The URL can be used to link to this page

A23 222,- � C �v'�,`�'' � �� '�- ��P ��C� � , I' � ��,sf ��.�� YE-�s �-� a- � �:�. m-��.Il IE-� � �.li �11� Applicant; �� Address/Location: Tmprovemen¢ Permit Permit Valid for: Five Years ___ Non-expiring �/ Type of Facility: ��,� New �/' Addition Number of Bedrooms Z/ Occupants�/ Employees / Seats: Proposed Wastewater System: .� Proposed Repair: -r.�� Permit Conditions: Authorized State Agent: (X) Owner or Legal Re 0 Tag Map: � Parcel: Z�� Subdivision Phase/Section/Lot # Water Supply: Projected Daily Flow: gallons/day Type: Type: Date: Date: The issuance of this permit by the Health Department does not guazantee the issuance of other required permits. It is the responsibility of the applic�ndproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if t6e 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 North Carolina °Luws a�rd Rules for Se►vag� Treatment and Drsnosa! Svstems'(15A T�1CAC l8A .19U0). Neither Person County nor the Environmental Health Specialist warrants that :he septic system will continue to f�nciiou satisfactorily in the futare, or #6at the water supply witl remair �oia6le. Authorization to Coostruct VVast�water System See site plan and udditiofzal atfac:hn:ents � �. � z�� Proposed Wastewater System: ,r :'�• (*)Type T Design Ftow L o_ gai./day New �/ Repair _ Expansian _ Soil LTfiR: . �"' gal./day/ft2 Type of F�cility: t�� 'L M'71� Bssement: _ Yes �iVo (*) System �ypes III6, Illbg, IY, und V, require perio�tic system inspections by the Ferson County Health Department. Wastewater System Requirements Tank Size: Septic Tank DOc� gal. Pump Tank _t� ,�__ gal. Grease Trap """ gal. Drainfield: Total Area �O sq. ft. "fotal Length —j� ft. Max. Trench Depth �� in. Trench Width ` ft. Min.Soil Cover � in. Min:Trench Separation �_ ft. D�st.ributi�n; Distribution Box �C / Serial Dist?•ibution / Pressure Manif�ld Specifications: A�itho►iz�d State Agent: Issua �ate: Permit Exaira±i T'he system permitted is: Conventional /Accepted X/ Alternative / Innovative . I accept the conditions and specifi�ations of this pe.rrriit. ` (X) Ovvner o, f�cga; Representati�e: �C Date: : Person Counry Environmental Health, 325 S. Mot-gan St, Suite C, Roxboro, NC 275�3%ph: 336-597-17y0 (rev 5/12) �.��. sf ��.� �� I��a-��.��.Il IE��.Il� Applicant: Location: System Type (From Table Va): Type V& VI Expiration Date: (3�eration Pern�it Taz Map �� Parcel # _ 7yv Subdivision Phase/Section/Lot # # of Bedrooms Product (IIIg): ��( a►� � Type V& VI Renewal Date: �_ This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and I�isposal, and all conditioas af the Improvement Permit and Construction - Authorization. f� v Scale t�T'� PCFiD, rev. 12/14/12 '}� • LG��L��/ (Auth�rizad Agent) N�, - L �L� Zicensed Cnniraciar) A N J � ��`Ga ¢i , /11/, � ! O '�'6"s lOdO � 3� t v�� /t 4� �Tiate j t z/v�t G — � ) "� 3 ti� ` � (�r�' i�zQ �A FA-�.+... .._-� `�-`��x � 'TA,J�G t� �—�x � A �^►p ��-� -� L t nt � s � o�-r-�,—s � �--� �- �� aiL � �l +�,�-�� Co�-r��-rb � �1'� w '�� `�.Z.