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A26 125r� ' � H O � W U � a t.,�..� � �� ' d _ �o . �� .. � � . : ; ` � APPLICATION FOR SERVICES >.; , ;,.:: , . _ _ _ w Improvements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) ,_ RepaidReplace existing Septic System Improvements Permit (Mobile Home Replace) ,_ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well ' ; „ '�ater 5ample to bekCollected: . , .r.:_. . .> :. , . .. . rsac�e�ia W Chemical Petroleum Pesticide — Lead 1. Permit requested by: . ,- P�Y J`„k��, �wn /prospective owner/agent: % Y�. Address: � z � �� v� � . ,. ome Phone #��'i � �� 'c'l� t �� usiness Phone #:�q�� 41'�� 7. Dimensions or Proposed Structure; Width: ��T" �"�� T,,...��.. croc��\a.t' 8. Wha[ type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? Name and addre�s of current owner: 9. Water supply t}'pe: � �,r.� private � . public ❑ community ❑ spring ❑ �., �RC,� Are any wells on adjoining property?�'es ❑ No �. .`__� �,, �o -,.,�� If so, identify location: ion: Lot size: Tax Map#: � . Parcel#: � _ � a n , Township:,1�\�f G l'1'-G�' Y�i��u . Directions to property: State Road #& Road �� zt.�cREe l.ok'1 ��c1�r,�,–CRAT.t, c�('�. — Number of occupants or people to be served: �_ 10. Type of structure/facility: Proposed:.�Existing: Q Type of dwelling: M�p� L� R� House: � Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: _�— Garbage Disposal? Yes ❑ No I•� 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 PeI'Son 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. 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. Z Signec� Owner or Authorized Agent Permit Issue� � Permit Denied 0 ��' Plat Observ�d � Signature Date �o;� � � ��_ �� ' '� ,� n C�� -� S r��r ��3 `� � � s. . '.Ft�C?ORSSTtEEVALUA770Pf.�; ...;: ; AAE�'SI >':� < . • A�12., . ;: ,,.. ..'ARFA3 � AREA4 >._ ..: ...: .._ _ . 1. SIAPE (%) S S S PS /� /✓l� PS � ps V�� /.o U U U 2. SOII.TEX7URE(12-361N.) S �� S S S (SANDY, LOAMY. CLAYEY. NOTE 2:l CLA� S G✓ J�-- U U U 3. SOfLSIRUCIl1REQ2•161NJ � S S S S (CLAYEY SORS) S�,/t PS PS PS �� U U , U , S S S S 3. SOII.DEP'CH(IN.) ' S ?6 v PS PS PS / U U U 3. RESTRICiIVEHOR20NS(IN.) S S 5 S (IMPERVIOUSSTRATA,ROCK) S /�/,7 U U U 6. SOILDRAINAGFJGROUNDWATER p S S S (DCTQtNAL R WTERNAL) S / � 4% PS PS PS V U U �. sonre�Ena�urr s s s s l�CO[AATION RA7 E) S /� � PS PS PS �� U U U E. AVAiLABLE SPACE Srr S S S � O /� PS PS PS � U U U 9. STIECLASSiFICATION(SEEBELOW) � ` J SOIL SER]ES S-SUITADLE PSPROVISIONALLY SUITA6LE U-UNSUTTABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property ]ines, roads, streams, gullies, wet areas, fll areas, wells, water bodies, slope patterns, etc.� C:1Ar1IPRO�DOCSAPPSEC.ST1 FWANCE.PC • <. d ��`v�g�� P_-�� t tb-31-�1�' requested by: spective owner/agent: �--. • ► _ � �- - ..,-� � x /zo lV.Lr- � Va ome Phone #: �� 4�� SS� d usiness Phone #: c _ a 2. Name and address of current owner: 3. Pronertv Descrintion: Lot size: � Tax Map#:� Parcel#: �.n i r�l�ve t� � I� . Directions to property: State Road #& Road f ames, etc. 0�� S� I 3 3� Number of occupants or people to be served: Dimensions or Proposed Structure: idth: 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? 9. Water supply type: private� public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 10. Type of structure/facility: Proposed:'�Existing: ❑ Type of dwelling: House: j� Mobile Home: ❑ Business: ❑ Type of business: Number of Employees: Number of bedrooms: �_ Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No 0 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 Pei'sOn 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 a�lication shall become void and all fees paid forfeited. �5 ._. � � z Signed Owner or Authorized Agent v� Permit Issued ❑ Signature Date Permit Denied ❑ Plat Observed ❑ FACTORS-511`E EVAi.,i7A770N �itPA l AREA 2::: AREA 3 AREA C, L SLOPE(�) ... S � S_... . .... 