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A24 4B� y4 z �. 'Person County Health Department � Sewage System Improvements Permit Date:� 1D�� This Permit Void After 5 Years Permit #'��"'��'�` Owner: a �! e ,�TY�� _�T SR# Subdivision Name: Lot # Lot Size: s �Type of Dwelling: Water Supply: Private: —L� Poblic: Community: Bedrooms: � Garbage Disposal Basement Basement Fix es INFORMATION CERTIFIED BY Environmental Health Specialist: r or re��e� '�e REPAIR: REEV UATIO : Size of Septic Tank: ��a0 gallons Size of Pump Tank: Nitrification Line: � � � Depth of Stone: 12 inches r � Ye Maac Depth of Trenches: -� �' Altemadve System: Conv. Pump PP Pump . Date Well Approved: ��Well should be 100 f� from any sewer system BY �_ Enviromm �tal ea Specialist Date Se � e s proved: I BY Environmen[al Health Specialist ER CATE OF COMPLETION ,� Contractor. �$,�,Gj i S � -------------------------- � � � Sewage System location, installation, and protection must meet state and local � regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tar�k and ni?rification line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to redocation. � (G.S: 130 A-335F) _ . Location of sewage disposal sewage system sketched on back. (OVER) _ . _ w 4 FtOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located � � � - �� S'%�#' I 3 3 � T ��J S� f l'EKSUN CUUN'1'Y GNVi1tUNMGN'CAL I�G4L�C�� WELL LOC . , . - D�dKu�t� t�.�.lbl Date:g-��TE 2P Et�.. _ SR# � ' �wner: �� , � Loca�ion/Directions: , , c,.�„r..,,�,.,., rr., � ..��„ Drilling Cont�actor: � WELL CONSTRUCTION � Dist:u�cc from Ncarest Properry Linc Distancc from Sourcc of Pollution--�� ,/ Total Dcpm:.�5�.1— Ft. Yicld: : TZ GPM Static Watcr Levei Ft. Watcr Bearing "Lones: Dcp[h Ft. FG F� Fc. Casing: Depth: From�_to��Ft. Diameter:�inches TYPE: Stcel Galvanized Stee] ✓ If Scccl, does owner approve: Yes No Weight: Thickness: � Height Above Ground: Inches Drive Shoe: Yes No Wcrc F'roblcros Encountcrcd in Sctting thc Casing? Ycs No IF "ycs" �ivc : c�on: Grout: Type: Neat Sand/Cement ✓ Concrete Annular Spacc W idth ��. Inches Water in Annular Space: Yes No Method: Pumped Pressure Po•�ed ✓ � Depth: From � to�_F�• Materials Used: No. Bags Portland Cement Weight of 1 bag__lbs. If mixture (sand, gravel, cuttings) - Ratio: �o ID Plates: Yes ✓ No -: z :: slab Ycs ✓ No I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. _ �-�5 Signan:�c of Conva � Datc ,�ooiicatfon Date. '� -�"U � �lmourrt Paid. �1�� i �: __ 2� (.:1'" �'— Psrson Cauniv lieaith Deoartme� Environmentai Heaith Section APQLICATIOPI FaR SE�VIC�S �ax �ao � �� P9r�d #: � Y� IF_THE INFORMATTON IN THE APPl.1CATiON FOR AN IMPROVE�IIIEiVT PERMIT IS FALSIFiE�. CtiAPIGE�. OR THE SiTE 1S ALTERm. THE�i THE IMPROVE�AE3dT PEi�MiT AND AUTHORIZATtON TO CONSTRUCT SHALL BECOME INVAUD. . 1) Permit requ�ted by: (Ownerla er�prospective owne�: '` Home Phane: -� Address: - -d,�� Business Phane: - �/b3.� -� � � Name and addrEss of cumerrt owner. 3} Property Dexrtption: t�t s�ze: �'�� ownsh� Diredions to the property (Induding road nar�� 4) Proposed Use and Structure Description: answer eacf� of the foilowing questions: a) Propose�� E�asting ❑ � b) � S�dc Built �, Moduiar Q� Single 1Mde q Double Wide ❑ ' c) Number of Hedroams: d) Number of occupants or people to be senred: e) Basemer� . Yes Q,. No C�1f yes, # of bassement fatu.res; • : -.