�o� � Ct✓��i nf�`� Tax Map: / '� Parcel #: � Septic Tank System Checklist (Type II I� Nofes: Systein Type: i � Pump System Checklist P� Ta�,k I�itsa�2at� State ID �c Date: C�paci�y: Riser (6" rnir�.) �. N�NIA �X Box M�del: Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (I2") Conduit sealed PressurQ Ma�i¢old Numbsr of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Nates: WELL CONSTRUCTION RECORD North C�rolina • pcpartment of Environment and Natural Resources - Division of Water Quality - Groundwater Section ��'ELL CO�TRACTOR (I\DIVIpUAI.) NAME (print) WILB�RT 7O_N�'.� CERTIFICAT►ON 8�4,9—A �� ELl CO.�'1'H;�C'I'OR CO�IPANY NnM�___$�KIN WILT�TAM.�',Qj�j ��i PHONE s j 1 S'f.�T� ��'eLL CQ�STRl:CT10\ PERMITM ASSOCIATEO WQ peRMITM _ (ifapplicable) (ifapplicablc) �. 6. 7. � ��'�Ll. I;SE (Check Applicable Box): Residential 0 Municipal/Public O lndustrial O Agricultural ❑ �lonitorin� ❑ Recovery ❑ Heat I'ump Water Injection [] Other 0!f Other, List Use `vELL LOCAT {�-{� Near�j o��•n: � County `�-I`Sd� O � iSucci !�ame, Numbcrs, Cornmuniry, Subdivision, Lot No., Zip Code) 0 WN�R: CC Address i�6�� a�� J G 2.�57t� Cny or Toy�n Statc Zip Codc ��)- � .�rc� codc. Phone number � ' �� DATE DRILLED '' " TOTAL DEPTH: DOES WELI. REPLACE EXISTING WEI.I.? YE�T,L7 NO [� STATIC WATER LEVEL E3elowTop ofCasing: 3C�' �', (Use •'+•� if Above Top of Cuiny) TQP OF CASING IS 1 FT . F7', qbove Land Surface' 'Top of c�sine terminated at/or bclow Iand surf�ce rcqulra � r�rl�ncc In ¢ccord�nc Ith ISA NCAC 2C.0118. YIELD (kpm): ___,�__^ METHOD OF 7'EST_ATR BLOW ��'ATER ZONES (dcpth), �'J fJ ^ 10 -- 1QU I I. DISINFECTION: Type Amount HTH I?. CASING: Wall Thickness Dep qiametcr or 1VeighdFt. Material From 0 To�_ Ft. 1 9 SDR 21 �VC From � To Ft. � From To Ft. I3. GROUT: Qcp�j,.� Matcrial Mcthod From O To w Ft. CONCRETE POU�„ From To Fl. 1�3. SCR��N: Dcpih Diametcr Slot Size Material From To F�. in. in. From �— To Ft. in. in. I�. S�ND/GRAVEL PACK: Depth Size Material From To Ft. • From To Ft. 16. RE�tARKS: Topographic/Land setting ORidge OSlope OValley OFlat (check appropriate box) Latitude/longitude of well location (degrees/minutcs/sccondsj Latitudc/lon�;itudc source:OGPSOToposraphic map (check box) e T � DRILLING l_OG Fram T� _o �.r•E,ormati cs r' tion 4 - s�__ �!3 � � — �� 'S� �OCATION SKETCN' Show direction and distance in miles from at least two State Roads or County Roads. Include the road numbcrs and common road names. � I p0 NEREE3Y CERTIFY Tt1AT THIS WELL WAS CONSTRUCI'Ep IN ACCORDANCE WITH 15A NCAC 2C, W�,LL CO�STRUCTIOn STA��pqRQS, ANQ T A COPY OF TH1S RECORD HAS BEEN PROVIQ�D TO THE W�LL OwNER �_ (6_ I� SIGNATURE OF P CONSTRUCTING THE WELI. DATE Submit clie orieinal to the pivision o( Watcr Quality, Groundwoter Section, 1636 Mail Se�vicc Cente�- Raleigh, NC ?7699-1636 Phunc no. (919) 733-3221, wlthin 30 days. GW-I REV. 07/2001 DEC-20-2016 11:18A� fRC�- Req�sest fer �.