A25 177w
.Site E�aluation Application
Fee Collected YES �
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Da t e: �� � a'- � 1
NO
APPLICATION FOR IMPROVEMENTS PIItMIT
1. Permit requested by: owner �ruspectivP owner:
agent:
Address:
Home Phone �� :
2. Name and addres
current owrier:
3. Property Description: Lot size:
4. Tax map ��: �� Township:
Subdivision Name:
�3usiness rnone �i:
�
�l�L�c�i��e�-/
�— Lot ��:
S. Directions to rope� State Road �� & Road_Na�9,es, etc.
1'� /i/ �� /�, i:._ �_ r l.� o y, r� ��,l' r� , �
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6. Permit requested for: New Installation: _� Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? �� public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11,
Type of structure or facility: �roposed: _� Existing:
Type of dwelling: House: �/ Mobile Home: Business:
Type of business: Number of Employees: .
Number of bedrooms: Garbage Disposal? Yes ro
Basement? Yes No �If so, number of basement fixtures:
12. Clearly stake all. corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereb ranted to
enter the property for the evaluation. G.S. 1 335(F) � �
igned Owner or Authoriz ci Agent
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Permit Denied
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't?ACTORS - SITE EVALUATION AREA 1 AREA Z ARF,A 3 AREA 4
1. SLOPE (X)
2. SGZL.TEXTURE <i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3 . SOIL STRUCTiJRE (12-36 in. )
(Clayey soils)
4. SOIL DEPTH (in.)
S. RESTRICTIVE HORIZONS (in.
(Iutpervious Strata� rock)
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SOIL DRAZt�tAGE/GROUNDWATER
(�cternal & Internal)
SOIL PERMEABILITY
(Percolation Ratc)
$. OTHER (specify)
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PS
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9. SITE CLASSIFICATION � / � .
(See below) � J
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R.ECOt�4fENDATIONS / COMMFSITS :
S.�TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, c�ells. Water bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMEN�' �
WELL AND SEWAGE SIi'L; LOCATION IlvIPROVEMENT PERNIIT
Tax Map # ,� � S Parcel # 1%'7
Zoning Township "
Owner/Contractor � �a � Dat .�r � � — 95
Location/Address S2� / �� _ -�n C,��' 17 � !.. . /a-� � ., /��
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ��ic,+- � Size of Tank . _�'� S
SFD Mobile Home_�_ Size of Pump Tank � ��� _
Business # of Bedrooms 3 Nitrification Line ,)C3 '
Max Depth Trenches�� "
Permit Void after 60 months.
Permits may be voided if s
Well and Septic Layout by
Comments:
Date
Permit Void if not in compliance with zoning regulations.
Installed by,
Approved by
� .� M� WELL SYSTEM SPECIFICATIONS
In ividual Semi-Public Required Slab �
Public Replacement Air Vent !i'
Site Approved :� Required Well Lo� f/"�
Well Head Approved_ Well Tag J��
Grouting Approved �
Comments:
Date
by �,�Pn
Approved
This report is based in part on infortnation provided the homeowner or his/her representative in the application submitted for this pernut The
environmental health specialist is not responsible for false or misleading infonnation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the applicatioa Neither Pecson County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pernvtsam O1/95 rev.1.0
ORIGINAL
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NORTH CAROLINA PERSON COUNTY .
�, ____ NEAL C:HAHLETT _, CERTIFY iHAT iHIS
SURVEI' CREATES A SUBDIV(SION OF LAND tITHIN
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For lnorganic Chemical Contaminants
County: �So1+�l Name: G,-�'� �j�
Sample ID #: -�— � Reviewer:
TEST RESULTS AND USE RECOMMENDATIONS
I.[�Your weli water meets federal drinking water standards for inorganic cliemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic 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
washing, cleaning, bathing and showering based on the inort�anic cl:emical results onlv.
