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A26 60�� } . Evaluation Applica-tion� A �. -'L� .. �� . . Fee Collec`.ed YES NO � �. �- �55 CIL � � 5� � D a t e : �"N � � ��f � APPLICATT.ON FOR IMPROVEMENTS PERNiIT 1. Permit requested by: awner ospective owner:�G '^� -''a f �j r �agent � —� ,✓�/ ✓��rorn. � Address : � "`� � o �'� Home Phone �� : 9/� '" d'��%'.` Bus�`iness Phone ��: ' 2. Pdame and address of current owner: �� 3. Property Description Lot size: � �� c�"a,r // '�/� �4 d/�'vc l/i' �/ 4, Tax map �f: Towns ' : Subdivision Name: � � S. Directi��ons��roperty: State Rgad .J / �(/O e" G2/J� i" o�' / o�s 4� JCc / rs / D _o-✓co�-� C �--A�� etiJ^G o.V / J/� /�i��" � 1 �il � 1 � . � � , v^ % A � � �� f� o � -�Z ..�`.S' /v� & R/oad Name,s�tc . ^ . . U f.'Jsr �-�` ou. � l`i�o.o.. - � cs. c � �aC e., . s �./ �� i � - - - 'ir�c-J`/si� . .Pc�.. � -/. .. . . . t� 6. Permit requested for: New Installat;ion_: Repair: Addit.iona,l.Ren�ovation re-using present system: 7. Number of occupants or people:,to`be�.served: � • -- � ,, 8. Dimensions o£ Proposed Structure: Width: ��•' Depth: �� 9. What type (if.any) additions, expansions, or replacement is anticipated to the struc- ture or faci7.ity that �his sewa� ge disposa�r system is intended to serve? /' �/ .Z- �` �. r-� �.� .,- Y.� o.. .� e w. i� . .� �rsc �.r .r �` �' -m-� �a`- r'' ° ✓'N t ve-- 4L .0 s� ". c i-a �'i ��✓� i e• r.✓c• � r' ea r.t/ /' u e �+° e v�' � �' " Wa•ter suppYy private? � public? Other source? (Specify): Are there any wells on adjoining propert,y? 10 11, 12. community? __ _ spring? If so, identify location � .. \. �l / re •! i,�r�.v � Type of structure or fac.ility:.:; P;r:o.po.sed: ✓ � �Existing�.fj�o-�+� • Type of dwelling: House.:.� � � '� Mobile Hom . Business: �� Type of business: � •:.:��:.� Number of Employees: C Number of bedrooms: Garbage Disposal? Yes ro � Basement? Yes No �:.If so; number of basement fixtures: Clearly stake all. corners of -th:e ptoperty.and the corners of all proposed structures. .... , .. �� I hereby make application.,�t:o..'ttie .Person County Health Department for a site " ` H evaluation or existing system e:va:lua.tzo'n for the on-site sewage disposal system for g, the above described proper:ty....',I��agi,ee' that the contents of this application are true �"' and represent the maximum fae;il-it,'ie's�to be placed on the property. I understand if �. the site is aTtered or the intended':'use changes, the permit shall become invalid. Permits are valid for 60 months �fr:om.dat.e of i ue. Permission is hereb granted to enter the property for the evaluation.- G.S. 0 3�) / //. : v/ . - ';;.: - . . . .. , ... . ... : , . , Si ed Owner or A ri d Agent i , � i t . .. : , ,_; �� . ..,._� _..,.__c � . ia�_ Qbser�:ec. :'��"L�R� - SITE 'G�IALUATIO?d AREA 1 ARFA 2 ARF.A 3 A,RF.A 4 � '. . 5L0�� ,r ----.. SC : �—'L: .: �CTi�E ( "t2-36 :n , } {�a�d}, icamv, clayey, t,�t� 2:1 clay) � �OIL STFUCTURE (12-36 :in. (Claye}- soils} .. S O Ii. D EP'r'H (�_n -) . ?.ESTRICTI�'E HORIZOHS (a.n. ) (I�ervwous Strata� rock) �, ..J SOlL JF �I1�.GE!GROUNDWATEF? (� ternal & Internal) - .� SGIL PEFL'-`'�'�ILITY �Percolation Rate) OT'r.ER (specify) S PS U S PS i.t S PS U S PS � U '. S PS . U ' S PS . U` S PS U S P S. : U_. . , ._.v�._.__... . S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS ;t S PS u S DS U S PS U S PS U S PS U S PS U S PS U �. SITE CLASSIFICATION (See belov) � SOIL SERIES .� ` • � S-- Suitable PS - ProvisionalJ.y Su�,table U- Unsuitable � = CO:�`��ATZONS /COMMEI�TS: �T:� CI.t,SSZi'ICATION DI.F.G�tAM (Irc1u<ie: So{1 areas, property lines, roads, streaas, gullies, ue� areas. fi�l 3reas� wells, �a�er b�dies, slo�� patterns, etc.) � .�`9�-. � �'8?' 5�� ,P�. � a� U � cd a Tax Map #, Zoning_ Owner/Con Location/Ac � � ��: �.