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A24A 11ApQiication Date: � � 7 � � . Tax Niao #� � � `� � Amount Paid: � RecEipt �: Parc�! �: l � •�,��: �� - - --_ � � �.T� � ]� �a:avaa-�a�a_---^�-^ �aa��.IL 11E'��.11�1�a APPLlCAT10N FaR SEiiVICES iF' THE INFORMATTON IN THE AP�L9C.4T➢ON FOR Aid IIlAPROV�ME�IT_ PEff�flAIT iS li'�CaRR�CT. F�1LS9FiEi3. C9;ANGE� OR THE S1TE IS ALTERED. THE�1 T�iE IflAP4tOVE1ME�IT PERRAlT_,4ND AaITHORI�►'P10N 'TO COPJSTRUCT SHALL BECO�tiE IMVALID. . • 1) F'erneit requesiecJ by: (Owner/agent/prospective owner): � �� O�� Home Phone: �� 3� PO7(7 Address: �l c� h Business Rhane: � �� Nc 73Y3 2j Name and addr�ss of current owreer. 3) Peoperty Descriptton: Lot size: �� a c r�Township: Subdivision: Lot # Directions to the property (including road names and numbers): �) F�r�posed Use and $tracture Description:,answer each of the following queStions: a) Proposed .,_,/Existing , Type of Structure: h e�k �d�,; � i.,g L-- Width: 1 3 Depth: �� , b) Number of Bedrooms: � �. Number of occupants or people to be served: _ c) Basement: Ye$_, No _, Will there be plumbing in the basement? � d) �arbage Disposai:.Yes � ' . No _ � 5) if�fater �upply.'Type: Private _(new _ or existing�, Publ'�c , CommunityJ Spring _ �/1Me any wells o�n adjoining property? Yes No _ If yes, please indicate approximate locatiori on the 'site plan. � . � 6� Does your pro�erty caniain girevi�usty identifl�d ju�sdl�oe�al wetEands? Yes_.., No_ PL�1�E NO"PE THE FOLL01A11P1G: 9 A PLAi OF 'iHE PROPE�ZTI( OR SiTE PL.Aid MllST BE SU�MI�'TED VUITN 'ri�IS APPL9C.�►TlON. 9 PROPEitTY LINES AND CORNERS N{UST BE CLEA6tLY MARKED. -, ➢ i'HE PR06?OSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGG�D. � THE SITE IUiUST BE RE�►DILY ACCESSiBtE �OR AN EVALUATIOPI BY TtiE HEALTH DE�ARTiVtE�JT � STA�F: � ' I hereby make application ta the Person Caunty Health Department far a site evaluation for the on-siie sewage disposal syst�m for the above-described property. 1 agres that the contents of this application are true and represent the maximum facilities to be piacad on the property. l understand if the site is aitered or the intended use changes, the permii shall became invalid. �_ � or Legal Representative �- 7 -O `1 Date PCHD, rav. 06127/D2 Application Date: a"� �'� � Tax Map: �T� Amount Paid: Parcel #: � �t-- Receipt#: �� _... . - - _ �� (� � �� ra-s nic-aan:a,•-k„ �c�,�rn�.:,m11 IL-3Ix-, w..71�]Ea Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) Fee is de endent on the e of s stem ermitted) � Mobile Home Replacement or Building Addition 0 Permit Revision $150.00 if site visit re uired $75.00 ❑ Wetl Permit (New/Replacement/Repair) � Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $I50.00 or $300.00 1) Services Requested by: Name: ��it�. � a�r�- Phone # (home): 33Co �3� �'070 Address: �4 P�ne 5 �'es � (work/cell): qr9 59Q 137� Se. w.�+ra . �Jc� �73�.3 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: sr� ac�dress aloov+� 4) Proposed Use a Type of Structure: p Residential Business/Type: Other EncloS� e��'�'� ►a'�i0� Number of bedrooms O / Number of people served (seats/employees): Basement: Yes ✓ No (with plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: ✓ Private Well (Proposed Existing _) Community Wel(: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A completed annlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of a[l proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am su6mitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): Date : �'-�$�� 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) t � � �� ' + �. 1 � Tr ��, � L 4 � _^ � � �.� � -S� '�'� m�.�-i7��pii"Ti'IrYil t�i]YJZt�.�.