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A25 9: w �� .. . The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water S��1j� and Sew ge �isp sai IMPROVEMENTS PERMIT No. , Date—�.!�� ,�_____ Owner: r'► ► <" �� Location: Contractor: Water Supplp: Private —� Public Sewage Disposal Facilities: No. bedrooms "'` .�_ Dishwasher, Disposal� J washing machine, other au omatic appliances � Size of ,��k: --'�(''�� Nitriflcation line:, �L � Other disposal .� . Water supply and sewage disposal facilities location, ins a tion� and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFOftE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. /J �� t � � Date approved: Sign� � �� ani ian Well: '"� ` � r J � �� Sewage Disposal: Counter- aigned �� . .i . ` `'; 1-�--,,c �...� B3'� (Ow r or his representative) Cert�cate of Compl ion Date Approved: BY: San rian (OVER) Location of well and sewage disposal facilities sketched oa back. NOTE: 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 .r . • r - - �� . , v .� y,o Apnlication Date: ��9 �� Amourrt �aid• �, .b O Rec�ipt #: - �3 3 $0 Tax �laa #: /K o� 5 Parcal �: q ' �� I�I�..�� - - —� � � �T1��Y' ��-s�a-��.�-�-+� <eaa.��.71 IE�Lom11�]La. APPlJCA710N Ft3R SEi21/IC�S � �� D`�� ° IF THE INFORMATIOM IN i'HE APP�ICATIOPI F�R AN IAAPROVE�AEAIT PERMIT 1S 1NCORREC'�', F:�,L.S1FiED. Ct-IANGED OR THE SITE IS ALTERED. THEA� i'HE IAAPROVE�111ENT PERMIT AAID AlJTHORIZ�►'il0(d TO . CONSTRUCT SHALL BECOME INVALlD. 1) Permit requested by: (Ovme agent/prospec�ive ownerj: �• ri Home Phone: �9_� � / � Address: -� Business Phone: 2) Name and �ddress of currer�t owner: � • o- _�Tx�� 7�C- 7s �z 3) Property Description: Lot size: Townshlp: Subdivision: Lot # DiceEtions to the property (Induding road names�and numbers): �• 4) Proposad Use and Structure Description: answer ea h of the fo lo ing questions: a) Proposed . Existing , Type of Structure: �• Width: � Depth: b) Number of Bedrooms: � Number of occupants or peopie to b erved: 1_ � c) 8asemen� Yes , No ✓�11 there be piumbing in the�basement? d) 6arbage Disposai: Yes . No ,L . 5) Water Supply Type: Private �new or existing�, Pubiic , Cammunity� , Spring Are any wells on adjoining property? Yes ✓ No _ If yes, please indicate approximate lacatiori o� the �site pian. 6) Does your property contain_previously ider�tified �urisdictional wettands? Yes_ No f PL�EASE NOTE T�IE FOLLOWING: ➢ A PLf�T OF THE PROPEiZTY OR SIT� PI�TI MUST BE SUBMITfE� WITH THIS APP�ICATION. ➢ PROPERTY UNES �►iV0 CORNERS MUST BE CLEARLY MAR6�D. �, 9 THE PROPOSED Lt�CAT10N OF A►LL. STRUCTURES MUST BE STA6(E�D OR FLAGGEi3. 9 THE SITE MUST BE RE�►DILY ACCESSIBL.E FOR AiV EVALUATION BY THE HE�L.Ti-i DEPARTMEiNT STAFF. I heceby 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 faciii�es to be placed on the property. I understand if the site is altered or the intended use changes, the permii sfiall become invalid. _ Cwner or Legal Representa�ve 9� 9- o �-- Date PCND, rev. �6127l02 ��"; �� ' �� ' � � �L.J� 1V� �� IEnavaa-��* � e��m.11 lC-yT�m]l�a Lo i S �u�n n ic�n � � I`� Sta.te Ageut SITE SS��CI-3[ Tag lYMap # �a�Parcel # � . . . Section/Lot# N / 11 - q�-i a- Oa - Date . � sy� �o�o� �� npro��,�� y. The c�tractor must, flag the syste»s prior to� beginning t,he mstaAa[�ion to insure that pmpef'gy'ade rs maintained S�: f�Or�� 0 6 (,Jt t(, 5��. _rn,�O.rK�d �/ S�rnP � p�a,�� ` Fla�s (Y10 �.7c� � Pi� �� mg�� 4. 09�� The i�isirict `Healt�h Depor�ment CASWELL - CHATHAM - LEE - PEHSON COUNTIES �. Vl/ater S�i �1 ind Se�wage �is�osal �� IMPROVEMENTS PERMI'T No , Date_—�. ! s%. Sl�l Owner: ��--��; ' — iri/�.atiaii: w-n .-r. , . Contractor: �L..;_+�-p�� ••r � Wates Supplp: Private .— �r Pablic . . 7'�✓'�_t r^� � '_ Sewaqe Disposal Faeililiea: No.. bedrooiris �� t r washing machine, other au matic . appliances Size o! �ahk: I�itriflcation � Dishwasher� Disposal. .