�Y n ��- � � , .. PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Parcel # Subdivision Name Lot# vr • � SEWAGE SYSTEM SPECIFICAT'IONS ttepa�r�/ Lot Area �n�. Size of Tank S� Mobile Home Size of Pump Business # of Bedrooms�_ Nitrification 1 �� Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered o' en e c nged. Well and Septic Layout by Comments: Date �/- /8'�� Installed by,� Lc�,.r i Approved by, ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab _ Public Replacement Air Vent Site Approved Required Well Log Well Head Approved Well Tag Grouting Approved Comments: •� Date Installed by Approved by, This report is based in part on information provided the homeowncr or his/her representative in the application submined for this permit. Tl�e environmental health specialist is not responsible for false or misleading information contnined in the application. The environmental health spccialist is also not responsible for eoncealed conditions on tho property or for sWtemenLs in this report that may have �+csulted from false or mislcading statements provided to him in the application. Neithe� Person County nor the environmental health specialist warranu that the scplic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam Ol/95 rev.1.0 � ,, r �c9' �a `�a �� s � � ' �� S� c. L y� �\� ��r�i� PERSON COUNTY HEALTH DEP A ��} 5 3 WELL AND SEWAGE SITE, �TMENT LOCATION IMPRpVEMENT PERMIT Tax Map # (� p�cel #_� p Zanirig TownshiP p/ ' P U1,�,ner/Contractor .. ' �� Location/Address `—' Date — �_ g,� ,n �"1 ,� , , • /l,,l- _ 1.` �.� ,. 1 r � - Subdivision Name. rayout / �� `1 �� 5 J�, 5(ee,r�ie w � �"4 .ove� �� Lot# SEWAGE SYSTEM SPECIFICATIONS � �� 7� J` �� s� y� y� HP s�,� pF Repair Lot Area�, R�78'�, �.-�J Size of Tank �(� �v� . SFD Mobile Home Size of Pump Tank ,� 1�_ n `�,.,,�i 3 K✓` #� Bedrooms 1a ��'� Nitrification Line / � %' / G _ J� � n� hk�,-��.'h /n Yil/fr�z� p �� jv �✓�f�',"'�2� . M� De th Trenches � � pe�t Void after 60 months. Permit Void if not in compliance with zoning regulations. permits may be voided if site is altered or ' en ed u e changed. Well and Septic Layout by Comments: _ Date - / /�.�7� Installed by_�' ��i o � ��Approved by ,. . G WELL SYSTEM SPECIFICATIONS Individual Public_ Site ApProved Well Head A G ou ' PPr Comments: Da e� Semi-Public Replacement � Installed by xe d Slab �r��Vent Required Wel Wel/ __o Approved by 'pus repo� �S based in part an infonnation provided the homeowner or his/her representative in the application submitted for this v ��uo�ental health specialist is not responsible for false or misleading information contained in Ute appiication. 'p�e ehvvontnen�� ealth 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 P�°�ded to him in tha appl]cation Neither Person County nor the environmenta! health specialist wanants that the septic tanlc system wi�� continue to function satisfactorily in tha future or that the water supply will remain potable, c:lami o Pr �pemutsam Ol/95 rev.1.0 ORIGINAL Application Date: 3 �� " ( � Amount Paid: I 6� UD Receipt #: 1 �— I ( %� �-`#"'46 `f An ❑ Improvemeat Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mo6il� Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 '�..��,?,) f ll Jld��L.1�� Tax Map: �'7� � � ��.� Parcel#: —7P0 J��rao-a.a-�cnAnmeas�sn.d.s.� ]L'��.si.]��.��. for Services Services Re uested � Construction Authorization (Fee is de endent on the e of ❑ PermetItc�ision ❑ Repair of Existiog Septic System Application: No Charge/ CA $150.00 or $300.00 X 1) Applicant Inform tion: Name: C� �, d✓1 r.� e.� �n p� Phone (home): -S�'1r� :5�� Address: (work/cell): 59 Z i S�i 3 ,C 2) Name and address of current owner (if different than applicant): Name: �..; � (,�a� 5-�a F� Phone: .