5:,: :::.: .. S : .. . PS PS PS PS U U U U 2. SOIL.7'E7C7URE (12-36IN.) S S S S (SANDY, LOAMY. CLAYEY, NOTE 2:1 CLAY) PS PS PS PS U U U U 3. SOIL STRUCTURE (1236 W.) S S S S (CLAYEY SOILS) PS PS PS PS U U U U 4. SOIL DEP'III (IN.) S S S S PS PS PS PS U U U U 5. RESTRICI7VEHORIZONS(IN.) S S S S (IMPERVIOUS SiRATA, ROCK) PS PS PS PS U U U U 6. SOII. DRAINAG&GROUNDWATER S S S S (EX7ERNAL & INTERNAL) PS PS PS PS U U U ' U 7. SOIL. PERAIEABILITY S S S S (PERCOLAATION RATE) PS PS PS PS U U U U R. AVAII.ABLE SPACE S S S S PS PS PS PS U U U U 9. SITE CLASSiFICATION(SEE BELOW) SOIL SERIES S-SUITABLE PSPROVIS[ONALLY SUITABLE U-UNSUITABLE RECOMMENDATIONS/COMMENTS : SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, iill areas, wells, water bodies, slope patterns, etc.) C:�AMiPRO�DOCSIAPPSEC.SMFlNANCE.PC 'B 1071 PERSON COUNTY HEALTH. DEPARTMENT i ,,, • WELL AND SEWAGE SITE, LOCATION Il�ROVEMENT 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 has been issued. Tax Map # ,�" o� lo Parcel #�� Zoning Township O�i "�P � 1 � Owner/Contractor ' Date ,�r-- / � � �_ Location/Address � � N . sR � a y 2 �� /1-, n-�-�. �� -f-� � T�J [� �� P-1--t" tnl e4r C' r� d �+- Yr� �_�t Subdivision Name �� (� Lot# T� ' S.R.# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area , c� � Size of Tank ��s SFD Mobile Home Size of Pump Tank rv�r� Business # of Bedrooms�_ Nitrification Line �Op X 3� Max Depth Trenches � � " Permits may be voided if site is altered Well and Septic Layout by Comments: Date I�—�-9i �, Installed by Approved by � � l-f Well Permit Paid ELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab _ Public Re 1 ement Air Vent Site Approved Required Well Log Well Head Approved Well Tag Grouting Approved t Comments: Date -`_� Installed by �5 �lil� \ 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 environmental health specialist is also not responsible for concealed conditions on the property or for state�nents in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person Cou�ty 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 , � � � , , / � l� , ;, . � • , , - �. _ =`, � - ..,� �� . . � -�� ; - . . _t , ,�. , , • . � r _ : •_ _.. , : � . . . , 1' � - . . . . � . .. . - . /t . ' . ' ' � . • . /t� ' ALFRED F. COLE. JR. : � . . J . . . .. - .. � . P!. QI. 1 .. ' _j . . . . . . � - � f •. . . C.B. 19 i � Y'. f � ' , � ' / • . �` ' Ci�NtROL CORNER . . • �� 1 NF @ STCNE FOUt•ID �- \ „NS � ! �TY, N. C. 8� ASSOC. -65 p• 500' 600' N�� _ �— � � . � co � - - ,,;� �.._ . S85°36'28"E 60---�_ o?y ',� / y, 4B, F MF\ ,� S \ �� `�. �� 2. 46 AC. G. � \ � � �;;•. R /•.ti' \ . • NS �� `. �� .-O FI `. . ' �� `� V • % ' �� . 'O / � `� . � �� ,; � : j �- , ,. _ /� ';�� . • 30.OJ`��. �� - ;,. _ . . . .f �• wQP � � � . . . � � � 1 �`. "� �.. � _ . : � 1 .q� 3 .� ��;� Q� . � o , � :� �r� 2: 7 9.A C: F- , N �,� ; : � �_ � �Q' � '.1� j z� : � ; �� ti i �� U' ? � ��l ��il � �,� l �n ; � a �'' �� ! � U !(� �b�l I��1S' J �\ ' � W1?1,L �.pG ' I�atc: � �9 - 9� �wner:.� „�,• .�z��-� _ _ SR�t /�.�� Loc;ation/Direc �ons: ��a 521��a fo/33y�0�;�/�,ee ;Lo�z _� . .� S u h. ....._...,, . d i �� i �: i � r� ;�am e' �.,r' �� ._.. _ ____ ..._... .� _.. --- �.0 i i� � .� : — ... 