� s Other disposal facility: ' _ �e. �'_ Water supply and sewage disposal facilities location, i tio�r, and protection must meet state and Iocal regulations. - Septic tank should be pum�,ed out every 3 to 5 years, :and _shall be'mait►- tained by owner in such a manner as�not to,create-a'public�health�hazard. Septic tank and nitrification line;:1VIUST BE INSPECTED AND AP PROVED BY A MEMBER OF.THE"DISTRICT.HEALTH.'DEPARTMF�IT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- EAED AND PI�T INTO USE. � . /J /� _ ,� , Date approved � Sign¢ o "` " _ AIII lAII Well• � � Sewage Disposal• Counter- • - +��,� , ... � �gn "��•.......�' ..'''�_ �� ./r��" HY' (Ow r or his representative) CesliScale o� Compl on Date Approyed: By• San ian , (OVER) Location oi well. and sewage disposal facilitiea aketched oa bacic: -"• �' . ,� � � � f y �• � N � d � � z `° O ti N � b x �• °� w .- �. b � o � � � � w v, o tD � �C w ". O � �.aa � � .. ..° °. N � �. � a m � N � � � � y �. � o y� M a � y O a w fD eT y r� � y � er r � � M � � N y `� c' fD y � o � � w w �(p. � R� `�7 � � ,.., �� I � n�� `�� ln'A�YA �` d7►]kA�'�k sp ]C11 t�d�.91 1�1� cf?•� � tE ll'ii Date: � / % 3 /� Name: � << � �� V�✓ Address: � 1 4� VLlr�+r � � � � �+ � �D�. vti,. �� .�r7� Re: Bacteriological Test Results Dear WellOwner: Tax Map:� Parcet:� Your well water was sampled on (/� 3/� and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: � No coliform bacteria were detected in the sampl.e. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacterialogical 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 soil. Fecal coliform bacteria arz associated with animnal and/or huma.� waste. Tha presence of either total or fecal coliform bacteria in well water may indicate that a new o� �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 �nay rot be safe for use. Young children, the elde��ly, 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 for total or fecal coliform bacteria should be vro,verlv disinfected and retested prior to resumin� normad 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, G-� - Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person Co�!nry Em�ironmerrtal Health; 325 S Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, FaY 336-597-7$08 • •&.=� � � "� JAN-24-2018 14:30 y FRO�-HEALTH DEPT 3363226099 • PERSCIN COl1NTY WEAL7H DEPARTMEN'i' 355A SdUTH MAdISdN BL.Vp ROXBORO, NORTH CAROL�NA 27573 T-546 P.002/DU5 F-259 BACTERIOLIOGICAL WATER $AMP�.E ANALYSIS N�me of Owner or 7enant �.��1 •�� Address � 1QM. • �aunty , � Collecfed By Date Colle�ted -��` Time Coilected l=« Source: �Well ❑ Spring D Othe� Locativn: ❑ House Tap � Well Tap �.Other ��}� � � �"�' ❑ No Charge �Gh�rge a�a��ss�a��a��K��a��a��rM�t�s�a��a��rrs�a��Nra��rr��a��sr��r� ��r�+wr,vrr**t��rw*,r*f�*�,rwfrxx*�k��r�t**�*ytx*****�e�*,rxxt*#*t**ww*a**�k*�re�rxxsaic**** Total Galifarm FeC�[/�. CQIi Repor#ed By Date Repar�ed • . Fzesul�s Present ❑ 0 Report Called o YES fl NO c�ii�a T� Qbsent r ; �� i�1�'�,�� ne department af health and humen serviees s• w� � .t , � - �' � 'S f �S 4'� r�; / ; � �� 2 "F � (t-� � ' � � ;"' i'"';l`� ,�-..� .G { : + ;'`� � � { k f s � � � 7 � t , L � � s � f �� 5 L1 �. �< S�J �+ � f � i �/� i f ��{ e„ r�� i [ �l � � 'e� �� '�-? /�. �� 4„a e ^�"•� � "` �.`� � + . �"` r'�, $ � �IG f; c r, :.-`�"` ^� r . t�: i t_.a t � .1 �` t, ��"-� t.� ; <� i [ L_ a �..,.�' �. .�� `t... � ��C `� �...i' �� ! E a E � i ' �i � ^ 1 �•s �� .. � �,� ( F '" . �� For ir�organic Chemical Confaminants County: �lc � Name: ei � iv`f,�-- Sample ID #: S� Reviewer: � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic chenricals. 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 cir;,led substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inoreanic chemical results onlv. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Uon Manganese Mercury Nitrate/Nitrite Selenium Silver Magnesium Zinc nH 3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. 