�'r( �% � �% %� Address: S 3?O ,5�mora � t�,,n��.�o� !t1 C. a?cS7� 3) Property Description: Lot Size: /� �i Subdivision: Lot #: Address and/or directions to Property: � �' 3 70 �� nti a �r-G �d ❑ y�s L`�no Does the site contain any jurisdictional wetlands? �es ❑ no Does the site contain any existing wastewater systems? � yes Cd no Is any wastewater going to be generated on the site other than domestic sewage? O yes C��n Is the site subject to approval by any other public agency? 0 yes CTno Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4�posed Use and Type of Structure: esidential 3 ❑ New Single Family Residence Maximum number of bedrooms: � ❑ Expansion of Existing System If expansion: Cunent number of bedrooms: rJ Repai.r te Ti�alfisnctioning System �'Vill there be a basemeat7 ❑� es �n^ With plumbing fixtures? �s ❑ no ❑Non-Residential )r�. �ZS- 8�� e��(e�s..'o, �,,1 ] Type of business: Total Square footage of Building: ( Maximum number of employees: Maximum number of seats: 5) Water Supply: ❑ New well C�-Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional 0 Accepted ❑ Innovative 0 Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. l also understand that if the information provided is inac �ate, r ifthe site is subse uentiv altered, or the intended use chanQes, all permits and aPnrovals shall be invalid. � �� z Signature (Owne egal Representative*) ate * Supporting documentation required. 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) , � � � � � �? � ` � . � .� �� , �� 6 d� -� � � �1./� � li � J:t_.:.d.liTl.�]I1I"{� � 1iiS.71(�Zi�i.«,.Ei.� �� JiCtia[�.11i��L � �ann�a��a�� 6�fl$Il�Ilfl�I P✓g�I�D�flc� ��fl� ��D��flHIlt��Il$5 Tax Map #:�_ Approval i�equested for: Parcel#: 1Vlobile Home Replacement Building Adclition flppl:cant Narxie; 5�' Address: . o b a C 75l Phone #'s: i 1f� � q�l -- S I`7 � Permit Located: ✓ Yes No Installation i�ate: -� Design flosv: 3� U(gpd} Current Contract with Cer#ified Operator on file (if required): Water Supply: �/ Well Public or Community Wastewater system shows no visual evidence of failure on: 3— Z 8— � 2 (date) (Applicant's signature if site visit is not required) ��n�a��p�� °�� , 3 � �9 -1 z Envir ental Health Specialist Date 11/15/OS . _ . . . � . :.��, �(� �� `�J'd. � . .) � � � � �1.J 1�1 �� 7E�m�vnu-�,r,,,r„-,• ��.11 ]H[�a.Il�a . _ � i SITE S�TCH �� . � � Name � � Tag Ma # �Z�e � Patcel # �� P . Subdivis' . � SPctinr�,/L.�t# � . � �-29-�2 . . Authorized .State Agent . � Date . System campor�ents ne�resent a�'i�iroaaimata�contours only: The contrac�tor mustfkig the system1Drior to ; _� beginning the installa�tion to insure that propergmde is maintained o� � \. ��5 �� we�� ih asemPrt�'� ��-�--�.�,-�-�:�:.M�..�,_.:, ��"'� ��i':�� 3��:63�. , ,.,�� " .`��' {�3��,, -- �'�'�. : G��' s. � �� o ��►� � , � ,S�- ` i ,�!`� i r� :3732 � � �� O � �% (,� �. ;i � � : , �►�- � � � a�� , �. 1 ::10D Feef � North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: H. KELLY Name of System: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 LINDSAY T WAGSTAFF 5370 SEMORA RD ROXBORO, NC 27574 StarLiMS ID: ES031617-0038001 Date Collected: 03/15/17 Inorganic ID: Date Received: 03/16/17 Sample Type: Raw Sampling Point: Outside tap Sample Source: Well Temp. at Receipt: Sample Description: Inorganic Chemistry - Hexavalent Chromium Profile P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slah.nc�ublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Time Collected: 1130 Collected By: H Kelly Well Permit #: A26-60 GPS #: Test on sample was not performed due to the following reason(s). Invalid Sample Comments: Sample pH <8 therefore sample could not be tested for hexavalent chromium. Another kit will be sent to collect another sample for hexavalent