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A24 181_�� s� ��.�� _ '��--�' �� )�ysu-a�a�r��raTmm ��rn��.� ��,�� Tax Map: �2 Parcel: � $� Subdivision �p Phase/Section/Lot # � Permit Valid for: Five Y ars Type ofFacility: �j� S. Number of: Bedrooms 3 / Occ Proposed Wastewater System: C Proposed Repair: ; ,r' Improvement Permit Non-expiring � New � Addition �Employees�_/ Seats: Permit Conditions: �-� �j `� ��C'� � � Water Supply: (Ne� � Projected Daily Flow: 3!'v a, �a�llo,ns/day Type; �q— Type.�-q _.� Authorized State Agent: � Ir✓�.� Date: ?�C�-(�- (X) Owner or Legal Representative.�,�.�� -� Date: �- Z`�-�(,o The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicanbproperty 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 North Carolina �Laws and Rules for Sewa�e Treatment and Disposa! 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 supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Propos d Wastewater System: �✓►�p �p/�� i-5� �(*)Type � Design Flow 3 6 � gal./day New i� Repair _ Expansion — Soil LTAR. •�o gal./day/ft2 Type of Facility: `3 ►� 1� (Z,PS • Basement: � Yes _ No (*) System Types Illb, IIIbg, IV, and V, require periodic system inspections by the Person County Nealth Department. Wastewater System Requirements Tank Size: Septic Tank �� gal. Pump Tank S ��gal. Grease Trap ` gal. Drainfield: Total Area Q�!� sy. ft. Total Length 3 d� ft. Max. Trench Depth � in. Trench Width � ft. Min.Soil Cover rP in. Min.Trench Separation � ft. Distribution: Distribution Box / Serial Distribution / Pressure Manifold � Specifications: 'j-2� �/� � S�-e� � Authorized State Agent: Issue Date: 7`-«"� `� Permit Expiration Date: '��(�� The system permitted is: Conventional /Accepted D� / Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: Date: "1�2`i �Ito Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) _�— — / 1 DRAINFIELD I LOT 3 �� l�e � � �:� co� ` � �I( S� � �K �-za-c �� - .__---- ,- � � , - ,� �Q P��t`EN _ � — a� ��~ 1 � / SEE J ROAD DATA �- / NOTES PUMPLINE TO DRAINFIELD 2A. SEE PLAT CABINET 16 PAGE 491-496 FOR PUMPLINE DATA. 3"PUMPLINE INSTALLED FROM LOT TO OFFSITE DRAINFIELD AND PREVIOUSLY INSPECTED BY THE PERSON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. REFERENCE IS MADE TO THE RESTRICTIVE COVENANTS RECORDED AT DEED BOOK 856 PAGE 428. 3" PVC CONNECTI4NS SHOWN ON THE LOT AND DRAINFiELD ARE APPROXIMATE LOCATION ONLY. WELLS MUST BE 50' MINIMUM SETBACK FROM ANY DRAINFIEID AREA OR SEPTIC FUMPLINE EASEI�ENT. WELLS MUST BE 10' MINIMUM SETBACK FROM PROPERTY LINES AND 25' MINIMUM SETBACK FROM THE BUILDING FOUNDATION. ESTATE ROAD VARIABLE WIDTH R/W (PRIVATE) �'�, � �� .� �uS � l0 � �tx�d-�►��- �i ►��L � ��Kqq,e eks � `� t (o �,�� (�►��C Sv' laK� << . 1�� ss� ��.�. ?� �j (�Y �%tAr►� � I ✓l� �D /�'ir ✓l � ��'�P � � � `� � 1 � � G r1 � `�' �i A✓t i'� C� � S�Sln S�'�'e �1'S � j� P INSET DETAIL DRAINFILED LOT 4A SCALE 1"=60' 31A 12' PUMPLINE EASEMENT 133 — _/_ . 1A � m !1 1 Uv—�-�.C�j �Yi � . 4A �� 30A � �C E 0 _ _ _ _ _ _ _ _ _ _ _ 15�PUMPL INE_EASEMENT _ _ _ �ir�ssu►-�e � Ntatn i �d �Q � . � 4A DRAINFIELD DATA / L-121 S03°44'36"W 64.15' / L-122 S06°43'13"E 32.82' L-123 SO4'41'S4"W 23.52' L-124 S10'32'46"W 21.1t' L-133 N88°06'15"W 71.70' L-134 N21°38'47"E 88.76' L-135 N86°18'20"W 26.82' L=136 S56°31'54"W 33.51' L-137 S72°50'21"W 37.98' L-138 N19"05'02"W 60.13' L-139 S32°05'S6"W 36.06' L-140 N88'32'06°W 136.60' � J � ��.� ]��I��.�T . .:. :�:�:�� ]E�;�•o��;��! a3[�mfl� � . :'�.;::,�< �•' • . �ob �o . . .,, �:.