� .li 1L�'it�tl+li!L.7�. �u��ing Ar�dfl�ions/ l�o�i�e �oa�ae Re�lac�;�e�ts Tax Map #: �� Approval Requested for: Parcel#: �� Mobile Home Replacement � Building Addition Applicant Name: � �`n'�� Addt'ess: � Q 0 t o� � ,, r � �i•^� �- 3 �� Phone #'s: 23 �{ �� Permit Located: �_ Yes � No � Installation Date: � Design flow: (gpd) Current Contract with Certified Operator on file (if required): C Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: ��' d� (date) (Applicant's signature if site visit is not required) � Comments: ��SS!�� 13 � C,� ,�x��'�►-, � ��dit�on/�eplacE�ent �pp�a�ed M � �� Environmental Health Specialist Date 11/1 �/OS � �� , \ . . . __ , : . � r0 �\� SR �3'4 • ' \ `�\ �,\ � �O `� � _\ , p ,,\ _\ ,,\ �IF R.r �,q T , \ �,,\ E E �� _ A S M� � � �� Ns o � Nr �, / IRON � S � �l�Sg� / lpo �5 / � •Op� / ' � i i / ' � i � � i / � i � i i � , � , � � , � � , � � � � i � � IS �H / i � / _1,�G��'�/ �I �'C �! O . � � � W � C./ � > � �� ',�/<%l�v�/,� / PINESBOROUGH A:C R E i o i /�"� � D � ESTATES LOT t7 ! � i �!� �� / � PINES60ROUGH � N . ESTATES , j i �,�,� P. B. 11 , P 15 3= 18 � �' �:ip""'L - / _ N °� t . : � , - O N � � �i��l�'1� � m h� !\ .�y � ; i . f . � = aI \\`� � � �Ura�� ,�. �; �y., f'fi ..i� � � pN ,/ � ( 7 �� • � �-------- 1 • . 1- . j. � ..' , "' '_"' ' '-. ' _ ; ` i --� � ,v ^ / � ( i M � �� ----- � �or � z / _�� iicar � ' - Pi:NES80R0UGH � ' � ?� � POLE i ' � ESTATES i > �__ , N � j J8. 7. �u 4i 0 t �o 3 , � � \ � � � � � 2.22' \ \ I CM IF � CONTROL CORNER � �� CAROLINA POWER 8 LIGHT HYCO LAKE ��k 48\ l�1� 420' � �l CONTOUR IS � \ � � I✓�� . . ��'�'�` �:r /JO ]c eh�� 'P�. �Q�c� �ur �'Yf «r J S'yy ��nc5b�ro��i� F��"- �� mo�'�� jl,��C. �7�Y'-3 (h) �3�.. �3� �4'0�� C�,,� �3`�- 7yf'- �:2�q � _.._....._-_,.�_,�.�:,- �b_� ��,:-m � L'erson County Heal.th Oepartment �;xistinq Sekaqe System Report For: is-obile Home.Keplacement I/Addition Fiame Phonet�c��` �� Z7� Business� ��_�L�j�j ' Tax Maprt �%� —)' Requestee: � � �--� c�l �c�.I�CI� � . � �1� N�,.a��a� _ Location/Directions: �'J1t v T/(� ��nn LP�/f Original Permit Lacated , Septic System Desiqned r'or: -4� 0 � Kesidential. �� Business Other (specify} � Hedroo�as � # Employees Other llate Installed Water supply �ype ot System Nitrification Line - Tank Siae Certified Operatcr Required �1�- � -- . On.site wastewater disposal system sliowes no visually apparent � malfunction cn �`i�"13`� I - �ermission is qranted to: �C'�1,10� �I t� 6�Y�•�i - According to the attached site� plan. , `Y -.. " _ .�i�-�"�.�' . . . - .. � �m'S:�?"' 0 �� , . � �,� y � � � �� 1��-a.��:�.�,�.�. IE-7I��..11¢l� �uilding Additions/ l�obile �oene Replacements Tax Map #:6�� Parcel#: I � Approval Requested for: Mobile Home Replacement �_ Building Addition Applicant Address: Phone #'s: Pernut Located: Yes � No Installation Date: Design flow: ? (gpd) Current Contract with Certified Operator on file (if required): n�� - c, ' Water Supply: �_ Well Public or Community Wastewater system shows no visual evidence of failure on: �v" (date) ��$�� (Applicant's signature if site visit is not required) Comments: _ ,. � . _ , i. G . � . ` �_,��li�� Addition/l�eplacement Approved �-, � ��"-�,� 2 r� < < Env onmental Health Specialist Date 11/15/OS � � J! � �•{ � �..�.� � � �J �. V �� IEna�n�onan�nca��a�.m.Il IE��m,Il�ll�a Date: _�/ ?�'/ � 7 Name: �j,�J �G/1/�1%Y Ti' Tax Map:� Parcel:� Address: �„� . ��rl.��.t� C ,�3T.� Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on �/ �/� 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 t1:e soil. Fecal coliform bacteria are associated with animnal and/or human was�e. 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 coliform 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 not�ed of the test results. A well that tests positive for total or fecad coliform bacteria should be�roperlv disinfected and retested nrior 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 systerr►, 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, �� d� Environmental Health Specialist Person County Health Department (rev. 4/20i 16) Person County Environmental Heslth; 325 S. Morgan St.: Suite C, Roxbor�; Nr 27573, Phnne: 3:�fi-579-1790; Fax 3?6-59?