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A27 104,C� �e�►��.tJ -S/Z�/,z � � ✓s. f — ��. .,�,�9' �� r/ i�v�� /!3 G�tC(��,�� .��,� n��es • f3v�/� ��'� �� o �� w�r�� CvN�� w<�� ,✓,��.� �,��.� �� . �f�� cl�o�/a�s�v� o.� �,�� . � �� 3 � �3 �� cJi�D ��i�A �Z N� ��' %£ �� ,�;��y �� A/lication Date: J� O� l� �(r �} Tax Ma Z7 AmountPaid: __��' `� ` '~�'j�)l 11 �� Parcel#p. /D� Receipt #: ��; J $� D � �• � �� IC.�rao n�u-�cnr*,•,,,�rc3snd.s.11 7H��e�,ll�lh. C:�d� Application for Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobils H�me Rspiacement or Buitding Addition $150.00 (if site visit required) ❑ Well Permit (lvew/Replacement/Repair) $300.00/$200.00/$75.00 Services Re uested ❑ Construction Authorization (Fee is de endent on the ty e of 0 Pe:mitRc�isioa Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: � Name: Ec.��- EN �N �T Address":� � 2) Name and address of current owner (if different than applicant): Name: Address: 3) Prop�rty Description: Lot Size: Subdivi ion: _ Address and/or directions to Property: i�f %�� `,1 S �-e� s� CR! � ��%-C�M�� Phone (home): 3.j �p .. ;s q 7� 3 9 g A� (work e�j3�3� — � !� — �/1 �� Phone: #: ❑ yes �Yno Does the site contain any jurisdictional wetlands? ❑ yes � o Does the site contain any existing wastewater systems? ❑ yes �o Is any wastewater going to be generated on the site other than domestic sewage? � yes �o Is the site subject to approval by any other public agency? ❑ yes �o Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) roposed Use and Type of Structure: esidential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number o edrooms: ❑ Repa�� to Analfianctioning System �TJill there be a baseme^t? L' yes ❑ ne With plumbing fixh::es? '-J yes ❑ no ❑N�n-Residential ,� t Typeofbusiness: �v Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well 6d'Existing Well ❑ Community Well ❑ Public Water ❑ Spring � � Are there any existing wells, springs, or existing waterlines on this property? ❑ yes Ql�o 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 cert� that the information provided above is complete and correct. I also understand that if the information provided is i ccurate, or i{the si is subse_quentiv altered, or the intended se changes, all per its and anproval.s .shall be invalid. A�..,� t/'Y.� � nn� � OS�v� f� Signature (Owner/ Legal Representative*) �` Supporting documentation required. 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 evaluallon. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �� -.�� .�� .�� . �, > � � � � �� 1L :i�_.aIl.�'A�<m�rn �r^r� ��¢.L'1.� ��.�� Applicant Location: � T�x Map ' �rcel :; � S i�i:bd:i v i s�i�a n ' h�:s�e-Sect+io�nLat i Improvement �ermit � ��rau# i�alid for 've �ea�s 1�To �Eapiration , Type �of Facility: � New Addition �ater �n�ppiy V�c�,(,� # of Occupants # of Berlrooms 3� Projected Daily Flow 3lva g.p.d. Proposed Wastewater System: � Type: Proposed Repair: � -r� ; �� Z`YPe: Permit Owner or Legal Representative Authorized State �Agent: � The issuancs of this pe�it by the Health Departinent in does not guarantee the issuance of other peimits. It is the responsibility of the' applicantfproperty owner to in sure that all Person County Plazming and Zoning and Building Inspeciions requirements are me� 3'l�is �lmprovement P$rmit i� subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not aifec#ed bp a ci�ange in ownerstup of the properiy. This permit was issned in compliance with the provisions of the North Carolina `Laws and Itules {or Sewage Treabnent and I)isposal Svstems' (15A NCAC 18A .1900). Neither Person �ounty nor the Environmental �ealth Specialist�warrants that. the septic tank system will continue ta function satisfacton7p in the future or'that the water supply will remain potable. ` -- . . � � � � A�thorization �o Constraei Wastewater System (Reqaired for Bnilding Permit) * See site plan and adrlitional attachments (_). . Proposed Wastewater System: - Type .