-- ,-, - -. ..,. _ _ . _. _ � Garbage Disposai: Yes �, No 8' S�6 �'0. ,� `� � yj Dimensions of Proposed StruQure: Width: � Depth: j3,Q � � � 5) Wai�eer SuPP�Y =YPe: Private �(new Q or�e�dsUng �)� Public Q. Cammunity a, Spring-� . Are arry welis on adjoining property? Yes 0- No Q if yes� loc�tion 6) Please Indlc�te Desired System.Type: (systems can be ranked in order of ye�ir preferenca) Comrerrtlonal _Madffied Comrenttonal _ Altemative lnnovative Other (specify): � . CL�ARLY STAKE ALL CORNERS AND LtNES OF THE PROPERTY. STAKE THE CORNERS OF�ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR S1TE PLAN TO Tii1S APPLCATION i hereby make appGcation to the Person Caunty Heatth Departrnerrt for a site evaluafion for the en-siie sewage disposal system for the above-desaibed property. i agree that the cortterds of this appiication ane true and represerrt the maximum far.iTities te be ptaced on the property. 1 understand if the site is altered or the intended vse changes, the permit st�aU bec�me invalid. I understand that as applicarit, I am respcnsible for identiiying and maddng property lines, camers and maldng the siie aa�ssible for the personnel of the Persan Courrty Heatth Departmerrt to condud thear evaivations. I understand that I arrt respansibie for nofiiying the Heaith epartmerrt ifi my pra erty ca ' s wetlands as designafed by the Army Corps of Engin Ovmer or Legal Representative � .PCND, rev.la!'12J99 ,\ Person County Health Department Existing Sewage System Report For: Mobile Home lteplacement �ddition � Etequestee: �T � �/v lM'1��. Home phone# �9�— _� �7 � r � S ` � Business# " / l Location/Uirections: Tax Map# � �! e� S ��/ G�c� � � Original Permit Located Septic System Uesigned r'or: 3�G �� _ Kesidential _� Business Other (specifyj # f�edrooms � # Employees Other _ � � llate lnstalled �� Water supp y �%tl%� � 'Pype or 5ystem. � / Nitrification Line � �D � x� Tank Size C� CJ v Certified Operator Required (v O On site wasL•ewater disposal system showes no visually apparent malfunction on �/� l� / �: , Yermission is granted tos n �u�-2: � � � According o the attache site plan. Comments: �7�f � e� ` 1.� � 5�'f� �-r-A r,/� -�'ro r; Environmental Health $�C.. o'x3a' � .. "t `� -r �.:-r-��'•'�.�=�_,��".�_`` . .. - . _ .. . � � . . - � � 0�0b �'1.\ 00 � . - . . �� assal . --- N r _ � Q . r � 'P;�.w �� .O � i� J �4 f � �/ w, �f� M, , � � 80, s �� v: � �bZ.Q� ,�9,� � �' � Z I y � � �n � .�FZ i �' .,.:.,. ss � /9.S � � -•.;.: ; � .y-� ; � .,.` t3c it r: r rs : `L` �i54 N.i 0.1A1�� . � � . i.�.��'L'2 °V:,,� �/' Y .l y'�� . ' � `ti � 5.�� i t:. F'. '��v��,��t'l.. F i`\ / ./� � �F`~'4M ~ �. � � . �� 1. �� . �� )�A.y"/�' ' �.4 . � � � • ~V.. `� y& + 1`�,`��-�' `, '"'�.� . `''� , , . ! i .�� . �.,� ,, S� �•, � ��y :� K d::h"" � . , � r� . _ , 'r. �� r�, .,_ a � � I �e k \�, �' n31 �ti' ��.. .�,�' . j' .t,.� . _.J . .y��. . ,' d f Ce y t� � ` .!d '' . - � . r� . . �iF . �_�M'� . `�.<j .� � �� . ' ,�.. � � � 9 ""k - �.i � �� .._ ,. , � .�,� `��..� w� � ��` � � �� 'anl�� , '��` y y ,«}j i a , � . r t �� 1�£y� : r � .. ' � c _ e . 1�' . � _ .. �•.^�4.. ., t , . - . , • . . y�..... ' . . ` ' - �' ;. � J �; t r . ,. � :�.�n fr .� Person County Health Department Existing Sewage System Report For: Mobile Home Keplacement �/1�ddition ' Requestee: ��f/1J W . ./�1�„r^�_ Home Phone# ��— � ��9 ��j�%� ,,! / � � `i S/%1;'f ! � Business# "- I l Location/Uirections: `Eax Map# � �.P��,��1 �� Original Permit Located Septic System Uesigned r'or: �� U� �� Kesidential � (3usiness Other (speciEy) # I3edrooms � # Employees Other _ Uate lnstalled - �� Water supphy �,�r t1� �'��i�� Type of 5ystem Nitrification Line Tank Size ��irQ�i►:r►.