A26 214Application Date: D I
Amount Paid: ZOI�
Receipt #:
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Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 �ndl
Mo6ile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$ 3 00.00/$ 200.00/$ 75.00
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i[=.' z��+-a�•<D��:an�.:�s�, Il IHI�-�, Il11�
ilication for Services
Services Reauested
Tax Map: �
Parcel#: �� �
���'� N �
�, C� �
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Ezisting Septic 5ystem
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf matio : �`��`� �/��' ���2�
Name: /�i' .,c� �.U�(_��S Phone (home):.�J� ��'�'�(��� (���
Address: • (work/cell):
2) Name and ad ess o�' current owner (if different th,�tn applicant):
Name: / C�acl�
Address: a S �l
Ec�s��. G � 77 �
3) Properly Description: Lot Size: j'd s"�'"Subdivision: Lot #•
Address and/or directions to Property: �n.e+ �n r'I/ �t-� ��/'�- �- —
❑ yes '8_�"n Does the site contain any jurisdictional wetlands?
❑ yes Cf no Does the site contain any existing wastewater systems?
O yes �s any wastewater going to be generated on the site other than domestic sewage?
❑ yes �� ��the site subject to approval by any other public agency?
❑ yes [�J-r� Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑R ilential � �x S� �
ew Single Family Residence Maximum number of bedrooms:
� Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? 0 yes �With plumbing fixtures? � yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: W�Qew well ❑ Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes Q�r�
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative � Other ❑ Any
I cert� that the i� formation provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
T� - S,� - J�f
Date
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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S 79 194p� E I
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Applicant; j�R:�1��� �n%�ODS
Address/Location: Mov�vJ. �
Taz Map: �'� Parcel: Z/�
Subdivision
Phase/Section/Lot #
b
Improvement Permit
Permit Valid for: Five Years 7(, Non-expiring
Type of Facility: � S3R �a�1.S'� New x Addition _
Number of: Bedrooms / Occupants8�x/ Employees / Seats:
Proposed Wastewater System: Atcit�rEA �+ a5%� P-�O�ct�a�—
Proposed Repair: A��+c�E.� w �i�c �.1��c�►v
V4'ater Supply: t�vc� w-�
Projected Daily Flow: �'O gallons/day
Type: �S6
Type: �6
Permit Conditions: 1"u��th�'t� Sr� � sv��. DiS��''� � C�Sv�Q P�10 �.,� �+�v�s�c,r� L�3e� 5�`j- IhgO
Authorized State Agent: 'D�y�. 1
(X) Owner or Legal Representative:
Date: I-�a-1 S
Date: 5 � � � 1
The issuan�e of this permit by the Health Department d�es not guazantee the issuance of other required permits. It is the responsibility of
the applic�ntlproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws
nnd Rules for Setiva�E Treatment and Dunnsa! Svstems'(15A NCAC 18A .19Up). Neither Person County nor the Environmentat
Health SpEcialist tivarrants that the septic system rYill continue to fanciivn satisfactorily in the future, or #hat t�e water supply wifll
remair �otabfe.
Authorization to Coostruct Wastewater System
See site plan and additional attachments �_).
�
Proposed Wastewater System: �1c.cC.S'cEA w' �Sya '� (*)Type"�.13� Design Flow y�� _ gal./day
Nev� �( Repair _ Exp�ansion Soil LTf�R: �•� gal./day/ft2
Type of Facilit�: y-�R, HouS�, Bsser�ent: _ Yes j� No
(*) System Types Illb, Illbg, IY, und �; require periodic system inspections by ti!e Ferson County Health Department.
Wastewater System Requirements
Tank Size: Septic Tar�k ��� gal.
Urainfield: Total Area �y�0 sq. ft.
Trench Width 3 ft.
Pump Tank `" gal
'fotal Length �SO _ ft.
iVlin.Soil Cuver � in.
Grease Trap `" gal.
Max. Trench Dzpth 16 in.
Min:Trench Separation � ft.