-780R North Carolina State Laboratory Public Health Environmental Sciences Microbiology 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: ES100317-0076001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JIM BENNETT 735 SHORE ACRES DR SEMORA, NC 27343 Collected: 10/02/2017 10:00 Received: 10/03/2017 08:23 Sample Source: Well Sampling Point: Outside spigot P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Angela Heybroek Well Permit Number: A24-9 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 10/04/2017 E. coli, Colilert Absent 10/04/2017 Report Date: 10/04/2017 Explanations of Coliform Analysis: Reported By: Susan Beasley 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. �� nc dapartment of hQalth and human services �� .�Y �� n l� KS� .��'� `a F y�.� ''� y.(y�, B `Y�� i�37 �� ii � J li � � " li �[p�� , � x� � � t �'�.�y+�'.�U � G & �Ea� � � � �� :1 � �FYY i+^�� TY � � � �.� �� Y•GII� Fo� Inorganic Chemical Contaminan�s County: O Name: Sample ID #: — / Reviewer: TEST RESULTS AND USE RECOMMENDATIONS I. 0 Your wel l water meets federal drinking water standards for inorganic cltemicals. 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 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, uniess 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 inorFanic cl:emical results o�lv. � Arsenic � � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron Man�anese Mercurv . NitrateMitrite Selenium Silver � Ma�nesium Zinc nH 3. [r�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 !ow sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the innrsanic 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 IS 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. ❑ The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, c(eaning, 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 Magnesium Man�anese Selenium Silver pH Zinc Fnr neore information regarding your we!/ waler results, please call tlee Nord� Carolinn Division of Public Henith at 919-707-5900. North Carolina State Laboratory of Public Health 3012 D stnct Drve Environmental Sciences Raleigh, NC 27611-8047 htta://slph. ncoublichealth. 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 MATT HILTON 325 S MORGAN STREET 844 PINESBOROUGH ESTATES RD ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES100317-0003001 Date Collected: 10/02/17 Time Collected: 08:45 AM Date Received: 10/03/17 Collected By: H Kelly Sample Type: Treated Sampling Point: Kitchen sink Well Permit #: A24A-11 Sample Source: Well Temp. at Receipt: GPS #: Sample Description: Comment: Inorganic Chemical + Metals I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness < 0.001 < 1.0 11.00 < 0.01 < 0.05 < 0.20 < 0.10 < 0.005 < 1.0 < 0.03 < 0.0005 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m m 0.05 m 0.002 m 7.7 N/A < 0.005 <7 0.05 0.10 Zinc < 0.05 5.00 mg/L Report Date:10/16/2017 Reported By: Deddie .�loncol" Page 1 of 1 INITY � Mr�P ' T° SR ,3 ` � � , , ��x n-��.� �1 a� A - i 1 _ �4 -` '`� , , �_,\ 6�, �__� _`-_ pRIV ,\\_ . � r� �� _ i ''� ��S �''� / � ` � NF � �� ' - _`�RON Iv � � , / ` / / / / � � / / / LOT 9 /� PINESBOROUGH ESTATES / . � / �or �o / PINESBOROUGH � ESTATES / � / v�- � _ � /� o N � MN � Z � � � � / � � I N I 2t o, � � � - % ^ � / �4•zs % � '� / � � � �� \ ,—� � % � � � a �� z . 2z � ^� .\ � % \ � CM j IF CONTP.GL - CORNER � ��S�o� �2. ?8 , SO. lJ i�✓ � a9'os„E �oa, IF �.�� A��E LOT 11 PINESBOROUGH ESTATE; p,g, 11, P, i5 & 16 LOT 12 PINESBOROUGH ESTATES Lv�•�•11VV1 IY11V1 1 �71 . � � ' M�,Y 2002 , HAMLETT—JE 21 ? 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