�� x . , Naalc Tax Map # Patcel # ��..::.:.: x ��S�ib.' o : .. Sectiofl/Lot# 1luthori�ed State Ageat Date S,ysten� co�jl'mlerrrs �iveaent ap1brvxinurle�conrours only.' The confmcMr �nrrs{�lagthe rystempriar io 6egenning ths msirrllahbn to iq'.s_r!rre ihdt�l�»pergnrde rs nwintaired 1 v �—��?� ) f �� I� �.�. a- � �. � � � ¢ �. Il I E- � � �, Il � Ta� �Ia �°� l Parcel # �g� P Snbdivision �QPS.P►nr� Phase/Secbon/Lot # ____�_ # of Bedrooms �3 Applicant: i?o � S� . ��' � Lte� o� � 0. viL � Location• s � �►uerat�on Permit System Type (From Table Va): Product (IIIg): C�a� � Type V& VI Expiration Date: Type V& VI Renewal Date: �g^ This system has been installed in compliance with applicable Nort6 Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. � �iw`�/ (Authorized Agent) IL� �-Q-t.vi 5 � , � � (�.icensed Con�actor) 3 � � p u.�,� � /ih.e r�� - -�- 7a' � Scale ItS �Z�-b P/� PCFiD, rev. 12/14/12 _ (�—� (Date) _��1 (Date) T a��s �- pum�� 1�� -}� Sln Yd �, �-��-�� dou bl� /��A�'l-2 Line r�� Z �c 3 r�-v � � 3 oa Tax Map: Parcel #: _ SepHc Tank System Checklist (Type II 1V) System Type: � h` � � l�ote�: ,S'� �1�ts l ?-5-t � w�-� (�� o ��''� �� • �. �' � �'� �.J 4 S � o l.u-�� cs�l (-�- �� ?-'2�c� i'� a �� aK A<<' sY s�e...t S�Y �.�e sn,' (�Cu�e %% L �e�e.�,fe� s�'��N, a��-e-tp �, � � Pump System Checktist 0 Contracted Certified Operator (Type IV Systems): 1Votes: %r'1 fl.s�— d�t- i�''r%� �A.t-e i� s/1� ��t�s�-�dC__ � y !"�� .( SP � Slr. WELL CONSTRUCTION RECORD ihis Forrn can bc csod for a�[e or mulaple wdls f. Wcli Con actar Infonnafioo• �-C � �/ 11 4J JE'yl�� WcU CmmactorYame � � y�� NC VJcI] Contactu CarificaCon Numba Barnette We�l Drillings Inc. co�y rr�o 2. WeA Corutr�ection Perrni't�i: �V z �� + Use all cppUcnblc ntp ronsuxruion permlu (t.e. Coraxry, Stcra Yarlouas, etaJ 3. WcII Use (d�e�k vrell use): OAgriCulEural OGeothamel [Eieoting/CoolingSupply) QlnduscriaUCornmucial Non-Water Snppiy Weri: QAquifcr Rcd»nrgc c ClAquiferSco�ageand Rocovcn� L7Aquifa%sc ❑Expetimcntai 3'erJ�nology QGeothermal (Clased I.00P) ❑Geat6ecmal {Heatin¢/Coolina pbiunicipa!/Public- mRt�`idrntial WatcrSuppIy {single} OResidenua! WataSW�P%Y (�) QGrvundwaitsRrmaf iation QSalictitp Barria OSwcmwaccr Drainagc �Subsidence Co�rol ❑Trdur �1am vnder�2t RelnsrSc 4. Date R'cti(s) Completed: f J� //��y R'eII TD# y �'�� 5a. Wetl L caiion• �o� �e�� Fuci6cyfOvnicr Naonc Facslity 1D1f rfagplimbio) Gai` � ��T ,.�.P��i+t ��o.tl�o/�O PErysicai Add[t,s, Cicy. and Zip Z,�� Sa�,s Counry Paresllde�m6ra rtNo.(PJN) For lntmal Use ONCY: I � SG.IatitudcandLongitudrindegrersJmiuuteslucondsdrdecimalciegrea: �y�r o: (i{vef] fie1d, ona latlloag u rufScicnc) . A �� • � � � N ? � �r ��ZW /� � �� Si wreofCctiSedWe1lCaavacur D S. is {src) ttremell(sj: L7t'ermsIIent or a1'emrotary By:lgnb+gthisfarm, [hereLr crrtrjy+3am U+e MellfsJ �(nrreJ corarnaued in occanla+u u�rb ISANGiC 02C.0100 or 15A NChC 03C.07R0 FYeI! Cc�atraetlon SYandaids w�d rhar e 7 Ia this a repair to �a ezisUag wdL• ❑Yes nr �o oopy oJrkls rrcord lras beu+pmvkdad fo �l�c w�e1! owncr If dris b a npair, /Fl( our kxown x�dl �ovturuc0orr informarion artd apfain du roture oJlhe rcpairy+rdcr�2l rcm�arla aer�7an ar on r!x bcckof drtsfore� ?3. fiite disgrlm vr additionai weil defaiFs: , You may use !he 6ack aEthis paoe to prm�idc additioual w�tl site dc�auls ar wr11 $. l�iambsr ol'�veIts cnrutractesi. � ednsUuction deia�ls. Yonmay eLsb attach additianal pagrs ifnectssary- For rnuitiplr injeuioa or nou-narer ruplsly �t•tUs ONLY�etrh the�re oofti0atfio8, ywaan �,yf o„��,Q,, SUBMiTTAL INSTUCTIONS 9_ 7'otal wdl deptb bdaw land anrfacc ! Lf � _ .