17r'illing Contr�tc:tar: ��.��-�`�'�.'�.�1�,C�� ` ��..�._..... ._.__ _. _ ._ NT n Dist;�r�ee fr�s�� Nct�tc�s� Pr�p��y Linc �_ D;st�j�c;c t�r�>,t� Saurce; of I'oliucion /o� Tv��l Dep,th:_ aas_,�___ Ft, Yic1d; .3 GPM St�tic Water Level Ft. 'Water Bcaring'loncs: Depch _ /,.�U Fc. �a� �t.___y__�Fc.___`___Ft. C'o,sing, Dcpth: Ftom,,,,,,�_to_,�� Ft. niarttetcr. Gl� _Inches TYPE: Stce1 Gnlvaztire� ,Steel ✓ if Stccl, docs owr�cc np�xovc: Yes No yV�ight: /.�,,,.,_ Thic�cn�ss: /� c�H 'g}�c A,bc� Gr�und: /�, inchcs Drivc �hoc: Ycs �c/ No .:� .� Wert %oblcros Encountcrod in Scttin� thc Cesin � � -� --. ,. �� • Yc�,_,�____ No v }' C. S�' 1 i C f:;.t $ J^; -�--".-..� C�rout: –"� r" " Z'Ypc: Ncat_._.a! ,Sznd/Cctllen! ----- . C.oncrctc Aruzt►lar Spacc dWidth__„___�-_��jnchcs T ��' Water �n Artnulat Spacc: Ycs„�,__ lyn ,.,� _ Mcthod; Purnp�:d____:____ P�ressure___� ;^__ Pourui_, / T�cpth: Fr�m_��,� to � F�_ Matctitls Used: No, $�tg$ Portiand Cemr:;t____� W�ight of 1 bag„9��ihs. If mixtur� (sc�.nd, gra►vel, ctittings) - Ratso�_.� ,�� ID Platcs: Yes.,,,_✓, No_____� —` �' ` 4 x a slab Y�s� .� ,� No --_.--_�_. �,INC; I,O�; De th --- ------ Fr�rti T� Fotmation Uc�M`w �. �tio� �, --- — --__r__ �. ___.. �.� .�US" --..e, ._.._._._.�._—____ , , ,t�, i�, — -- • �.�_._...._._.._ � ---- ---- _ � � _ — _.. _.._ ____._� ; H�REBY CERTIFY'�NATTHE,�3pyEYNF��tM,��rI�N �S C�KRL'•Ci' ANU'!'H�'f' TF�IS y��L WAS CnNSTRUCTED TN ACCORt��c��E w�t'CH K�c �ULA't�tc,�Ns �ET FORTK RY�TII�: PFi2St��; c:';':�;,;'I'�' H�ALTH ULPAR"�'MEN'�'. !' C . � � i3�%�;� �ibn<�ttsrc uf C'��rttr;�ct<�� __ _ -_ � '�'9� !),�t,. �� l � �� v� � �� L./ � �L.J �� IE��s��¢�.Il 1�3I��.Il¢]� Date: (� /�/_ � Nams: M oL�,� Tar. Map: , � Patcel:�' Address: 7 ,� � 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 resulis are noted below: No coliform bacteria were detected in the sample. Your well water is safe to ase f�r d: inking, cooking, washing �ishes, �athir.g �x►d shewerir.g, based on the hacteriolegi�a! resrdts only. � Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. 'L'etal col;arr,: bacieil^4 S.T: n4turslI;� fo�nd i:� il:e soi1. Fecal caliform ca�teri� ar� associatcd wit�t animnal and/or human waste. The, presence of either total or fecal colifbrm bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated gr�undwater may be entering the well. If colif�rm bacteria �re present i.n yor:r r>atQr s�mple, the a�ater 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 jecal coliform bacteria should be properlv disinfected and retested nrior to resuming normal use. The well mzy 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, �� . �z�%� ^ . Environmental Health �pecialist Person County Health Department (rev. 4/20/16) Persor. County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences IVlicrobiology Certificate of Analysis Report To: PEI�SON CO ENVIRONMENTAL HEALTi H 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sam�le ID: ESQ61416-Q06�001 ! ��l�� I�I �� I! (��u �� I� �� I��I �� 1�� l� ��I� ��I �� ) ES Microbiology ID: GPS Number: Sample Description: Comment: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Name of System: CATHERINE REYiVOLDS 175 WINDING TRAIL DR. ROXBORO, NC 27574 Collected: 06/13/209E 14:00 Received: 06/14/2016 08:27 Sample Source: New Well Sampling Point: outside ta� H. Kelly Angela Heybroek Well Permit Number: A?6-125 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Coliiert Analyte Test Result Analyst Date Total �olEform, Colilert Present Susan Beasley 06/15/2016 E. c01i, Colilert Absent Susan Beasley 06/15/2016 Report Date: 06/16/2016 Explanations of Coliform Analysis: Reported By: Susan Beastev i f , � 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 shouid not be regarded as a cdmplete r�port on the water suppiy. �� S nc deparFment of heaith and human services Private Well Information and Use Recommendations County: � Sample ID #: - . Fo� Inorg�nic Ch�rnical Cor►t�rninant� � ! �.c,,�_y TEST R�SLTLTS AND USE RECOMMENDATIONS 1. � Yo�.