Arsenic � Barium � Cadmium � Chromium Copper Fluoride Lead Iron
Manganese � Mercury NitrateMitrite Selenium Silver Ma�nesium Zinc oH
3. � a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/l. 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 iiiorQanic clremical 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
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, cleaning, bathing, and showering based on the inorganic chemica! 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 � lron � Magnesium
Manganese � Selenium � Silver pH Zinc
� . .....,. .. . . �.. . -. w .�.,J �:� __ .
t�nr .`in.QLtll.�llQll.l'..BQ pr��9y�n�y aII'W� (���[�ILf : .CRII:fI- 1Q�DT1it, Q O 1KA;li�Ltt%Sl0/t� y�-�
b b�F�x.%.� r/`r�'SE -QF.-D _.�_.,.` e l t`U o.�>..-'. L-J.��
.i� �
�� � North Carolina State Laboratory of Public Health 3�2 Dist?ct Drve
� Environmental Sciences Raleigh, Nc 2�s„-8o4�
htta://slph.ncoublichealth.com
�, �,xR�. � Inorganic Chemistry Phone: 919-733-7308
��� Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH BETTY JOHNSON
325 S MORGAN STREET
3749 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES081016-0036001 Date Collected: 08/09/16 Time Collected: 2:00 PM
Date Received: 08/10/16 Collected By: H Kelly
Sample Type: Raw Sampling Point: Outside tap Well Permit #: A25-177
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
Beryllium < 0.002 0.004 mg/L
Boron < 0.1 0.7 mg/L
Cadmium < 0.001 0.002 mg/L
Calcium 8 mg/L
Chloride < 5.00 250
Chromium
Cobalt
Copper
Iron
Lead
Magnesium
Manganese
Mercury
Molybdenum
Nickel
< 0.001
< 0.001
0.29
0.22
< 0.005
3
0.018
< 0.0005
< 0.010
< 0.01
Potassium 1.18
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
Selenium < 0 01 0.02 mg/L
Sodium 7 25 20.0 mg/L
Strontium < 0.5 2.1 mg/L
Sulfate < 5.00 250
Thallium
< 0.0001
0.0002
Total Suspended Solids < 5 mg��
Vanadium 0 0018 0.0003 mg/L
c 1.29 1.0C
Page 1 of 2
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: H. KELLY
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
BETTYJOHNSON
P.O. Box 28047
4312 District Drive
Raieigh, NC 27611-8047
http://slph.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
3749 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES087016-0037001 Date Collected: 08/09/16
Date Received: 08/10/16
Sample Type: Raw Sampling Point: Outside tap
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 2:00 PM
Collected By: H Kelly
Well Permit #: A25-177
GPS #:
Hexavalent Chromium (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
Hexavalent Chromium 0.47 0.07 ug/L
Report Date:08/12/2016
CAMA = Coal Ash Management Act
Page 1 of 1
Reported By: Cind'y Price
�� l
� 1 1 � �
��. � � � `1./ ���
1��nv�n�-ona�rnca��a��,Il IHI��.Il�ll�an
Date: �/ /� /�
Name: _� � (j/ b�i/ Tax Map:� Parcel: !�%
Address: ? � G — ,QD•
��,u6�� ,;�� �����
Re: Bacteriological Test Results
Dear Well Owner:
Yaur weli water was sampled on $� /�/�, and iested for both total and fecal coiiform 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.
)C Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Tota! colif'orm bacteria are naturally fou�id in the sail. F�cn.l c.oliform ba�teria are �sso�iate� w:th
animnal ancl/or human waste. 'I'he presence of either total or fecal coliform bacteria in well water r,iay
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 no#ified of the test results.
A well thnt tpsts pc�sitive for tetal or fecal celiform bacteria should �e praperlv dis:nfect2d and retested
prior to resumin� 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
flushzd oat of tr�e 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,
���
Environmenta ealth Snecialist
Person County Health Department
(rev. 4i20/16)
Persen Coun,ry Envi:cnmental Health, 325 S. Morgan St., Suite C, Raxbcro, NC 27573, Fhone: 3:i5-574-3790, Fax 336-597-7R08
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant -�1 �(�-►� � 0 0�
Address �7' cl l�C��c�-� County �i��sa �
)l.�'l � l ( �],
Coliected By
Date Collected � Tir�e Collec�ed Z� 0�
Source: ell ❑ Spring o Other
Location: ❑�Flouse Tap ❑ Well Tap ❑ Other
o No Charge Charge
..............................................................................�
****************************************************************************
Results
Present
Total Coliform
Fecai/E. Coli
Reported B
GL�����•�--
Date Reported � �� � ��
Report Called �YES o NO
Called To � � ���
C
Absent
❑
