A24 158� MAy-05-2016 10:16A� FRO�-
�ppGcatioa Dzte: � � � G
�moant paia: o o� o v
Receipt #: �G _
r °+��j�3�( Ap
= improvemeat Permit (Site Evalnation)
s2oo_oa�S3oo.o0 (if> 60o a)
_ �Iobile Home Repiacemea� or Building
SI ��.a0 (if �i�e visit required)
i� ��'eli Per�it (AFe�e/Ite Iacemrn��epeer)
5300.� _OG.00 75.Op
���.sf 1��I����T
� � ����
1L:uz�-�r�aA�omde�A IHf�dflL•da,
tion for Ser�v[ces
T-684 P.001/001 F-250
r� �vr�p: A a �
Parcel#: ��
Services Re uested
� Construcdon Authorization
ee is de endent on the e af stem ecm;tted)
� Fermit Revisioo
575.OU
I� Repair of Existing Septic System
Applicarion: No Charge/ CA S 150.00 or $300.00
1) Applicant Information:
Vame:
�ddress: • n
q� r
3) Vame and add � af cu r nt owaer (if dit%rent thao applicant):
\ atrie:
.�►ddress:
Phone (home): � � �
�wOi�C/CC���. � r
Phone:-���'� "' �J � t�
3) ProperN D�.scription: Lot Size: 3��ubdivision_ �t �;
.�dciress a�d/or directions to Properry: _.
D��a' no Does �he site concain any jurisdie�ional we�lands?
e:es Q n Does the site contain any existing wastewscer systems? �� �
� yes ls any wastewatcr going to be gencrated on the site other thar, domesric sewage?
� y'e� � [s the site subjecr co approval hy auy o�her public agene��? `, 1�
❑ yts t'J no ,�re �here any easemcnc� or righc of ways an this properry? v��
(if'ye�' is chccked, pl�ase provide suppocting documcntation) � � ��
�) Proposed [:se aad '�y�pe of Structure:
OResidential
1 �
336- S9�'-gz7S
Q\eK• S�ng!z Family Rc;s�dencc Maximum number of bcdrooms:
O E�cpansioa of Existing System (f expansion; Curre�t number of bedrooms:
Q Repai• ro �1alFunccionin� System Will cherc be a basemenf.� ❑ ycs ❑ uu Ub'itli plumbing fixtures? ❑ yes p no
r'JN�n-Residentia!
T�pe of businzss: Tocal 5quare tborage of Buildiag:
��Iaximum �u�nbecoi employees: _ Maximum numberofseats:
5) Water 5upp1�•: ❑ Nzw well U E�isting Wel! ❑ C�mmunity Well ❑ Public Water ❑ Spring
Are thcrc any cxisting wells: spririos, or txisting watzrlincs ort this property? ❑ yes ❑ no
6) If applyip�; [or `Aut6orization ta Construct', ptease indicate prefcrred �ystem type(s):
CI C:oo��anc�onal ❑�cczpred ❑ lnno�ativc � Alcemacivc ❑ Ochar ,_ ❑ qny
�! ceriif}• thiu the irr{p�•mcuio�r pruvided abov� i� co lele Rnd c�nrrc�4�r. lul.,v, understund that ifthe information provided is
� iuu� curute. or i!r � c' . is subse ntly alr , o r ' rendecl uce chcrnge.s, a// permirs c�!d approvals ll im�alid
-- ---- - . - - - �'s
Si�naturc (Uu�ner' egal Itepr�sentativv*) ate
� S�ipponinG ducumenta�ion �zquircd.
• Permits are valid for either 6U months or �re aon-expiring when accompaoied by an approved plat.
• � complesed 'Lot I�separation' form must accompany any application reqairing a site evaluation.
( I G�1: i P�rson Count�� Em'ironmrntal Heai�h, 32� S. !��loc�an 5�., Sui�e C, Roxboco, NC 27573 (336-597-1790)
ConnectGlS Feature Report
� _ ���
',4'EP. H�:�TI^I�_:
��� �1�: 9 2�- /��/
�/•
P�9180�1 COUf1ty E�rotM18f118� F'�1
32.5 S. Morgan Stn�eeR
Roxboro, NC 27579
�f�'y' �
��is �l�G��'Y��� � ;�,
�
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Page 1 of 1
�G �t2�! r �""
Person
Printed May 11, 2016
See Below for Disdaimer
�/� �5,��� ����,��.;� �,
�I/` loc� �
Total Lenath: 2?5.�� Feet
3Ene.56 Sq Feet
� g:3nG c�r.G2 .:,::re�
or Sq. h•9iles
- : fi0 Feet
�TICE: Recentiy, we have had several users report browser compatibiiity issues when trying to access our GIS website. Typically, ihe problem stems from users wno ha
wntly upgraded to the Windows 8 operating system or a new version of lnternet Explorer. We were able to resoive this issue by directing users to the Internet txplo�
>mpatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet explorer/products/ie 9/features/compaiibility-vi�
this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has be
epared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system �
rtified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, GonnectC
sume no leqal responsibility for the infurmation in this rystem Grid is based on the NC state plane coordinate system, 1983 NAD.