Distribution: Distribution Box� / Serial Dish•ibution i� / Pressure Manifold
Specifications: �-�� d+t. S�WP�- ��vraY ; 1F ►ki��. A D-AaX_L 1�A�-�a��.\ '��4�-
�a6� �,��.s. - -
Authorizzd State tlgent: p���l�- /a- St-�Ti� Issue Date: �-�o� ��5
Permit Expiration Da�e: �-� °'ZD
T'he system permitted is: Conventional /Acczpted �/ Alternative / Innovative . i accept the cotiditions
and specifications of this permit. /�
(X) Owner or Legal Representative: �1�-,---_-, Il�- ��`� Date: 1 5
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN '
Natne ��1E �"� `1�� Tax Map # .$ ZLy Pazcd # �r/ �
Subdivision Secrion/Lot#
Q�i�•1G1, . SMc'}� l -�o- 15
Authocized State Agent Date
System companents teptesent appmatimare contours on/y. The conttactor must flag t6e system p�ior to begianing the installadon to
iasvre rhatpmpergrade is maintained.
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��n�n.a-�an�*-n-�+ ¢��n��.Il IFIC��.11�I�n.
Applicant
Location:
Tax Map � Parcel #-� I y
Subdivision
Phase/Section/Lot
# of Bedrooms y
System Type (From Table Va):
Type V& VI Expiration Date:
Operation Permit
Product (IIIg): Z
Type V& VI Renewal Date:
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
���
f
Authorized Agent)
Pi, Lewis
(Licensed Contractor)
Scale �
PCHD, rev/12/14/12
-7— 2v —l�
(Date)
�-2o—i5
(Date)
r(,�i �ot5
�I �el �
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Tax Map: 2(� Parcel #: �_
�
Septic Tank System Checklist (Type II-I� System Type: ,1�1�
T
Notes:
Nitrifcation Lines
Trench Width: ,3 ft.
Trench Depth: �$ in.
Total Length: �{8'p ft.
Minimum spacing: '� ft.
Rock denth/aualitv
Grade (< .25" in 10'
Cover (6" minimum
Setbacks
From wells
Property lines
Foundations/basements
SurfaceWater
Other:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
InitiaUDate
✓
,/�
�
-20
�
Tax Map: �
Subdivision:
Applicant's Name:
Mailing Address: _
Phone Numbers:
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IE �ra.wn u- ��a �r�n. m �ra d.m.Il IE3L ��. ��l�a
WELL PERMIT
(New� Repair_)
Parcel: 2 i y
Pcft.S�r� W�f1iS
Lot:
Location of Property: 1'`��'o� ��aa�.y�st-� � A�� �� 3yib
Permit Co�ditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: �-���- i� - 5�'�
Certificate of Completion
�New Well:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
EHS/Date
, i5-t5
� _`'��'(s
Date: I��o-1S
OL,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date: _
Method/Materials:
Well Driller: �rnQ,�� License #:
Pump Installer: ` License #:
Approved by: , Date: �- ? o -/S
Additional Comments:
Date Sample Collected: "'1�-�- S Date Results Mailed: - Z�� /S
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 11/26/13
This fornt tan bc atcd fa ;
1. Wd Contractor Inl
Q .
Wdl Contnccor Name
} 3 7d �,
xc w�u cona�� c«tii
Barnette V
Compauy Name
2. �i'eU Constractioa Pe
Ltst all app/icabla wcfl consi
3. Wdl Use (check wdl
Watu Snpply Wdi:
QAgriculttual
❑Geothamal (Heating/(
QIndusuiaVCommercial
Non-Water Supply
�Aquifbc Recharge
�Aquifer Suxage and
❑Aquifa TesE
pE�erimental Techn
OGeothetm2l (Clnzed
QGeothcmal (iieatinl
a. �c� wai�s� co,
Sa We(l Location:
FaciGrylQwner Name
p}rysicat Addras. City, and
�� �
Counry
56. T.afilude and Longi
��w�n s�aa. � i�rnoas �
�6-Z�-�t
or multiple w�tls
.—�
H�
1 Drillinct. Inc.
� L�
rrmiu f.t Cnrmry. S/au. Vorinnce. etG)
�Municipal/Public -
Supply) �idrntial Watu Supply (single)
❑Residential Water Supply (shaced)
❑Gcoundwater Remcdiation
❑Salinity Bartiu
�Stormwatcr Ihairege
OSubsidenGe Contiol
❑Tracer
For lotnval Uu ONLY:
SO�L /iaDft �
L u�`' 2,�n� .� �
�s: ou�r� c�suvc r� m�a�
FROM i'O DL�l1i1
Q {�. � v ft � �
0
1 B:INNER GASING OR TOBING
FROM TO DL�MI
ft. Et
(L f4
ft tt
[t ft
tOilT: -
ro '
ft O ft
Ea �
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tt 2
i°' 1 S'L�i�2! � �`G/"�
e� a��
THtCtINEss MAteR1AL
ia
in.