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 inorganic chemical results onlv. ❑ b. Levels over 30 mg/1 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, cook g, washing, cleaning, bathing, and showering based on the inor�anic chemicQl 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 �(�ron Manganese � Selenium Silver �pH�— Zinc For more information regarding your we!! water results, please ca!! the North Carolina Division of Public Health at 919-707-5900. North Caroliraa State Laboratory of Public Health ` Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: 6'i:I�[�_t�]�I�T�:7 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 4197 MORTON PULLIAM RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES011218-0028001 Date Collected: 01/03/18 Date Received: 01/12/18 Sample Type: Raw Sampling Point: Outside spigot Sample Source: Well Temp. at Receipt: Time Collected: 3:00 PM Collected By: A Sarver Well Permit #: A25-9 GPS #: Sample Description: Comment: Rejected - nitrate sample over 48 hrs old when received. New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) �{iaiIi � � �� Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 8 mg/L Chloride 15.00 250 mg/L Chromium Fluoride < < 0.05 < 0.20 1.3 4.00 1.40 �/ 0.30 Lead < 0.005 0.015 mg/L Magnesium 1 mg/L Manganese < 0.03 0.05 mg/L Mercurv < 0.0005 0.002 ma/L Nitrite 6.2 r < 0.005 < 0.05 Sodium Sulfate < 0.05 0.10 N/A Total Alkalinity 18 mg/L Total Hardness 26 mg/L Zinc 0.13 - 5.00 mg/L Report Date:01/25/2018 Page 1 of 1 Reported By: .�CennetFi Greene North Carolina State Laboratory of Public Health 3�2 Di tnc�Drve Environmental Sciences Raleigh, NC 27611-8047 htt�://slph.ncaubiichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: SHEILA OLIVER 4197 MORTON PULLIAM RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES012418-0055001 Date Collected: 01/23/18 Time Collected: 1:10 PM Date Received: 01/24/18 Collected By: A Sarver Sample Type: Raw Sampling Point: Outside spigot Well Permit #: A25-9 Sample Source: Well Temp. at Receipt: 6.5 GPS #: Sample Description: Comment: Nitrate_Nitrite (Profile) Analyte Result Allowable Limit Unit Qualifier(s) 1 < Report Date:02/02/2018 Reported By: Deddie .�lancol" Page 1 of 1 �1�' )�� .J� �� .' � � � �� J.L � ZC�-�n.a-�,�-*„-�*',• ��¢�.71 �3La�mILtEIla WELL PERNIIT P]LEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: � �s Pazcel # � Township ApP,;�� Lo �s �Ou�, �, Subdivision: secdon: Cc�n c..ar�l - Cc F Fo 2d . i.)(Yl o t'-t�, {�c� l( i a.� _�� a�x -�- 4 I� � � - T e of t r V IndiPicival Community Pnblic R��uirements: Site Approved bp �� GtoutYn.g App ved bp r�� We11 Log Well Tag Air Vent Hase Bb Concrete Sla.b Well Driller. � r��.�C�''`t�- Well Approved By: Date• '�°5ee Atiached Site Sketch'� Wells must be 10 feet from property lines. Wells must be 100 feet from sepric systems. Wells must be at least 25 feet from anp bu�din� foundation. Other GJ c- t 1 �17� m� � I m u m� �-�-p�G �' a�� F��„r. �.�Mf, :.:. • - PCfID, =ev. 09/07/Ol �� D�[k� �D � �� `-- �-' " � a a ��:��.,1�-f�� c�t��r�� , ' c� � jC7��T � � � ��.��,.� ��.� ��.�� o �� °��oa Owner: � Location: � Subdivision: Well Log _ Tax Map�� Pazcel # C/ Lot # Well Construction Distance From nearest Property Line (Minimum 10 fest) (v Distance from Septic System (Minimum 60 feet) (,Qo Total Depth:18 (�} ft Yield: � GPM Staric Water Level: �_ ft Water Bearing Zones: Depth �� ft/7l� ft ft ft Casing: Depth: From � to _�� ft. Diameter: � in Type: Galvanized Steel Weight: Thickness: I j�� _ Height above Ground: �� in Drive Shoe: �/�es No Any problems encountered while setting casing? Yes �No If "yes" give reason: Grout: Neat: SandlCement Concrete GraveUCement -/ Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped Pressure Poured i Depth G to �c; Ft. Materials Used: No. Bags Portland cement Weight of 1 Bag Pounds If mixture (san -gravel, cuttings) -- Ratio to ID plates: �es _ No 4 x 4 slab �Yes No Drilling Log Location Drawing From To Formation G � �5�. 7�s' 8a ,�c �' �- \_ � � � � v a � Q � J��'� � �� I hereby certify that the above information is correct and that this well was constructed in accordance with r+ set forth by the Person County Healtli Department. Signature of Contracto � ID#�� Date �-/7-D