� Wastewater Flow �g:p.d. New Repair E ans' n � Soil LTAR. .'za "�'� g.p.d1 ft 2 � Type of Facility: Basement _ Yes ✓ No � � , � �}. �To� �aste�vater Syst�na �ees�wureaaents " 'Tank Size: Septic �ank: ��('�-rga�1 � Pnmp Tank: gal �Grease Trap: gal �rain�eld: 'Tot�l Area: �� sq ft -Total Length ,�p ft � 11�a�inum Trench Depth �_ in Tre�.c�'�idt,�t � ft lYg'iniffivaa Soii Cover. �. in 1dI'in'lmum Trench Separatioa: �_ ft �istributson: I9istribn#ion �o� ✓ Serial �istribntion Spe�cations: i H Y / � Antlaorize� Sta.ie AgQni: , Permit Expiration Pressnre Manifold Date: .r�'T', The type of system permitted is Conventional �C Accepte3 Alterna.tive. I accept the specifications of the permit. G i�wneY/��gal �8�prese�tative`� � -- Date: � �� o � � Z— ' PG� rev. l l/10/OS ConnectGIS Feature Report Page 1 of 1 _��--- Welcome to the Person County GIS Website. ConnectGlS has been prepared for the inventory of real prope compiled from recorded deeds, plats, and other public records. Users of GIS system are notified that the afc should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectG information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. 3T22 , �►/5T'� F�i��/9 �� j �I �. � � . /� / � �` � t' �r ��,, � , � r - � � � /�� C) W ...✓ �1 WI ELL �XoSr�,�q ��rE,y �� ,�� T�4►� �L 3ei52 �sas 0 g�1.3� ?dfi11 s�,� � �� '? C��.1 �� ! �o ►...hi. 'FT .A�CG� � E� "� �� /1J(,d�.-� � U u � �iq,�iG� `T��-" ?d53 -, �� . ' �c " �� ,` . . ��.a� `�� , . ��T1�7C�' ,:, 9 �.mm�vnso,.,�,.,..,mm.�.m.Il 7E7Ce�.Il�1�a SI�. S�E.T'C�I: -�o�Y Qil 3-r�a�15 �'o a r�c-�- `�G�{-c� �-r �5�� - I Z � a. Name '�'- p �.l ---*-r- Tax Map # A- L� Parcel # IO c.� � Subclivisio �Q,ft'� �ectiou/Lot# ! z— . Authonze tate Agent � • Date . °� sy.�„ ��a� �r,�s� �p„o�,��o»,�u� �,ry. The coairaclar must, flag ihe rystem�irior to • beginning idte insfaAaiwn io insure that�firopergrade is maintai�red http://gis.personcounty� : . � . � � � � � �-. 1 f < v;,;; • .. . ::: ,. . _ . . .. :.: . :.::: :: � . . � :. . . ..., � � �� n�n.�n��n�.n�cn,�na��.�. �c.��.�.��n Building Additions/ Mobile Home Replacements Tax Map #: 2�% Pazcel#: j0 � Address: / q7 �/,��,�j► �l,�;l��2 ,��l��fG �� Approval Requested for: Mobile Home Replacement �/ Building Additian , � ' -�ic.� �(>y,7�/�j �c %G Applicant Name: �� Address: Phone #'s: � Permit Located: � Yes No Installation Date: �,oi 3 /�'f.�p�i,L, Design flow: �(gpd) �urrent Contract with Certified Operator on file (if required): �✓� Water Supply: �/ _ Well Public or Community Wastewater system shows no visual evidence of failure ori:3 ?� ate) (Applicant's signature if site visit is not required�: - - Addition/Replacement Approved Enviranmental Health ecialist 5� � � "� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.nersoncountv.net ��sf ��.��T �� I-��a�a-��a„-„-„ ��n��.11 ��.71�I�n. Applicant: Loc�ti�r_: Operation Permit Tax Map Z7 Parcel # /8� Subdivision Phase/Section/Lot # # of Bedrooms 3 System Type (From Table Va): Product (IIIg): �z �,� 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. (Autho ze gent) -� , j�'-'V�i��a �:- �t,1� (Licensed Contractor) G'✓r " G`�'` — 7' Z�4 � Scale: �_ �i-�,cnE c� y�� 3 (Date) � z 13 (Date) Cj0 I.