorganic Chemistry Fax:ne� 919-715-867�$
Certificate of Analysis
Report To: ADAM C. SARVER Name of System:
PERSON CO ENVIRONMENTAL HEALTH JOHN NORTON
325 S MORGAN STREET
677 CLEARWATER LN
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES080317-0065001 Date Collected: 08/02/17 Time Collected: 2:15 PM
Date Received: 08/03/17 Collected By: A Sarver
Sample Type: Raw Sampling Point: Well head Well Permit #: A23-206
Sample Source: New 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
Calcium 76 mg/L
Chloride 16.00 250 mg/L
cnromium < u.0 i u. �u ���y��
Copper < 0.05 1.3 mg/L
Fluoride 0.27 4.00 mg/L
Iron
Lead
Magnesium
Manganese
Mercury
Nitrate
Nitrite
pH
Selenium
Silver
Sodium
Sulfate
Total Alkalin
< 0.10
< 0.005
16
0.160 �
< 0.0005
< 1.00
0.30
0.015
0.05
0.002
10.00
m
m
< 0.1 1.UU mgi�
8.0 N/A
< 0.005
< 0.05
18.00
32.00
0.05
0.10
250
Total Hardness 250 mg��
Zinc < 0.05 5.00 mg/L
Report Date:08/15/2017 Reported By: Deddie .�toncol"
Page 1 of 1
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Date: �/ 2Z—/ l �'
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Name: ��h r�'avL
Address: 7�i� �' �"u/°� G'� •
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Re: Bacteriological Test Results
Dear Well Owner:
Tax Map:�3 Parcel:�
Your well water vyas sampled on Sl / Z/� and tested for both total and fecal coliform bacteria.
Your water sample test results are noted beiow:
No coliform bacteria were detected in the sample. Your well water is safe to use for drinking,
coo ing, washing dishes, bathing and showering, based on ihe 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 soi;. Fecal coliform bacteria arz associated with
animnal and/or human waste. Tha 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
�nay not b� 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 should be proverlv disinfected and retested
prior to resumin� 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.
Sincerel ,
�Y�-Q„�
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person County Em�ironmerrtal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fac 336-597-7808
.�;,
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North Carolina State Laboratory Public Health
Environmental Sciences
Nlicrobiology
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
JOHN NORTON
P.O. Box 28047
4372 District Drive
Raleigh, NC 27611-8047
htto://slph.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
677 CLEARWATER LN.
ROXBORO, NC 27573 SEMORA, NC 27343
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES080317-0099001 Collected: 08/02/2017 14:15 A. Sarver
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Received: 08/03/2017 08:25 Angela Heybroek
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Environmental Microbiology - Colilert Profile
Test Name: Colilert
Analyte
Total Coliform, Colilert
Test Result
Absent
Sample Source: New Well
Sampling Point: well head
Well Permit Number:
A23-206
Method: SM 9223B
Date
08/04/2017
E. coli, Colilert Absent 08/04/2017
Report Date: 08/07/2017
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.
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