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APPLICATION FOR SERVICES
Permit. (EstablishedlRecorded Lot) I_ Reinspection of �xisting System (Loan Closing)
Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Bacteria
1. Permit requested by: .
�wner/prospective ownei
. � „�. ,� /1.
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
_ Chemical _ Petroleum I _ Pesticide � _ Lead
. Dimensions or Pro osed Structure:
Vidth: �.g X ��
aress �-� � • �-�r�••.
,_._��r ��� ��3�23 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
me Phone #: .�-�i7 - �l�d R'
siness Phone #: -
Name and addre�s of cunent owner: 9. Water supply type:
�/.11� i �. ..1 n � � /.� � i �<l�.�t2 .+�� +�l private �j . public ❑ community ❑ spring ❑
— Are any wells on adjoining property?Yes�i No �j.
,�Y. �,,;� _ C_ �,� � If so, identify location:.�n1 4�� S t�� c� � _
. Property Description: Lot size:
. Tax Mag#: a -5
Parcel#: 3
Townshin: ��� .
. Directions to property: State Ro #& Road
lames,�tc. ,., � ,� �"A4���E C � FN
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or neonle to be served:
10. Type of structure/facility: Proposed: DExisting: Ci
Type of dwelling:
House: ❑ Mobile Home: � Business: ❑
Type of business:
�umber of Employees�
umber of bedrooms: b
'Garbage Disposal? Yes� No�1
Basement? Yes ❑ No� If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Depai'tment for a site 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Si�ncci Owner or Authori��d Agent
Permit Issued b�
Permit Denied ❑
Plat Observed ❑
;'
��� `
S ignature Date
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S-SNTADLE PSPROVISIONALLYSUITAIILE U-UNSUT[ABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ll
areas, wells, water bodies, slope pattems, etC.� C:WMIYRO�DOCSWPPSEC.SA1 FINANCE.PC
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B 1318
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION TIVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
6as been issued.
Tax Map # A a s
Zoning
Owner/Contractor n R
Location/Address 5 7 � � cx-F
�' (a v-f-� n� l o-f- c� �� R� R 1.�-
Subdivision Name
Parcel # � g /
Township
m �v Date 3a
rc,ncnrd �'.l���,r�h T/[-- en f�r�l,ie
S.R.#
Lot# 'C�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� b A<<� Size of Tank I a�C�
SFD Mobile Home Size of Pump Tank /�1 A
Business # of Bedrooms_� Nitrification Line s�a ` x��
Max Depth Trenches �(� f n-
Permits may be voided if site is altered r intend s c�anged.
Well and Septic Layout by �/ . � �u���
Comments:
Date Installed by �, 2pu�� s� Approved by �, e���i,��
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual 5emi-Public Required Slab
ublic Repla ment Air Vent
Site Approved Required Well Log _
Well Head Approved Well Tag �
Grouting Approved
Comments:
Date I�� I I- U! l� Instalted by
Approved by.
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The enviroamental 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 application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:lamiprolpermi�sam O1/95 rev.l.l
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56631 j�,
°rtho A. Southem
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Carol Hatchett
D.B. 211-640
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53.51' N :
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p Joyce B. Loftis
� D.B. 245-733 3
�s�� R �,. `O -
Existing iron Ptn
Found On Line
�g� �8
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4.81 Acres
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ne department � � � � � � � � � � � � � „T � � � � �
of healf6 end ���� o
�luman s8�vi�2s � �� � �
Fo� Anorganic Chemica/ Confaminants
Count3'� Name: l}.� � 4.�
Sample ID #: Reviewer: �
� TEST RESULTS AND USE RECOMMENDATIONS
1. [] Your w$1! water meets federzl driaking water staadards for inorgani� c,�emica�s. Your water can be used for
drinking, cooking, washing, cleaning, bathin� and showering based on the inarFanic chemical resalls onlv. You may
nave other water sampling results that are not taken into account in this report.
i. 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, ualess you install a water treatment system to remove the ci�cled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inoreaKic chemical resul�s onlv.
Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron
Manganese Mercury Nitrate/Nitrite Selenium Silver Magnesium Zinc oH
3. � a. Sodium (evels exceed tha U.S. Environmental Pratection Agency's�(USEPA) Health Advisory (evel for sodium of
20 mg/l. The North Carolina Division af 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 ha�e� on
the ino�ganic chemical results onlv. �
❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. � Re-sampting is recommended in months.
5. 0 Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferab(y
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 6e used for driqking,
cook�ng, washing, cleaning, bathing, and showering based on the inor�anic chemical resu[ts nn[v, hut aesthetic pr�blems
such as bad taste, odor, staining of porcelain, eta may occur. You may w2nt te instali a house�old water treatment system
to address aesthetic problems.
Cadmium � �hromium � Fluoride � Iron
Selenium Silver pH Zinc
Far more informa[ion regarding your weli water results, please cal! ihe North Carolina Divirian of Public Health at 919-101-5900.
North Carolina State Laboratory of Public Health 3�12 D st�ct�Drve
Environmental Sciences Raleigh, NC 27611-8047
htta://slph. ncaublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: ADAM C. SARVER Name of System:
PERSON CO ENVIRONMENTAL HEALTH SHANNON CHAPMAN
325 S MORGAN STREET
220 ARCHIE CLAYTON RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES050917-0023001 Date Collected: 05/08/17 Time Collected: 12:45 PM
Date Received: 05/09/17 Collected By: A Sarver
Sample Type: Raw Sampling Point: Outside spigot Well Permit #: A25-187
Sample Source: Well Temp. at Receipt: 1.5 GPS #:
Sample Description:
Comment:
New Well I (Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Arsenic < 0.005 0.010 mg/L
Barium < 0.1 2.00 mg/L
/��J.Y:...Y i A A/1A (� !�l1G rh.�/I
Calcium
Chloride
Chromium
Copper
Fluoride
Iron
Lead
Magnesium
Manganese
Mercury
N itrate
N itrite
pH
Selenium
Silver
42
< 5.00
< 0.01
< 0.05
< 0.20
0.19
< 0.00.'
0.10
1.3
4.00
0.30
0.015
9 m
0.062 x 0.05 m
< 0.0005 0.002 m
< 1.00 10.00 m
< 0.1
8.0
< 0.005
< 0.05
12.00
5.30
Total Alkalinity 160
Total Hardness 140
Report Date:05/12/2017
1.00
0.10
< 0.05 5.00
Page 1 of 1
Reported By: Deddie .�toncol
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��fmavTu �cd <ann �t�n:��,� .tr3 t�,�.� �.�<r.�m,�� �%
�
Date: � / i � /�
Name: „t.1;, LtG r��tn
Address: Zd e � 1� �
.z tC�br;.�o ��( f C � c-7�_
Re: Bacteriological Test Results
Dear Well Owner:
Tax Map:���Parcel:_�
1
Your well water was sampled on �/�/� and tested for both total and fecal coliform bacteria.
Your water sample test results are noted beiow:
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 arz naturally found in the soi�. Fecal colif�rm bacteria are associated with
animnal and/or human waste. The presence of either total or fecal coiiform 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 rot be safe for use. Young children, the elderly, and the individuals with compromised inzmune
systems are especially vulnerable and their physicians should be notified of the test results.
A well that tests positive for total or ecal coli� rm bacteria should 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,
c.�
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC27573, Phone: 336-579•1790, Far 336-597-7808
North Carolina State Laboratory Public Health
Environmental Sciences
�ilicrobiology
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: ES050917-0054001
� ������� ������ ��� ����� ����� ����� ����� ����� (��� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
SHANNON CHAPMAN
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
httq://slph.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
220 ARCHIE CLAYTON RD
ROXBORO, NC 27574
Collected: 05/08/2017 12:45
Received: 05/09/2017 08:22
Sample Source: Well
Sampling Point: Outside spigot
A Sarver
Susan Beasley
Well Permit Number:
A25-187
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Date
Total Coliform, Colilert Present 05/10/2017
E. coli, Colilert Absent 05/10/2017
Report Date: 05/10/2017
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.
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