htt�:,',�gis.pe�soncounty.7et/C�rnectGIS_v5/Dow°nload��ile.ashx?i=_ags_mapb698 �a3b6;; �
�
5�'1 1;?015
��` i +�f ���� ��
� � ����
I�+ �rawn�r�aairua¢3nad<m.Il ���a.Il¢Iln.
Tax Map: � Parcel: / �
Subdivision:
WELI, PERMIT
(New 1� Repair_)
Lot:
Applicant's Name: �
Mailing Address: �1 G^/ , ,�j.
. �
Phone Numbers: ��� -�ly ��-t�s��
Location of Property: .�/��,�y�� �%/PpD��r� ���i� !� y-C�� fI ,�.
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 permi£ does not guarantee a potable water supply .
Other Conditions/Comments: /!��si n w/n � Ld��l ����rc �'�.���.� - 1'�
Permit issued by:
(�New Well:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
S/Date
�,ZZ�Itc
--�6�-�'��
Date: r 1 � ,�_
Certificate of Completion
Ol,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
Well Driller: parne�P License #:
Pump Installer: License #:
Approved by: Date:
Additional Comments:
Date Sample Collected: � % Date Results Mailed: �% /�,
EHS: L�,
��.
Person County Environmental Health
325 5. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 il/26/13
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
P.O. Box 28047
4312 District Drive
Raieigh, NC 27611-8047
httn://slph. ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH LEASIE HUGHES
325 S MORGAN STREET
4415 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES082416-0036001 Date Collected: 08/23/16 Time Collected: 11:30 AM
Date Received: 08/24/16 Collected By: H Kelly
Sample Type: Raw Sampling Point: Well tap Well Permit #: A24-158
Sample Source: New Well Temp. at Receipt: 3.5 GPS #:
Sample Description:
Comment:
New Well I (Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Cadmium
Calcium
Chloride
Chromium
< 0.005
< 0.1
< 0.001
47
8.40
< 0.01
C�II�7
< 0.05 1.3
m
�
�
Fluoride < 0.20 4.00 mg/L
Iron < 0.10 0.30 mg/L
�_..� � n nn� n n1� mn/I
Magnesium
Manganese
Mercury
N itrate
Nitrite
14
0.038
< 0.000:
< 1.00
< 0.1
8.2
< 0.005
0.05
0.00�
10.0(
1.00
0.05
Silver < 0.05 0.10
N/H
m
Sodium 20.00 mg/L
Sulfate < 5.00 250 mg/L
.,
ness
170
Vanadium < 0.001 mg/L
Zinc < 0.05 5.00 mg/L
Report Date:09/09/2016 Reported By: Deddie .�loncol
Page 1 of 1
����
.,,������1TFl "
nc department
of health and
human services
� � {s�t t r �� �sx �; '�x � � i� F s;�... � y S! �,�.� �� t„� ��.-t m,� �y �m s;. � ��.t �^y .
5 � ?y r 5 ;�
. Y 1 �£ i # �3 � � � � +�$ � 1 :i E9 �' �I� � Fi i � ir �
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�a � t �
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Y� , ^ '�a� i .,, �1 �� ( t, iv iz t ��wx�s F � �,+":. � 4 �i £ � � �.::;�,.
.�. . . � rc., h -�..� ��,,..� �.�. �. ti �...� w�` ��: � ,3 � � ;� �' x� �Sz � m .: �d ��� . � ��ff .� ;,& -� :�%
Fo� lnorganic Chemical Contaminants
County: �j Name: —
Sample ID #: � Reviewer:
TEST RESULTS AND USE RECOMMENDATIONS
1. [�Your well water meets federal drinking water standards for inorganic c/temicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inorQanic 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 inor�anic c/zemical results onlv.
Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron
Man anese Mercu Nitrate/Nitrite Selenium Silver Ma nesium Zinc H
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
tlie ii:orQanic c/iemical 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. ❑ 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 I S minute sample at the well 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,
cooking, 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.
