A25 47,
' - -- PERSON COUNTY HEALTH DEP�RTMENT
- � WELL AND SEWAGE SITE, LOCATION IlVIl'ROVENIENT PERMIT
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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
has been issued.
Tax Map # � — � � Parcel # � %
Zoning Township u �,, �
Owner/Contractor �3 r� r ate D�
Location/Address � �, ('o /1i1 � e�s R� �
S.R.# /331
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area %6 c. Size of Tank d d
SFD 1% � Mobile Home Size of Pump Tank
Business # of Bedrooms '� Nitrification Line qd o��-t'�' / 3�0 ; a��.�- �h
Max Depth Trenches !� 7'0 � 0 i a ��t �s
Permits may be voided if site i
Well and Septic Layout by �
Comments: .,� �-1/�,rm-
r
�o r �c�-� oEti�' s Q r�
Q-�{+'� r_1 i� ci lucj 1'� w�, i
m
te l o-���Q y Installed by ��� Approved
ell Permit Paid WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public
Public Replace ent
Site Approved 1/ YVj���a�
Well Head Approved
Grouting Approved � l� -
Comments: .� � s 1`a // w� I l i_/U4
r•ti
Date
�.,e I 'vest��k �v `
Installed by �
Required Slab �/
Air Vent
Required Well Log
Well Tag
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�vc.-� j-�l� .e, l,v,e.� ,
Approved by.
'cco c��.��
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 environmental health specialist is also not
respoasible 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:\amipro\permit.sam O1/95 rev.l.l
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Appllcation Date: 3 —� �� �
Amount Paid: J��
Receipt #:
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Tax Maa #•
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APPLICATION FOR SERVICES
Parcel #:
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n�ee�
�i �"� � � �ap y
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IF THE IIVFORMATIOPI IN THE APPLICATION FOR AN IIIAPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZA'iIOM 70
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Ownerlagent/prospective owner): �� a� /�/.� �>� �' �.�- y�
Home Phone: �� 3/o -- � 4 r- 3.� ( � Address: 3�?� ,� ��! �� �s sLl c L 2 ca
Business Phone: . 5.��, �,� , iu c_ z. ���� j
2) iVame and address of current owner. ��.�rf-1 2
3) Property Descriptlon: Lot size: ��, Township: , ubdivision: Lot #
Direetions to the property (Including raad names and numbers):
4) P�roposed Use and Structure Description: answer each of the following questions: �,¢/1-� uS e� yl,��-.c
a) Proposed . Existing , Type of Structure: Width: . Depth: �
b) Number df Bedrooms: �.�� Number of occupants or people to be served: L���� ��
c) Basement: Yes� No _ Will there be piumbing in the basement?
d) 6arbage Disposal: Yes �� , No
5) Water Supply Tyqe: Frivate �ew _ or existing 1, Public_, Community_, Spring _
Are any wells on adjoining property? Yes�b _ If yes, please indicate approximate locatiori on the
'site plan. . ,; . ��: �
6) Does your property contain previously identified jurisd(ctional wetlands? Yes_ No°_"�
,
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTI( OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICAYION. .
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAC(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HE�ILTH DEPARTMEPIT
STAFF: �
I hereby make application to the Person County Health Department 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.
Owrier or Legal
�3-/m-O�
Date
PCND, rev. 06127IO2
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. . � . � � . tho�ized State Agent . � Date .
�� � ' System cumponers�r s��,s�sfent approasimtrta �contours o�ly: The co»imctor mu�t flag fhe rysi`em prior fo .
�.� beginning the i��utaAa�ion to i�sure that prn�ergrade is �nurnfained
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PL�iSSE SEE s�T`�A�YD P]L�N �'p�d WEL]L S�.I��I�JYJ'I'
Tax Map Z Parcyl #�,_ .. Townslup;
Applican�:
Subdivision: � T „+ � �
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Type of Water Supply: V Tndividual _ Community Public
Itequirements:
Sita Approved By:
Grouting Approved By: �
Well Log: �
Pump Tag: � �
Well Tag: � �
Air Vent: ` �
Hose Bib: � �
� Casing 13eight: '
Concrete Slab: �� � � ' � �
Well Driller: EV o� n S
Well Approved by:
*�**See.Attached Site Sketch*�**'
Liner:
7nstalled by: � �
Depth set:
Grouted• .
Date: .
Water Sample:
Wells must be 10 feet from property lines.
Wells muat be 100 feet from septic systems,
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:,
PCHD rev 01J27/0�4
����
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nc department
of health and
human services
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�_R., .a° rx .c:�`i �'�e:u:3* `�:ac<� �� y. Y�:nt .i.�ec� � � Ya�
Fo� lnorga�ic Ci�emica! Con#aminants
County: ►J . Name: � p�
TEST RESULTS AND USE RECOMMENDATIONS
1. 0 Your well water meets federal drinking water standards for inorganic clle�nicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results 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 inor�anic chemical resu[ts onlv.
Arsenic Barium
Man�anese Mercur
Cadmium Chromium Co e
NitrateMitrite Selenium Silver
Fluoride � Lead � Iron
Ma�nesium Zinc aH
3. Q 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 ii:nrennic c/:emica! resul[s 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 inorsanic chemical results 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
,�,
Maneanese Selenium Silver pH Zinc
For naore informatio�: regarding your we!/ water results, please call tlie Nort11 Carolina Division of Public Health at 919-707-5900.