olingRLNm) ❑Otha(eacplainonder#2lRemarks) 1 fk �Q «' � �'� gJ�/3%j%����``�/✓�-
�% (� �- //� !i L>i° `rZ 1/f.J� '!1' S�19/Y�''r� 3 ��G
� I w /l-�,wC�� ��� �v Z� � � ft � � d C��
tz rc
GZi �a eQ ' '—:� �. sc
FaciliSylD#(ifapplicablc) � f�
�� �`/�i �-r ��_ fL ft
p Fj 2YiliEl4tARIGS - -
/ / ���
parccl IdertificationNo. (PIl`�
dein.degrees/mivates/scwudsor decimal degcees: ?.2. Certif"eatiou:
dLc;eax) _, �
; N % `� ' G' � `� � w �+�n��- ,/`� -��c��' - ��`L�
s��ofc�s�a w�t c�u�� D�.
6 Ts (arc) th� wdl(sj: ermanent. or �TemP��'�T By stgnrng rtas jorm. I harebi' �+�lY � nc� welt(s) K.zs (vne) crnrsrnrcted in aaardo»ce .
wrth ISiI NC.9C 02G .Ot00 w ISA NGAC 01C .0100 fYe!! Consavtuate Standar�s mid tl�t °
7_ Is this. a repair to an isfing:wel[: �Yts or OPIo aopyofihu +ecn+d has bcenP+flvtded ta!he w�li owner.
ff d�ts is a npatr, f+l1 om we(I consupction trr/'ormauov� m+dcsplai.n du i+murr ojthe �. 5ite diagcYDt or sddafionaIwell detailt:
rrpair wider EI L remarla ion oran thc beck of (hJ3 fortn.
You may usc t}ie badc nf this pao�e to provid4 additionat wefl site dctails or well
8: Number of welis co trvcted' � construction dcfaiLs. You may alsb.attaeh additional pag8s if necessary. .
For muGiplt injecrion or n-watu xu�ily vells ONCP with �T+� samt tontlrut6or+. yrou cm+ SUEMIITAL INSfUCfIONS
avbmlroneform.
9; Tots! wdl depti belo .13ed sarfaee: ���Q ((t) ?�4a For M Welis Submit this fam withui 30 days of completion of v�ell
FormrdtlpltwellsGsial/de rhsifd�'eren�iQmtr�t-3�IOO�mrd2(t�100'% ccffiStfuCtionfothCf0lloWing:
I0. Static water level b ow top of casiug: !� � ([t) Diaisioa of Watcr Qu�lity, Infarmation Processng Uoi4
!f iwter levtl ts above c�osrn trsc '+'
1617 Mail5erv,ia Center, Itsleigh,l�TC 27694-1617
11. Borehole diameter. O (im) 24� For Iniection Welis: in addition to sending the f,atm ta the addtncs in 24a
� l •� above� atso submi� a copy of this fotrt within:30 days of oompletion of well
12 W ell construction ethad: ,'�� � �1h /' /tt �'� � c�n�uct�on to the fallow¢m&
(�c a„ser. rotary. cabte, ' p�uh, eu.) Division of Witer Quality, Underguund.injection Contrd P�ognm,
FOB WATER SITPPL WELIS ONL'Y: 1636 A4ail.Scrvice Center, RalegL, NC 27699-1636
I3�. Yidd m Method of tesk B�oWn20 minute 24c ForlVater SuaniV & IniaHion �Velir. In addition ta sending the form to
igP ) tfit addie�.s(cs) abovy aLso submit one copy of this fwm within 30 days of
completion o€ wdt constnution to tho cauity health dc�azanart of thc county
', 136. Disiafection type: HTH an,o�� 1/2 Cup ,�n� ��r�ua.