Barium Cadmium Chromium Fluoride Iron Ma nesium
Man anese Selenium Silver H Zinc
For n:ore injorntalioit regarding your we!/ wnter results, please call t/1e Nort/t Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health 3�12 Di trict Drve
Environmental Sciences Raleigh, NC 27611-8047
htt�://slah. ncaublichealth. com
Inorganic Chemistry Pnone: s,sassasos
Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
LEASIE HUGHES
4415 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES090716-0006001 Date Collected: 09/06/16 Time Collected: 2:00 PM � _
Date Received: 09/07/16 Collected By: H Kelly
Sample Type: Raw Sampling Point: Well head Well Permit #: A24-158 �
Sample Source: Well Temp. at Receipt: GPS #:
Sample Description:
Comment:
Hexavalent Chromium (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
Hexavalent Chromium < 0.05 0.07 ug/L
Report Date:09/13/2016
CAMA = Coal Ash Management Act
Page 1 of 1
Reported By: Deddie .�Kancol
WELL CONSTRUCTtON REGORD
This fam tan be aud far cingle or multiple wclk
t. WdI Coatractor [aformation:
` ` n
�L?�C.1� �i! � ��_Y � Cl (�
w�u co�do� rr„M
3 3 `� --�
xc w�u c��c��u� rc�
Barnette Well Drilling, Inc.
Compaay Name
2, wat.Consancsoo eu,u�i a: � ��
Grst dl appftoab4..rell eonsuuuan Per,vitr (t.e. Gnmry, Srmti �'atim,c� ucJ
3. R'dl IIse {eheck woll use):
WatexSupply Wdl:
Qp��� aMunicipaUNuhliC -
aGeothumal(Heating/CoolingSuPP�YS �tsidcntial.VVatcSnPP�Y��B1e)
QlndustciallCommacial ORcsidwtial Water Supply (�)
Noa-Watu�
QkqeifaRccharge QGmltadwataReniedia[i0n
❑AQ{lifPt $LOCdgC 3RA KOCOVGj . OS3IIR1Lj� B8['C1CC �
❑AquifaTesE �StocmwaterDrainage
❑ExperimeataiTechnotogy � �SubsidenoeContml
OGeOthe�mai (Closed Laop) �'IYaac
rtr.r„N,r::;,alrtiear;no/c'�nlin¢Kr.hiinl ❑Othrr(eimiaiumder#2IRem�
�.bat�R'di(s)Comp[cted: '� � Wdlm# �' �=
Sa. WeA Lotadun:
L .�,-� X u-�J, �-�
FaafitylQcvnerName � FaaliCyIDB(ifappliablb)
��/�/�? K� �- �'vi�Gl ���i�-�
Plrysieal Addtess, Ciq'. and
� �� �
�'f� T � c�! /I.i �
�,ty Parul Idrntifiaiioallo. (1`IM
56. Lafitade aad E.ongi[udein degrtts/mirptes/sesonds or dscima� dcgreex
(�fwc,11 fid4 a�e larAous is sa�icieat)
3G 2�3— c�.S'� rt %`i � -�6.� �
6.�Is(are)�cw,eU(s): G@�manwt. or �'I'ea►porsry
7: Is ihis.srepair to an uisting;weU: OYes or �
if dvs i,r a rep�atr, fr![ om�bww+ well conrupaiai i�rnraum qodupl6:n r//e rmnor ofilx
sepa'v+mders2l rrmarlasurionnrartlx.bockofdds�l'otm_
8.:NamberoPwdlseonstrveted: '
For multipTt inJectFor� or noa-svarer sryqily rells ONLYwirh thesmne eaafiadioa: }+ou opr�
srd,mrtonejo+�++. ,
9.Totst�we�ldtpt�below►nndsadau: � ��% ��t�
�'ar aadtiple we!!s lat all depdar ifdr�ereri[ (uOmPle-3�2� �iond Z�LW'i
I0. Static R'ater tevd Bdoxr toP of casing: �`� ��� 161T Ma�1$ernce Center, Ra1ug�, AC Z7699-1617
/fttvlerlevN isabavb cttsia$, icAe "+�
11. Bore6ute diain�ter_ {ia) Z4� For Ibitctiue=VReLLt fn additi� to saidiqg du fotm to 1he addceu m 24a
� (L �bove, also iubraiE a cngy of thic foad withnr30 days of bompletion oE a�ll
LL Well canscrnetion mcthad:, �L-/ �/�,Q T a n`y �rai to tfie followm�
�i.c aug'x. totaz�'. eablc dirod posh. eta) T--
Divisiodaf Water QualitY. Uud�rg�vand.Injectiou Coutr�ot Pcognm,
FO� WATEIi SUPPLI' R'ELIS ONLY: 1636 i4tul.Savic� Centa+ R��h, NC 27699-16�6
13a.'Yie[d m. �G- � Method aftak BIOwn20 minute 24c �atli��te� SuuW9 Bc.Iniectioa �Vdir. In addition to stndin8 the foru► to
(gp ) thm agd�ess(,�S) sbov4 slso sub�niC one eopy of. t}iis f�in wit6in 30 days of
eompldion d€ wdl to��trttctioa to du cdunty hialdi dc�aRmait of tl�c county
i3�. v�r«aaa �,.� HTH ,,�,a�t 1�2 Cup ��
Fa Idemal Use ONLY:
, Zrc Se' l d , v=�
�rc ���jrc � �
a�x c�sn�rc �,:�a�a Rat� ;oR
� '�'O DLAM t
� t� Z N. f. �. ,
INNER CAStNG-OR-TIIBINC miLeiriial'�
IM � TO DIAME['E6 l
[t. R- io.