�el� Cs►sin� �epth �'�ri�ncc T-151 P.001/001 F-202 : 3i�a i��stii�g a vnt3�atC :iWri thc P��csnt� Caunn• t IeaIth I7irecs�r tv set 1�ss tk�r. the 67' �: c:�,5l�qa i'e4�lizeLi av che 'Re_p��larinitc (i,��,��inx 33��I1 �`on.slrx�.�livn und G�G1��v�t1�r Protecda� l�f ��S�.rn�ti�.,'1'rrlA �`aro_Ilttu�. �onsolidat�d bcdrut� «•�.s a.xottuter�d a: a, sb,llow cr�rsugh d�pth in :he w�i� L�ei�� unsuu�ied ai th� propctt}� t�ferssced below u� ju�y a reducti��n ir ca5in� depth. :�a rc�;�tiag a vatianco to scr a�i�tia�4rr. �= ��' c casi�c ;jnd attc�t ;i�t �hc c�sin� w,"e3 extetxi at ieast :G' into cos�s4iidatt�i t�edr '. I u�dtrstt�rd r�lrat Q rtqtrrsa far a Lartanrr daffis nor i„y,ts c�pprpwtl frum llie F�rso� �oux�y Haralt/t Directpt. c''r,��ry InLr4rmatio-�: Ta»� lvl.�p: „�_, �Wa.�cef �: _ �'��' pc�tit Aggtfc�a� � L� _ �.�.. �F�Y Loc2rivn: ��° /�IIJ'Ii.L. i� �.y �'orn�en .� � 't� �t11� _ . _ w � ��, j (�A/�S�.S ,11C._._ � � i� — �' ' ,�, +• �—$�► W�!t I�I1G.� LiCe:s� �;uRyb�r i�a1e This requ� mu�: bC �Aa,ilcd Or f�.�eGi t0: Pr. x�n Cot�nty t�nvirs�nmeninl HraZria 3w� 5, titBPe�Yt �1.. �U :C C Ro;�hnro. �C ?.75 :3 ?hane 3:�•i4?•l;�� l•d:c a'3ti.;Q7.7$�� (PCHIS beCC10l1) TJrr rtqtt�yctld a�eriaxcr !s Jt�kC� �J1xS6'f{ AJ} t/tC 1�tfVflf[t�flrlri �►/�el+�{%r�+f�j �U%►g. r%tL! va�aa�eC� a�plses uxl,y t� evsiltg dtpt�i. ' -�� ...._... ��' Peisafl Ce+�ry i�+:altb D� ar authcriced npt�scntati�-�; i7�;e Vr��if�taii/Malta�d,�Mii;M##a'��RA�i%ki#7lirY�frRtl�ltl�if)r�aie�:i*illli�rrt�N`�►yn�htts Tlte' t'��tustcat v�,ri3nce Ls {S,at a r v �{ ar th� fvll8wutg trosonrsJ� pGrso:t Cour:ty H�.lth Oiieytflt ;or auLherized :�prrsein3tit•e.} �`"— st,'P�T n� ��.sf ��.�� - � � �� IE��na-��.Il IE3C��.Il�l� WELL PERNIIT (New ✓ Repair_) Tax Map: ,� Parcel: ZZ'�i Subdivision: Applicant's Name: �'" � 'c..-''11'F V�%'�G� Mailing Address: Phone Num6ers: ?„�� - � �_ 7� _ Lot: Location of Property: ��% /t/`��}-�-�-"z, it,�, � ��. �� Permit Conditions: 1.) See attached site plan for proposed well location. 2.) .�ll applicable State und Courty regu�'ations governfng construeiion and s�tbacks 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: Permit issued by: �,e'�,�f,,� Date: // ��_ L'ew Well: HS/Date Location: -� �'`�`f Grouting: - — � Well Log: Well Tag: � � �e�tifi�at� of C�mplet��n . �i,iner: EHS/Date Pump Tag: -� d�� Air Vent: _�7 t��l�rA Hose Bib: Casing Height: Concrete Slab: Well Driller: Q �� a►'� Pump Installer: C!d z� Approved b�: � _/ Additional Co.mments: Date Sample Collecied: 3'13� l EHS: Person County Environmental Health 325 5. Morgan St.,Suiie C Roxboro, NC 27573 Depth: Grout: �Abandonment: Date: _ Method/Materials: License #: License #: Date: ' Date Results Mailed: Phone:336-597-1790 Fax:33b-597-78U8 11/26/13 �.��,?, ) f �� IE �.osa a-o aa�an.��cs��.Il IE3L �0 �eo.Il �Iln. SITE PLAN Name �'r'�1%�_ F'��A� E Tax Map #a�2?z. Parcel #-,�� Subdivisio�� • " A�� '��p , Section/Lot# . � Au onzed S e Agent ate System compoaents teprueat appmxrmate contours only. The contracmrmust flag t6e systempriar ro beginaing the inszallarion m insure rhar pmpugrade ls mainrained. - --- — __ __ _ _ � . . . . . . . . .' . _ . ,' NOW OR FORMERLY STEVE WALIACE p6 915-455 N F3fi'01'58° W 659.52 N 88'01'S8" W 498.46 �: �� -D-�x -ra 'F�Efl %�nl�t� �w�� D � �g� �.i�l � C�Z,�,�'p�J � m � � LS��/�'"�ic co p J / � 1 � �l►-r�,4-�.._ / �� 1�r�M �� z�o �a• �- /� /v 3 t,..