� A -� � North Carolina State Laboratory of Public Health 3012 D stnct D �e
�-"� Environmental Sciences Raleigh, NC 27611-8047
�� , ' htta://sloh.ncpublichealth.com
�,�2� , Inorganic Chemistry Phone: 919-733-7308
•��„�o Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY Name of System:
PERSON CO ENVIRONMENTAL HEALTH BOBBY R GRAY
325 S MORGAN STREET
3276 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES020717-0070001 Date Collected: 02/06/17 Time Collected: 10:00 AM
Date Received: 02/07/17 Collected By: H Kelly
Sample Type: Raw Sampling Point: Outside tap Well Permit #: A25-47
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 0.101 0.7 mg/L
Beryllium < 0.002 0.004 mg/L
Boron < 0.10 0.7 mg/L
Cadmium < 0.001 0.002 _ mg/L
caicium
Chloride
Chromium
Cobalt
Copper
Iron
Lead
Magnesium
Manganese
Mercury
Molybdenum
Nickel
pH
Potassium
Selenium
Sodium
Strontium
Sulfate
Thallium
Total Alkalinity
Total Dissolved Solids
Total Hardness
Total Suspended Solids
� Vanadium
7inr.
37.00
< 0.001
< 0.001
< 0.01
< 0.10
< 0.005
5
0.149
< . 05
< 0.010
< 0.01
7.9
6.44
1
27.00
< 0. 0
41.00
< 0.0001
255
290
300
<5
0.0051
< 0.10
Page 1 of 2
m
250 m
0.01 m
0.001 m
1.0 m
0.30 m
0.015 m
m
0.05 m
0.001 m
0.018 m
0.1 m
n
m
0.02 m
20.0 m
2.1 m
250 m
0.0002 m
m
500 m
m
m
0.0003 m
1.00 m
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:
BOBBY GRAY
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slah. ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
3276 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES020717-0069001 Date Collected: 02/06/17
Date Received: 02/07/17
Sample Type: Raw Sampling Point: Outside tap
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 10:00 AM
Collected By: H Kelly
Well Permit #: A25-47
GPS #:
Hexavalent Chromium (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
Hexavalent Chromium < 0.05 0.07 ug/L
Report Date:02/14/2017
CAMA = Coal Ash Management Act
Page 1 of 1
Reported By: .xennetFi Greene
Report Date:02/16/2017
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
htto://sl�h.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Reported By: Deddie .�tonco!'
�
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Owner• .�__
Location:
� Subdiviaian:
Gr
Graat Lo�
�,� Tax Map,�S� Parcel # _�
Lot #
', Wall Con�tructlon
; T}istar�ce From nc�r�st Property Line (Minircium' 14 fc�et) �
� Dist�nce from Scptic Systern {Minimum 60 feet) �
I Tota1 Depth: �a _ ft Yieid: �� ��PM Stati Water Level: � ft
� Watet Bcaring Zoncs: Ocpth �_,5 ft ! oc� ft/(e� ft ft
C�tsings
pegth: From _ d to �( r� ft. D'eac�ter; G,_ ��-/ in
Tygc: Gslvanizcd Stcel �! - T
Weight: �,�w. Thicknesa: ,u� Height above Ground: J?� in
Drivc 5hot: __�s No Any problema enco�tarad while s+ttting caain�? N�es `�lo
tf "y�s„ give reaeon: �_�, - -- --- -
Grout:
Neat: SanclfCemet�t t/ Concrete t�rsveUCemsmt
Annular Spacc Width ___�_� inct� Water in Annular 3p�ce Yes . �i�io
1v[ethod of (3rout: Yumped _____ Preaaure vZ�oured ._.�_ I)epth _,� to �-� Ft.
M�tertals U�ed:
No. Bags PoRtand �a�cnt 'A�ai�ht of 1 Bag �,�, Pavnda
If myxture {sand, gravci, cut'azngs) �• Ratio �„_, ta ,,.��
ID pi�►tes: �X�a � No a x 4 slab J�es �_ No
Llner:
Depth: Dste Inatalled:
i2�lliln� Lo�
Gtaut• __��....._._. In�talled by: __�_.._.
Loc�tlmm Dr��r4ag
Fromw -�- --�b ___..� �'or�rs�ti�an _�.� --- .
_._ � _, � s. �
i � -� � � ��
�..�._.��- �
-u-�.
�_ __�^
I hcreby aertify tteat the above inforsnetian ia correct and that this weli was constructed in acenrdenca with re3yulati�ns set fors}
by the Pcrson Cour,ty Hcalth Dtpartsnent. r
Si�aaturc of Cuntrsctor �#-_,��`-U�b Datc+ ��_ 3d - d r7
Pomp Instsll�uent
Pump Insiallation Contr�ctor: State Rsgietrativn Numher: ___ __.__....�._
Pump Depth: ft Static Water Leve�: R
Pump Make & Madcl: ......._____.._._.._.._.._... --- Pur.�p Siza and Rating: ___,....---- hF i3Pm
1 he�eby certify tt�at thi� pi�mp was installod �sd tha woli hea3 �crmplzicd accarding to the Yersun C�unty W�11 i��ules in �ftcct
�n shis dstt and that a copy of this record has bccn �ovided to thc weJl owrfer.
Puma fnsistler SiQb�eture Date: PCHI? rev Ol/2?�0-