chromium. Report Date: 03/20/2017 North Carolina State Laboratory of Public Health 3�2 D stnc�Drve Environmental Sciences Raleigh, NC 27611-8047 htto://slph.ncpublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fvc: 919-715-8611 Certificate of Analysis Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES031617-0037001 Date Collected: 03/15/17 Time Collected: 11:30 AM Date Received: 03/16/17 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A26-60 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 < 0.1 0.7 mg/L Beryllium < 0.002 0.004 mg/L Name of System: LINDSAY T WAGSTAFF 5370 SEMORA RD ROXBORO, NC 27574 Cadmium Chloride � Iron Lead Magnesium Manganese Marr.urv < 0.10 < 0.001 2 12.00 < 0.001 < 0.001 0.03 < 0.10 < 0.005 < 1.0 < 0.01 < 0.000: 0.7 m 0.002 m m 250 m 0.01 m 0.001 m 1.0 m 0.30 m 0.015 m m Molybdenum < 0.010 0.018 mg/L Nickel < 0.01 0.1 mg/L pH 6.1 N/A Potassium 2.75 mg/L Selenium < 0.01 0.02 mg/L Sodium 11.70 20.0 mg/L Strontium < 0.500 2.1 mg/L Thallium Total Alkaliniry Total Dissolved Solids Total Hardness Total Suspended Solids Vanadium Zinc < 5.00 < 0.0001 7 < 20 8 <5 < 0.0002 < 0.10 Page 1 of 2 � �� Report Date:04/05/2017 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 htta://slph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Reported By: Deddie .�toncol �U �y PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant �� Address �,?'�?b �z�l+m-Q� �. County Collected By � 1�G��-�1 9ate Collected � �Tim� Collected I l: 30 Source: ❑ ell ❑ Spring ❑ Other � c��t�s�� Location: [9'Nouse Tap ❑ Well Tap ❑ Other ❑ No �harge CtYCharge ..............................................................................� **************************************************************************** Results Present Total Coliform Fecal/E. Coli Reported By Date Reported o ` � /' � � Report Called `�YES ❑ NO Called To �� . ■ Absent ❑ Report To: North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slah.ncqublicheaith.com Phone: 919-733-7308 Fax: 919-715-8611 TOMMY WAGSTAFF JR 5370 SEMORA RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES050814-0031001 Date Collected: 05/07/14 Date Received: 05/08/14 Sample Type: Raw Sampling Point: Outside spigot Sample Source: Well Temp. at Receipt: Sample Description: Comment: Time Collected: 10:26 AM Collected By: Derrick A Smith Well Permit #: GPS #: Inorganic Chemical 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 11.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper 0.07 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 pH 6.0 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 12.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 7 mg/L Total Hardness 8 mg/L Zinc < 0.05 5.00 mg/L Report Date: 05/16/2014 �'�� ' � MAY 2 � 2014 ��: Page 1 of 1 Reported By: Arnold Hvll � � .�7-� - !�o North Carolina State Laboratory of Public Health 43012 D st?ct Drive EI7VIrOI7C11Gl7tal SCIeI10ES Raleigh, NC 27611-8047 http://siph. ncaublichealth. com �nOCg8i11C CileiillStij/ � Fax�e� 919-715-86�$ Certificate of Analysis Report To: H. KELLY Name of System: PERSON CO ENVIRONMENTAL HEALTH LINDSAY T WAGSTAFF JR 325 S MORGAN STREET 5370 SEMONA ROAD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES032317-0166001 Date Collected: 03/22/17 Time Collected: 12:20 PM Date Received: 03/23/17 Collected By: Sample Type: Raw Sampling Point: Kitchen faucet Well Permit #: Sample Source: Well Temp. at Receipt: GPS #: Sample Description: Comment: Matrix inte�ference in sample. Hexavalent Chromium (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Hexavalent Chromium Report Date:03/31/2017 Reported By: Deddie .�lonco!' CAMA = Coal Ash Management Act , Page 1 of 1 ��,��y -}-��-�- ��.q -�n7-5'��a �iG �D+�� , E�i i'�EnA�aIoC�GST