�l�c� , � / � Dt�,t� e� � � 9,303 �� L9 ,RE�s� rz .�e.�r� a � �� ,�� , PROPOSED � '�� 12'X40' J a��' HOUSE j�D04 . .' � � z vGn�M a�/ z�o e� 63.9' . Z5 � t-ro►� � Z�o � , �. 20.4 W ��-� 1 "_ �oo' 7,09 ACRES N 88°53'57" W 621.00 __..,�� .,�u.�rnc PROPOSED 12' X 12' STORAGE BUILDING 6 4� I OAK POINTE OWNE � ASSOCIATION, IN� i DB 246-510 ; PC 2-191A � RFr.N � 6881 _INA , , , . . . . . . . .' . . . ��. NOW OR FORMERLY STEVE WALIACE pg 915- 455 N 88'01'S8" W 659.52 N 88'01'58" W 498.46 �: ,�,� �-�x -� �'EEfl �nlSL� gw�, -1'�Kn �.,,�'� �A, �pl�D 1-ir� � � C�2,3,�'D�� / 7.09 ACRES � � LS��D"� co p J / � rliT�� ^ �� n�cM �� /� z�lo �a• � /� /v 3 L�r1� c� o' � � � DRAIN ELD a� � � 9,303 _ .FT. � 0 L9 ,RE� � +z. .�e.�t� N 88°53'57" W 621.00 ��v oniniT� nWNFRS � J (� 6� N OJ / �� S C� � �c �� PROPOSED � 12' X 40' J . HOUSE t,o�a y v�n�� p� ,� �o q� s3.s' . 25 � t-"r�`Q- , 2�0 � • � 2a.4 W ,�cc�.P'S�� PROPOSED 12' X 12' STORAGE BUILDING 6.4� �OAK POINTE OWNE ASSOCIATION, IN� ; pg 246-510 ; PC 2-191A � RECN _16881_ � 12118I2�16 15:05 4343745376 Reqt�est far �XI�11 C'�sir,� Depth Vririr�nc;c: PAGE 01 I am rcquestir,g � v�riance from thc: Pe.sson Cauntv 1 leald� �irect�r rto set less tha�r: zl�,e 62' af�a�ix►g zcc}uit�ed b� ch� `ReQz�lat�nn.,r C*ot�e►�ni�tsc �el14:"nn�tr��.Ln and Gr�Qrtr�d�a�,�r Fratectl�rr in �,�1+�h�. ?�'r,rth �:aro_11+tu�, Cansolid�tcd bcciruck «�-.�5 vncoutYtered at a s�.11aw cnaugh depth in the w�11 bcin� cun5�ructed ai thc propett�• re��r�nced below to justify a redu�cic�n in casin� u�pth. I arn r�quasting a variancc ta sct a minimum �T �?` � castne ��nd attcst ihaC Q�r ��sit�� will extend at Ieast 1�° ir�t� consolid�t�� ia�dr . I urtder.tta�td thpat a r�qtres�t. f'ar a uariance dD�S ridt impil �prOWi�ftclrlr i11� P�r"SOlt Caunty l�ealt/t Directpt. Property Inform�tion: T&.�c M�p: �, �Y�r�:e( �: ��.� .. Pcrinit AppIic�t; , i� �„ Prop�rty Lo�ati4n: � /�1�L1.- . � - - - - - - .,,,,,,,,_,.,, �'arnmen � ' �� Wlu.tnnn,sas I�c � 1�,._� -- :�-1b Wcll Drill�r I.icen� ti�intb4r Da« 'Thi�s request mu�t be rnailed or f�x�ced tv: PerSnn CoUnN Envir�nmental Heaith 3�� S, htorg�n Ss,. SWitc C Raxhoro_ NC' :! i 573 Phone: 336-Sq?- i �90 l�dx:3�d.5Q7_7�08 (PCHD �ection� Th� r�q.�Qstad }�arianc� is �rov�d barsed Qi: rlrr i„lfvrr�rarinr� prvvi�lrrl ubuve. Tf�is variaxc� ap�tlies ortly tr� cc�i� dtptJ�. � F'erson County Health IJ ar au�thari•r�d r+�gresrnr�Ci�-e) U�Ye �k*.