{Et} Farmuitlple welfs ltsr aU deprhs �fdi�(fermr (amnpfe-3(n}10p' md IQ100'y ] 0. Sts6c tivahrhvel bdow bop of c�.ang: o,2a (ftj lfxatrr lavel is cba�e cnsin� r�re "+- 11_ Bprehole diametcr: �m) 12 Wdl construction mtthod: � � (i_a auSe. sotaxy� eable, diroet Qush, e�,) FOR WATEEi SL[PP[.1' R'E[3S ONLY: csa. sr�ta ($z.m� .�„�_.,� MetLod of tat ��awn20 minut 13b. Divnfectian type: HTH ��t 112 Cup Frnm G1� =1 7,4a. For All Wdtx 8nbmii this fnrm within 30 days of cwnpletian of w2fl w�uc8dn to the'fvll4wing: Divisiou of Wxtcr Qualit]. TuformaLioa Procasiag Uai; 161T MaiT &erv,ice Center, Raleigb, i1'C 27699-16! 7 24h �r Iniemon Wdls: Ta addition to sending the form to the add� in?4a abwe, also submi! a copy of lhis form withen 30 days oF eomp}etian of well canstruction to thafoltowuog: DRision oi Water Qaalitp, Uade�g,roand Injec6oa Control Pragram. 1636 Dial Servia Ceater, Ra4igL,1�IC 27fi99-1636 ]Ac. Far Nater. �uQplv & TniecHoa ZVeilfi in add�tion to sending thc form ta ch� addnss(a) ahav� a�.co submit one copy of lbis form within 3Q days oC campleIIon of well earutruaion co the eounty halth dq�tmeni of the caanty whrse wnstructr�. Norty Ca�ulina Dcpa�tmentofEcviiammea[ aad NatiaaiiLem�eecs— Divisim of Watu Qualiry Revis�d7aa. ZOI3 �'d �LZ6-869-9££ ou�6uill!a411aMa��au��8 dZ��6096 8l ��N ��.sf �I��.�� --�- � � � �� IE �� n u- � � � � � � �. Il IE 3L � �. ll �:II� WELL PERMIT (New� Repair_) Tax Map: � Parcel: � �i� Subdivision: �� pSp✓v� Lot: _� Applicant's Name: Y`jc�� OS 2 Mailing Address: Phone Numbers: Location of Property: � C�• �QY� �'r /'/1/I�PSYJU'r�4� �S�Pt �S C�1 �T � � /)'� Q, •� � a'f' �� Permit Conditions: V 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 Permit issued by: Certificate of Completion �Tew Well: E S/Date Location: // � Grouting: / 1 � � �' Well Log: !t Well Tag: �^t� Pump Tag: _L� Air Vent: �/' Hose Bib: li' Casing Height: ✓' Concrete Slab: L/ Well Driller: �p � _� Pump Installer: << Approved by: ►^, __ Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 l /i PS Date: ��'� QLiner: EHS/Date Depth: Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: �� `� Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 �� 70�.�- , � ,��,,�. �� , ,.� r \.,�---.�� .-.. � �-,,� � � � � � � Il-�,��-a�-��.,r,r,. ��.�.�,ll IL-3I��.Il�7�. Sloped To Shed Water NEMA 4X Simplex Contml Panel 4" X+�" Pressuxe Treated Post 12" Separation Electrical Coxt�uit =: i ' a`! . • ... b" Cover • ' � Access Cover• • , ' . . � 1 : . � • - .• � .'' � ' ' � = ; , •�`, '' , ; . �.. Opening Filled With Anti Siphon Hole� � Inlet From Se pti,c Tank Portland Cement Gmut (D Hill) A" SCH 40 PVC Pipa 0 I � T�x M�� P�rcEl # � Suhclivision ' �- � Ph��,se Sc�ct�ion`Lot # Duct SealHoth Ends Of The Conchut � 24" Minixrnun ,• .� Threaded Gate Valve • -- • -- � Zip Co:d Ties � • own Check .�,N; Valve R High Watex Alarm Level ' (6" Separation) High Level - Puznp On ;, �� rVapozLock � �� • � Ho1e ♦ � DrxNdown �Up Hill) � .1: � . Low Lav�el-Pump Ofi � . �� :• 5 P:ecast Concrete Taxi]c 4" Conczete � ;.; (MaterialStrength>3500PSI) Block ` �•�:• •� : ? •. . _� . ' : .' . : ' • • • ' ' '� Concreie Risex b" Separation • '•� ' . � %�..c/��" ��-Poxtland Concrete Grout . _: Mutu • - ; � Ope„'"9 Filled With Supply � : poxtland Cement Grout Lina � • ' Outlet To Distnbutiox 2" SCH40PVC Pipe g Float Wires .' � •r F7oats +.. �Removable '.:' F1oat T:ee � .