Focm GW-1
N� �Iina p�a�mt o[F.uvironment and Na4aa1 Reso�ac�s— Divisim of Wa1er Qvaliry
Rcviscd Jan. 20 t3
��
������
ne department
of health and
human services
e � ( �
'Sy.�� �� � 4 � A._..� � �=� • ��•�.t � -1 5 E � .�.. f_� �,.. y�.C� � ..�. �.� �F
i c�_ ` � � f q
i € � � �� s� � �9� � � ! w•'i � i E I� �,.�t�� I
,.-„ -•. 3 K e �. ��- .., f--b � -,. L-�-.
�"''� I�^� � g ��� � -���``'`�t t(���`V�(�s rtr � .►�{ r� tkt ��.
+�,': ' ( t..S L....�' _.." �....�� R �t 4�1' �-✓� `•� S E e E e t�'�� /�� f i,j �.�4 f_ 6 �•? ! E l� �
For lnorganic Chemical Contaminants
County: -Q�/' o✓� Name: Q r ; e d�
Sample ID #: 2— 2( Reviewer: w�f,r
� TEST RESULTS AND USE RECOMMENDATIONS
1. �Your well water meets federal drinking water standards for inorganic chemicals. 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 inorQanic chemical results onlv.
Arsenic Barium � Cadmium � Chromium � Copper � Fluoride_ � Lead � Iron
Maneanese Mercurv Nitrate/Nitrite Selenium Silver Magnesium Zinc pH
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 inorQanic 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,
cooking, washing, cleaning, bathing, and showering based on the inorQanic 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 Cadmium Chromium Fluoride Iron
ManSanese Selenium Silver pH Zinc
For more information regarding your well water results, p[ease ca!! the North Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health
Report To: ADAM C. SARVER
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Envirot�menfal Scier�ces
Inor�anic C�temistry
C rtific te of Anal sis
e a y
� 3 �15�
Name of System:
PORSHIE WOODS
MORTON PULLIAM RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID
Sample Type:
Sample Source:
ES091515-0039001
Raw
New Well
Sample Description:
Comment:
Date Collected: 09/14/15
Date Received: 09/15/15
Sampling Point: Well head
Temp. at Receipt: 1.5
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slph. ncpublichealth.com
Phone: 919-733-7308
Time Collected: 11:00 AM
Collected By: A Sarver
Well Permit #: A26-214
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
Calcium 2 mg/L
Chloride < 5.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium < 1.0 mg/L
Manganese < 0.03 0.05 , mg/L
Mercury < 0.0005 0.002 mg/L
Nitrate < 1.00 10.00 mg/L
Nitrite < 0.10 1.00 mg/L
pH 6.9 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.90 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 22 mg/L
Total Hardness 9 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 09/21/2015
Page 1 of 1
Reported By: Debbie Monco/
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
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: ES091515-0076001
� ������� (����� ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
PORSHIE WOODS
MORTON PULLIAM RD
ROXBORO, NC 27574
Col lected: 09/14/2015 11:00
Received: 09/15/2015 08:23
Sample Source: New Well
Sampling Point: Well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
httq://sloh. ncaubl ichealth. com
Phone: 919-733-7308
Fax: 919-715-8611
A Sarver
Angela Heybroek
Well Permit Number:
A26-214
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present Susan Beasley 09/16/2015
E. coli, Colilert Absent Susan Beasley 09/16/2015
Report Date: 09/17/2015
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.
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
_______ ROXBORO, NORTH CARQLINA 27573_ _ .
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant f'(h'���Q �,(%����
Address �Sy��� �{��i:A� County a
Collected By , �
Date Collected �"Zi—[5 Time Coliected �� Sv
Source:`�Well ❑ Spring o Other
Location: ❑ House Tap �Well Tap ❑ Other
❑ No Charge '�Charge
�- a'
0
..............................................................................�
**********************************************************�****�********�***
Total Coliform
Fecal/E. Coli
Results
Present
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❑
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Report Called ❑ YES o NO
Called To
Absent
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Y