�*��kw#*�M**�ki�rf**N�s**�M*4�+tK�t**f*:s��i�«ex*t*#r*�!!k�k*f.s�x*R��Yf�kMr**�:��►*+e��* Tlte �equested v�riance ls �ot Q�nr,g„v�rt jor thefollowing r�rt,senrs)� Parson �aunty H�:alth L�ircctor (or authQri�cd r�prCsent�tive� ��Y� R,'f1t nQ North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: STEVE WALLACE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slah.ncaubiichealth.com Phone: 919-733-7308 Fax: 919-715-8611 8667 MCGHEES MILL RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES031417-0030001 Date Collected: 03/13/17 Date Received: 03/14/17 Sample Type: Raw Sampling Point: Outside spigot Sample Source: New Well Temp. at Receipt: 4.0 Sample Description: Comment: Time Collected: 10:05 AM Collected By: A Sarver Well Permit #: A23-222 GPS #: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 Cadmium < 0.001 0.005 mg/L Calcium 18 mg/L 5.50 z5o m Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.22 4.00 mg/L Iron 0.23 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 8 mg/L Manganese < 0.03 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L N itrite < 0.1 N/A m < 0.05 < 0.05 0.10 Sodium 18.00 Sulfate 32.00 Report Date:03/23/2017 Reported By: Deddie .�loncol' Page 1 of 1 —'.�. �r� �uf heal�tl�i end humen sBroiees co��: Sample ID #: >�'� � _ � ' 't t ' ! � � ' —�,, �;' , r_.,_ I s. e�', i� i`� ;- � Z �.-�,s,-° � s'• � i 1� S � � :�; ,� �� i t ` � ; . t � ° i � f �� - � � i�f� +.� � � � � 1 ! :�' � f < < <�, `,. � �� i �.4 �,�: € � � � r-- , , . � �j � � � r :, r�� '�' f�= � � �..-� , --�.-,# �.� •� , � '_, l,. . ,,. , t.-, �I_+ � � / a � '�• t-- i , � � �' f t i i y ` ' �s �I �_ e,.,.,� �_.^ L.� �t �.: �_,t �� F E 9 (�••_/ 0 I�i ig�" f_ ��' I V ' �� l�or lnorganic Chemica/ Confaminants � TEST RESULTS AND USE RECOMMENDATIONS l. Your wsl! water meets federel drin.king water sta�dards for utorganie c�emicm�s. Yau� water can be used for dr�n g, cooking; washing, cleaning, bathin� and showering based on tha inor�anic chemical results o�lv. You may have other water saznpling resuIts that are not taken into accaunt in this repo�. 2. 0 The following substaace(s) exceeded federa! drinking wateX 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 subs�nce(s). However, it may be used for washing, cieaning, bathing and showering based on the inoreanic chemical �esulls onlv, Arsenic � Bariurn � Cadmium Chromium Manganese Mercury Nitrate/Nitrite Selenium Lead Iron Zinc nH 3. � a. Sodium levels exceed the U.S. Environmental Pratection Agency's�(USEFA) Health Advisory leve! 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 h�ed oa the inor�anic chemical results onlv. ❑ b. Levels over 30 mg/) may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc. 4. � Re-sampting is recommended in months. 5. � Re-sample for lead and /or copper. Take a first draw, S minute, and I S minute sample inside the house (preferably the kitchen) and if possible a fust draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. 