�� ri Certified Operator Required (vQ - On.site wasL•ewater disposal system showes no vlsually apparent malfunction on .7 / � [� / ,.: Yermission is qranted to: .- t < <� (1 � According Comments: �� ' > the attache �� _ � �� D � �C 3a � �o�, site plan. ,b ��oQ� �� Q� m Ettvironmental Health $�C.. � J ! � �., � �� `C� �/ � �.J l V � � ��n.�nson�an�nra��a��,� ��Il�I%n. Date: _�/��/� : / • � �" ' i/ ! Lr ,! iry.�.�i � C Re: Bacteriological Test Results Dear Well Owner: Talc Map:'�'�Parcel:�� Yaur well water was sampled on �/�/� and tesied 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 col�f"orm bacteria are naturally found in the soil. Fecal coliform racteria a.re asseciat�d :v:tr animnai and,�or human waste. The pres�nce of either tetal o: 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 col form bacteria are present in your water sample, the water may not be 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 or total or ecal c�lifor ,m bact�ria should be preperl disinf�cted arzd ; etested prior to resuming normal use. The weli 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 flus�ed out of the system, please contact the rIealth Department to request a re-sampie. For additional information, please feel free to contact Environmental health at 336-597-1790. Our offce hours are 8:30 to 5:00, Monday through Friday. Sincerely, �'�� L�� , Environmental Health 5pecialist Person County Health Lepar�ment (rev. 4%2U/16) Pers�n County Environmental Health, 325 S. Mcrg�,� St., Suitc C, Roxbor�, NC 27573, Phone: 33u-5;4-1 i9Q ca�e 33b-59i-7808 �� 1�'�� nc department of health and human services �, � �„'3 � Q, r s� � � a� � ,�+ t � � � � �� 1 � � iz �s'.�_ y 7a r� sz`�t 'k� +`°. wj'� �. 9"'� sts�a ^s i�ses'i ; r � € �� r�ww� +� :,a�.r � �� ttf .g �� e �n p� a 3a g :� j ii � i� � � r:, �,�,+"+t; �� ki w lt` r� '.`�,w.a t,�s �'.�r:. i3 �, .<S ,. „, ? � ¢i' e. �:.z� s; � i% � »:,x,�� e'::s � m c r ,, *� g � � k d' ' ,✓ ..,�' � °y. �•a � �''L � ` �. � �`4 v ,y`'�'� ,��' n �^�s { ^ ��`�1 f�T F� � � �� # i, � 1 �1 s� � � �� auaa � � r � a�� ;! � �, � '«� ��+.�;i -�,� � w ., ,� .» �.� �.4� .�� , , ��-� ,�� . .:E .� � �� a .. '�,,�a ��a �,� m �,� � � ��,� County: • ,2 v�l Sample ID #: Fo�- lnorganic Chemical Confaminants Name: � r pp� Reviewer: 1 TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic cl:emicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorQanic chemical resu[ts 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 wasliing, cleaning, bathing and showering based on the inorQanic c/:emical results onlv. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron Manganese Mercury Nitrate/Nitrite Selenium Silver Magnesium 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 the innrQanic c/remical results onlv. [�b. Levels over 30 mg/I 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 tl�e 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 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 resu[ts on[v, 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 iirformatio�t regr�rding your we!