E� 2 m
,. ::-;_
SCREE�Y . :. :. : -_., . , . :
� m ow�ereR st.ora
ft R �
ft ft �-
, _ ,.:_. , _ ;
G1toUi'. - .
)M TQ NfdiTRUL � .
� k- ' , O�' ° ent
fc �
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SAY�DIGtilC'4�L'PAGTC .Cajib crsbleY : _� �-
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it r�--
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rG t �.
2Z Ctrtit"�eatiun:
���L'-L2r�'":t � � "' '�
Sigaumcoff�fified Wdl Camcaaoc ���� �. �
�y sr`gMng,Gtrin.,r,. ! herrbr cerr�y dwr rhe.,rea(� »,os (werel aoruora�d in aocad�t .
vfdrlSA NC(C 02C.0I?O or /i4 NCAC OIC.BZOO IPcJ! CastivuloicSYariddrdr mid rh�la
�?P1'9r%�{k le?�rd 6nrbr�bpw.vAfed m die xetl orxer.
23.5'itE �ot Of's�ddiltioaa� WC{L dtta�lx: �
You m�y ust ttie bai� uf rt►is pa�c ta p�ovide. adilit�onal wdl. sito dttanls ar wcll
i�istruction dda�ils. Yon may alsd.attachadditi0dal pages if i�a�i.
5UB1tii�AL IlVST[7C�70N5
24a For Ail Wdl� Submif this-fotm wittwt 3U da3rs of Goinpldibti of wdl
cdarstinttion tothc foliowivg:
Division o[WaterQnalitf, Luformatioo Processiag Usi4
�
Fam GW-� ' � North Grtiina Dcpu�neatafFavimnmeot aod NaCmal Resoaoes-Divisim of WucQinGty RevisedJan. 2013
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �u� ►�+-y� -
Address ��ls /VI.�� ti��� �i.c �� County
t�.cl'
Collected By ��Z,t �.�_
Date Gollec#ed � , /�� �! �_Time Colle6ted Z✓ = �D
Source: dNVell ❑ Spring ❑ Other
Location: ❑ House Tap Ia' Well Tap ❑ Other
❑ No Charge ❑►�harge
..............................................................................�
*********************�***********************,�***************,�************�*
Total Coliform
Fecal/E. Coli
Resu�ts
Present
0
❑
Reported By
Date Reported �� + � �` �
Report Called o YES o NO
Called To
Absent
�
.
� 1l
� �., �
��� �+ �l/ � �./ ���
��a�n�on�nn�nca��a��.� ���.���in
Date: // l ?� / l�o
.,i .s':�
• � � - i �� �
i
. p, r.v. ./ I
Re: Bacteriological Test Results
Dear Well Owner:
Tax Man:� Parcel:�
Your well water was sampled on �0 /�/l�, 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.
7ota1 coliform bacteria are naturally found in tl:e soil. Fecal coliform ha:teria ar� a�so�iated s�:tl:
an�mnal and/�r human waste. The presence of either total or :ecal coliforr.i bacteria 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 samp[e, the water
may not be safe for use. Young children, the elderly, and the individuals with compromised immune
systems are especially vu[nerable and their physicians should be notified of the test results.
A well #h.a! tss!s positive or total er fecal celiform bacteria should �e 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, piease coi�tact tt�e Health Depariment to request a re-sampie.
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,
��
Environmen al Health Specialist
Person C�ur.ty H:,altr Department
(rev. 4/20/16)
Person Co�n.ry Er.v:renmental Health, 325 S. b4organ St., Suite �, Rcxboro, NC 27573, Phone: 33u-579-1790, Fa�t 336-597-7808