� r � . �. . ' . � • L. .� .. � GAI.LQN PU11�' TANK �ncr�v�e �� .��. � IPI��.�� = � � �T�']�`� G�-e � �e � 1�� .�t ��.�t,� Owner: �- Tax Map: 2 Parcel #: ��l Date: /Zl �' "� I.ene Tap Tap (Sch) Tap �'!o� Line Lengtta &'�ow /�oot # i�aame�er(in) ( m) �;� (ft) i 3 �E n Z S o � � , z5 � �. 3 4 5 6 7 8 -� Z �e,�-1- 1�0 (-� 9 10 � 3� o ft of line x 65 gal. per 100 ft=� Q sd� --� ; 100 = � 9 S gal 75°lo x� gal = r`f � gal per dose �O gal per minute (gpm) = Flow I�ate �riction �ead � Loss: •�ft per 100 ft o supply line x'�" %`f a� ft of snpply. line =100 = 6' s ft � ��$ ft x 1.2 = ft of friction head � � Manifold Siae: � " Force Main �uize: � " PVC �otal Dynamic �ead =�� ft of Elevation head + 2- ft of Pressure head +� ft of Fricdon Head = �_TDH Pump I%quirement: � GPM @ �a • ft of Head � � Drawd�wn: �� gal per dose ;� ga.l per inch = s inch drawdown per dose 30 Ceuersl IBesign �forsna�+un �� :.. ..� :� hy ��s . , ,. .. i i i i �� i u� 1 1', ,.��,; - 9m� � — � _ � 1 1 � ■�c�»�o�c�o ��*��a9��'�� ..........._..........._.......... :� :�: Max No. Taps off one side duce b �s :or ta ' �oth 't8 S 3/a" tape �� 4 = 9 � 16 9 4U+ 22 _ � �,,, �P 2s-��a� . . • - . : �`iow er Tap 9i�.e iLlcn¢rial Flow GP1�t ?," Sc}ied30 �.� !, " Sclied 10 i•� ;r, " �ched 80 1 �l 1 =% �' cched ?0 ls".� �� ! � �.a � �..�� "`� �l./ � �.! �� n�n�n�onnn�a�na��.Il ��m,Il��a Date: �/ ?• / l � Name: ��✓ �O�f Address: � Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Pazcel: /�/ Your well water was sampled on `� /�/ 1%, 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 naturslly found in the soil. Fecal co[iform baoteria are asso�iated with animnaI and/or human wasie. 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. IJcoliform bacteria are present in your water sample, the water may not be safe for use. Young childrer., 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 totad or ecad coliform bacteria sho:sld 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. 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. Sincerely, .� Environme al Health Specialist Person County Health Department (rev. 4l20i 16) Pers�n County Environmental Health; �25 S. Morgan St.: Suite C, Roxboro; NC 27573, Phnne: 3?6-579-t 790; Fax 3?6-597-7gpR North Carolina State Laboratory Public Health Environmental Sciences f111icrobiology 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: ES080817-0089001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: BOB ROSE THE RESERVE LOT 4 SEMORA, NC Collected: 08/07/2017 15:00 Received: 08/08/2017 08:37 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://siqh.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Susan Beasley Well Permit Number: A24-181 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 08/09/2017 E. coli, Colilert Absent 08/09/2017 Report Date: 08/09/2017 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. �� S nc department of health and human services ��r�� :�� °�� ' �� For lnorganic C�emical Contaminants County: Name: � Sample ID #: � / Reviewer: TEST RESULTS AND USE RECOMMENDATIONS I. 0 Your well water meets federal drinking water standards for inorganic clte�nicals. Your water can be used for drinking, cooking, washing, cteaning, bathing, and showering based on the inorFanic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. 