/ water results, please call tlre Nort/� Carolina Division of Public Health nt 919-707-5900. AUG-31-2016 14:31 FROM-HEALTH DEPT 3363226099 T-Z42 P.U01/001 F-681 ,• P�RS�N COUl�TY HEALTH DEPARTMENT 355A SOUTH MAD150N BLVp RdX60R0, NORT� CAErOLINA 27573 BACTERIQI.IQGIGAL WATER SAMC�LE ANALYSIS N�me of Owner or Ten�nt �,��Oc�� ,�G(, . . L{ County � Address � �- Go�lected By �- il�.U'�� Da#e Col�eated �%��%i�v _7ime C�llected �� Saurce: CY I�Yell D Spring ❑ Other Location: �use Tap �1 We[! Tap ❑ Other ❑ Na Charge �/Charge ■ a a a � s � � � a � � � � � � r � � � a � � � � � � � r � il � � a r � I a � � a s s i � � a z � s � � r � r � � a i � � � � � � M � � a � � � � � � r r r � #*rrr*ar##**�*�Wwtxs#*#�r*r�r*�rww***#�w,r**ict�r*ww,r**#*f**�e*wx*�F*f�*wwxx##tf*t*rerr�e T�ta1 Califarm Fecal/E. CQIi Results P�esent � Reported B Date Rep�rted Report C�f[�d ES ❑ NO Catled To �' • � � �' � Absent ■ ., North Carolina State Laboratory of Public Health Environmental Sciences Report To: H. KELLY Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: FAYE WOODS P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 4591 MCGHEES MILL RD ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES083116-0051001 Date Collected: 08/30/16 Date Received: 08/31/16 Sample Type: Raw Sampling Point: Outside tap Sample Source: Well Temp. at Receipt: Sample Description: Comment: Time Collected: 2:30 PM Collected By: H Kelly Well Permit #: A24-46 GPS #: Hexavalent Chromium (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Hexavalent Chromium 0.18 0.07 ug/L Report Date:09/12/2016 CAMA = Coal Ash Management Act Page 1 of 1 Reported By: Deddie .�lanco! Report Date:09/12/2016 North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis CAMA = Coal Ash Management Act Page 2 of 2 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Reported By: Deddie .�tonco! � f "� North Carolina State Laboratory of Public Health 3012 Distnc Drve �Environmental Sciences Raleigh, NC 27611-8047 � htto://slah. ncaublichealth. com � ti.�R , Inorganic Chemistry Phone: 919-733-7308 "cc� �,,,� Fax: 919-715-8611 Certificate of Analysis Report To: H. KELLY Name of System: PERSON CO ENVIRONMENTAL HEALTH FAYE WOODS 325 S MORGAN STREET 4591 MCGHEES MILL RD ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES083116-0052001 Date Collected: 08/30/16 Time Collected: 2:30 PM Date Received: 08/31/16 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A24-46 Sample Source: Well Temp. at Receipt: GPS #: Sample Description: Comment: CA Well Monitoring (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Aluminum < 0.500 3.5 mg/L Antimony < 0.002 0.001 mg/L Arsenic < 0.005 0.01 mg/L Barium < 0.1 0.7 mg/L lium Calr.ii�m romium balt Copper I ron Lead Magnesium Manganese Mercury Molvbdenum Potassium Selenium < 0.002 < 0.1 < 0.001 74 27.00 < 0.001 < 0.001 0.01 < 0.10 < 0.005 41 < 0.01 < 0.000: < 0.010 < 0.01 8.0 3.34 < 0.01 50.70 0.004 mgi� 0.7 mg/L 0.002 mg/L mg/L 250 mg/L 0.01 mg/L 0.001 mg/L 1.0 mg/L 0.30 mg/L 0.015 mg/L mg/L 0.05 mg/L 0.001 mg/L 0.018 mg/L 0.1 mg/L N/A mg/l l�! m m Strontium < 0.5 2.1 mg/L Sulfate 58.00 250 mg/L Thallium < 0.0001 0.0002 mg/L Total Alkalinity 357 mg/L Total Dissolved Solids 410 500 mg/L Total Hardness Total Suspended Solids Va�adium :' Zinc 360 <5 0.0077 0.000 < 0.10 1.00 Page 1 of 2 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant �,�,�od'[7 � Address ��'11 �c��S nll.� �j County �t�'-�2� aJ �-.cj. , Collected By -�t- 1��1�—�/ Date Collected `��oli�o Time Collected 2� � Source: [YWeil ❑ Spring ❑ Other Location: �louse Tap ❑ Well Tap ❑ Other ❑ No Charge Charge ..............................................................................� ******�**************�*********************�******************************** Total Coliform Fecal/E. Coli Results Present � Reported B Date Reported � � � � � � Report Called ES ❑ NO Called To � • � �% �b ❑� Absent