6. Q The following substance(s) exceeded federal drinking water standards. Your water can 6e used for drir�king, cooking, washing, cleaning, bathing, and showering based on the inoiPanic chemical reaults nnlv, hut aesthetic problems such as bad taste, odor, staining of porcelain, etc, may occur. You may w�nt to in�tall a household water treatmznt system to address aesthetic prablems. Barium � Cadmium � Chromium _lFluoride _ � Iron Man�anese Selenium Silver pH Zinc For more infoimation regarding your we!! w�ter results, pfease call the Noith Carolina Divisian of Public Healtk at 919-707-5900. North Carolina State Laboratory of Public Health Enviionrnenfal Seier�ces inorc�anic CFiernistry_ Certificate of Analysis ' Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Name of System: STEVE WALLACE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sloh.ncpublich ealth.com Phone: 919-733-7308 Fax: 919-715-8611 8667 MCGHEES MILL RD Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH � StarLiMS ID: ES031417-0030001 Sample Type: Raw Sample Source: New Well Sample Description: Comment: Date Collected: 03/13/17 Date Received: 03/14/17 Sampling Point: Outside spigot Temp. at Receipt: 4.0 Time Collected: 10:05 AM Collected By: A Sarver Well Permit #: A23-222 GPS #: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L _.. _ . . .. . _..__--- ------------ --- -.. _ 9 . _ Barium _ _ _ ______ < 0.1 2.00 m /L _ _ — ---- _ -------.. Cadmium < 0.001 __ 0.005 _ __ __ mg/L _ -- --- ------ — - Calcium 18 mcL/L _ _ _ . . _ . --- -- - -- -- - -------- -- - --- _ _.. __ _ Chloride 5.50 250 m�, /L ------- _ _ _ - --------- ---- - ---- --- ---- ---- --- Chromium < 0.01 0.10 mg/L _ - --- --- _ - -- --- ------- ------------ --- -.... Co�per __ < 0.05 1.3 m�/L_ _ - - ------------- — ----- - __ . - - Fluonde 0.22 4.00 m�/L _ _ ---- -- __- .. --- - - ---- __ _ _ ._ Iron 0.23 0.30 mg/L --- --- --- ---- ----- - Lead . < 0.005 0.015 mg/L __ __ - ------- ----- ----- ------- . -- Magnesium 8 m�c /L _ _ ------ --- - Manganese_ < 0.03 0.05 m�/L _ - ----- - -------- ---- - Mercury _ _ ___ __ __ < 0.0005 0.002 _ mg/L ___ _ - -- Nitrate < 1.00 10.00 mg/L _ Nitrite_ - . _ ._ .---_. - --- -�--- < 0.1 ------- -1.00 -- - m-�� . pH 7.3 N/A ' -- . -. --- ------ �-- -- -- -- -- _ _ .__ . Selenwm < 0.005 0.05 mc�/L __ -- _ - - --- _ .._ --- --- ----- ---- - . Silver < 0.05 0.10 mg/L _ _ _ _ - - - _ . --- _ - --------- - - ----. Sodium � 18.00 m�/L _ _ - -- --- - - — — --- -_ __ -- Sulfate 32.00 250 mg/L_ _ -- - - - - ------ ---- - -- - - - Total Alkalinity _ ___ 79 mc,�/L _ - ----- - - — --- ------- ------ -- Total Hardness 77 mc,�/L Zinc - ---------- --- — - < 0.50 5.00 -- -- m9/L Report Date: 03/23/2017 Page 1 of 1 Reported By: De66ie.�lmtco! �� }a. ,� `��` � ��'��`"� "�F�a�uud¢pnrnu�:;��,�mst��.��: ��"'��e�m.��.��n Date: � / � � /� Name: S�2,� �Ja 11� c�2 nn Address: �'(� � 7 �"t c G�rR�S /' � �' l(►�`�� uQa 1��1 wo ,�/'��7 S,_? � Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel:�� Your well water was sampled on �/� 3/� and tested for both total and fecal coliform 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 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 soil. Fecal coliform bacteria arz associated with animnal and/or human waste. 