�r well water me�ts federal drinl�ing wat�r standards for i�aorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anir chemical results ondv. You may have other water sampling results that are not taken into account in this report. 2. U The following substan�e(s) exceeded federal drinking wat�r standards orthe North Carolina 2L calculated health levels. The North Cazolina Division of Publie 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, bsth:ng and sho�✓ering based on th� inor�anic chemiral: esu[ts onlv. Arsenic Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron Man¢anese Mercurv Nitrate/Nitrite Selenium Silver Magnesium Zinc � pH 3. [� a. Sodium levels exceed the jJ.S. Environmental Protectien A�ency'� (USEPA.) Health P.dvis�r}� level for scdiu;:� o� 20 mg/1. Tne N�rth Carolir.a L'i•rision of i'ubIic Healtn :ecommends that on:y individuals �n no or lo�v sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inorPanic 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 icitchen) and if possible a first draw, 5 minute and a I S minute sample a± 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 tl-ie inorpanic 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 Cadm�um � Chr�mium � Fluoride � Iran � Magnesiiim ivlan�anese Selenium � Silver pH ��inc-� For more information regarding your wel[ watv_r resulls, please call tlle Nortli CarolinQ Division of Public Healtle nt 919-707-5900. Report To: H. KELLY North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry �ERSON CO ENVIt�OiVMENiAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN: 566000331 EH StarLiUIS ID: ES061416-0038001 Sample TyGe: Ravr Sample Source: Well Sample Descria±ion: Comment: Certificate of Analysis Courier # 02-33-75 Date Co�lected: OE/13/16 �a:e Received: 06/14!16 Sai�pling Pc,int: Outsida tap Temp. at Receipt: 3.5 Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto:!/s�oh.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 GA7HERIN� REYNOLDS 175 �YINDING TRAIL DR ROXBORO, NC 27574 Time Coliected: 2:00 PM Co�lactad By: H Ke!!y VVell �e� mit #: �6-125 GPS #: 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 Cadmium < 0.001 0.005 mg/L Calc�um 2 --- _---�� ----- - C� �lor�de — --- --- < 5.G0 25r mg/L Chromium < 0.01 0.10 ___ mg/L Copper -- - < 0.05 1.3 -------�------ - Fluoride < 0.20 4.00 _ mg/L _ _ Iron < 0.10 0.30 ___ mg/L Lead < 0.005 0.015 _ ng/L _ _ Magnesium < 1.0 __ mg/L _ ____ Manganese < 0.03 0.05 _______ mg/L ___ Mercury < 0.0005 0.002 mg/L Nitrate 1.30 10.00 ___ mg/L _ Nitrite ----- — < 0.1 1.00 -------- mg/L ------ - pH -------- ------ 6.9 -------------- ------- N/A --- --- ------- --------- ---- -- -- Selenium < 0.005 0.05 __ _ ___ mg/L _____ ___ Silver < 0.05 0.10 _____ mg/L Sodium --- 6.50 --------�� ----------- Sulfate ------------ — <5.00 ---------- 25C ---------�'�� --------- -------------- ---- ------- - TotalAlkalinit�--------__ _ _---_------ 13 _ .--�---- ------- ----- Total Hardness � � _____________ -_____._..____mg/L ----------- ___- _ ----- Z�nc 0.10 5.00 mp/! Report Date: U6/23/2016 Page 1 of 1 Reported By: ae6aie.�foncoi