0 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 chemical results onlv, Arsenic � � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron 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/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 innrQanic c/re�nical results o�tiv. ❑ 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 15 minute sample at the well head to determine the source of the lead and/or copper. 6. �he following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorQanic chemica[results onlv, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to instal I a household water treatment system to address aesthetic problems. Cadmiwn � Chromium ( Fluoride � Iron Selenium Silver � pH Zinc For nrore information regarding your we!! wnter results, please cal! tlre North Carolina Division of Public flealth at 919-707-5900. North Carolina State Laboratory of Public Health 3012 Distnct�Drve Environmental Sciences Raleigh, NC 27611-8047 httq://siph.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: H. KELLY Name of System: PERSON CO ENVIRONMENTAL HEALTH BOB ROSE 325 S MORGAN STREET LOT 4 THE RESERVE ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES080817-0030001 Date Collected: 08/07/17 Time Collected: 3:00 PM Date Received: 08/08/17 Collected By: H Kelly Sample Type: Raw Sampling Point: Well head Well Permit #: A24-181 Sample Source: New Well Temp. at Receipt: 2.5 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Barium Cadmium ,._�_:..._ < O.OUS < 0.1 < 0.001 130 < 5.00 z.00 m ).005 m m 250 m Chromium < 0.01 0.10 mgi� Copper < 0.05 1.3 mg/L Fluoride 0.37 4.00 mg/L Iron 0.21 0.30 mg/L Magnesium Manganese Mercury Nitrate Nitrite pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness < 0.005 17 0.086 _ < 0.0005 < 1.00 < 0.1 8.1 < 0.005 < 0.05 15.00 220.00 N/A m m Zinc < 0.05 5.00 mg/L Report Date:08/18/2017 Reported By: Deddie .�tancol� Page 1 of 1 Application Date: � s � � � �� q -J � � � � �� Tax Map: AmountPaid: �OOd, OU ��D�. �� i��a� � Parcel#: Receipt#: C 4 3 i-4 I 7 6d �- c.i�`�k 1.5� i 6 C�+/ � o-� � � � �� s� ��.� ��T � � 2 �8. i � - = - � � e�F-F�s�� c� � 1�.��i��Y )�1��2 c-f�, �'e aa� n v� �ca ga �+-+*-�+ � ua d.:,zn.11 ��C a�.m.Il ��ia � Application for Services (Septic Systems and Wells) ��2�a�Y;,�"'�d- �� `'" t-�`La �Improvement 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) $3 00.00/$200.00/$75.00 Services Re uested ❑ Construction Authorization Fee is de endent on the e of s stem ermitted) 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Service �ques edb� — Name:�al�� \�.A`'t•'•`Jf� _ Phone#(home):33� c�C�-�.l�� Address: � `S �`�.,>, - L.r-c (worWcell): :�3 • , ��'� r , n�. � � O� 2) Name and address of current owner (if different than applicant): .AIOYI�� S�u��.wc� Name: �'S' G mr� " Address: � :. 3) Property Description: Lot Size: Subdivision: � Address and/or directions to Proaertv: _. _, 4) Proposed Use and Type of Structure: Residential �. Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes � No (with plumbing: Yes No _� Garbage disposal: Yes No `i� 5) Water Suppl�: Private Well � (Proposed� Existing � Community Well: Public Water System: . Are there wells on the adjoining properties? No _ Lot #: —�I 31 Yes '� (please show location on site plan) Note: A completed application must also include: ➢ A pladsite plan of the property that shows property dimensions ahd the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): <.- �� Date • �� ,�� 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � Z�_ ( �Q �� G�( � S� ��= � �j��\� �i,�� • �� j(1 h�a-� ' I �-�_ �