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 colaform bacteria are preseht in your water sample, the water snay rot 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 properlv disinfected and retested prior. to resumin�; normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or piumber 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. S incerely, � Sa� 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, Far 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences IViicrobiology 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: ES031417-0092001 � �� (�� (�� ES Microbiology ID: GPS Number: Sample Description: Comment: Environmental Microbiology - Colilert Profile Test Name: Colilert Name of System: STEVE WALLACE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slah.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 8667 MCGHEES MILL RD. ROXBORO, NC 27574 Col lected: 03/13/2017 10:05 Received: 03/14/2017 08:48 Sample Source: New Well Sampling Point: outside spigot A. Sarver Angela Heybroek Well Permit Number: A23-222 Method: SM 9223B Analyte Test Result Date Total Coliform, Colilert Present 03/15/2017 E. coli, Colilert Absent 03/15/2017 Report Date: 03/16/2017 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 suppty. � i/�/�� . < <�,�� 6 Application Date: p� `��'� f �� Amount Paid: � 00 . b � ��• ., � � �� Receipt #: j 77� ( ( [�� C� ` ]G��s.m��¢�.Il lf-3C�ffiIl,�Ila Aoplication for Services Services �iprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) � Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision Tax Map: /°+�`� 3 Parcel#: �_ �� l -�v ntiee,'� D Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: i( Name: S� � J� � I `�� Address: �' �� .G ' � 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): (work/cell): ��/_�'Z7� oZS � Phone: 3) Property Description: Lot Size:��Subdivision: Lot #: Address and/or directions to roperty: ❑ yes no Does the site contain any jurisdictional wetlands? �� 1�� ❑ yes Does the site contain any existing wastewater systems? `� S� 0 yes �n�o Is any wastewater going to be generated on the site other than domestic sewage? �J{� ��v ��1�� yes �3To/Is the site subject to approval by any other public agency?� �� s��+/ 0 yes � Are there any easements or right of ways on this property. �� (if `yes' is checked, please provide supporting documentation) �4) P posed Use and Type of Structure: ential ' ew Single Family Residence Maximum number of bedrooms:. ��,� / Occupants: ❑ Expansion of Existing System If expansion: Current number of bed%oms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employ s: Maximum number of seats: r Su 1: I� New well ❑ Existin Well ❑ Communi Well ❑ Public Water ❑ Spring 5) Wate pp y g tY Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: 6) If a ying for `Authorization to Construct', please indicate preferred system type(s): Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. 1 also understand that if the information provided is inaccurate, tl�e s,�te is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. (Owner/ L�gal Representative*) * Supporting documentation required. /� � O `i �° Date • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)