�i • �T• �`'� z�� , $L" y / Sf�il" �1p � z�" -r� —� 1.n1 � r'�' • Line Length I �o � � �o, Total �op ' Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� System Type: � Notes: Pump System Checklist Pump Tank � InitiaUDate State ID & Date: Capacity: R.iser (6" min. NEMA 4X Box Model: Piggy back plug Hard wired Alarm functionir Mounted on post Above Qrade (12 Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Tank Com onents InitiaUDate Pum model: Block 4") Nylon retrieval rope Float tree and attachments On/Cff float swing: in. Alarm float (6" separation) Anti-si hon hole Check valve i hreaded union Gate valve Conduit sealed Outlet sealed pprove an secure riser Supply Line Size and material: in. sch. i,ength: ft. Copy of OP e-mail Date: �� J �� .•. � �f. � �!' ,.--a i-w sr v r v v�rv tr v� l. ��' �rnw n�t a:� u�n. ��rn�c. �rn tL.en, ll lE 1[ �:..�n, l� �7�n Date: 7 / J� / /�v .. � . � .�i. •r �� . � � � � - � . .�r� � .. _/,!_ . � �i. ��ii � � Re: Bacteriological Test Results Dear ��/f��q�/i�_: Your well water was sampled on �/�/ /(v , and tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). The results of your water sample are noted below: � No coliform bacteria were detecied in the sample. Your well water is safe for normal use. _ Total coliform bacteria were detected in the sample. _ Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil. Fecal coliform bacieria are associated with animal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or 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 samp[e, the water may not be safe for crse. i'oung children, the elderly, and individuals with compromised immune systems are especially va�lnerable and their physicians should be notified of the test results. A well that tests positive or total orfecal coliform bacteria should be properly disinfected and retested prior to resuming normal 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 (597-1790) 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, Environmental Health Specialist Person County Health Department Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790, Fax: 336-597-7808 (revised 07/29/13) � North Carolina State Laboratory Public Health Environmental Sciences 11�icrobiology 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: ES032216-0087001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: BRENDA BARNETTE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sloh.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 197 WAGSTAFF CARVER ROXBORO, NC 27574 Collected: 03/21 /2016 14:00 Received: 03/22/2016 08:31 Sample Source: Well Sampling Point: Outside tap H Kelly Susan Beasley Well Permit Number: A27 -104 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice owens o3/23�2016 E. coli, Colilert Absent Darneice Owens 03/23/2016 Report Date: 03/23/2016 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. y, � � ne department o.., �,� �� „� � � �,;,,,� � � �".�, r .a z �;a., �., � � of health and �.�;i ei a �� -�s � �w�.�� s �>..-;� , «� � � I ;� '" � �� human services t.n..u�, � �.' �.. '� s,�,�,?� '�s" �;�:�r9 i��± `�� ' �....,�' � � �s � � u -�`1�.-�' � � �,� �� For lno�ganic Chemical Cont�minants - ' ��1+1�� — 4� �— • �� Sample ID #: �-- p Reviewer: TEST RESULTS AND USE RECOMMENDATIONS 1. [�Your well water meets federal drinking water standards for inorganic cliemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based an the inorsanic chemical results on[v. You may liave other water samp(ing results that are not taken into account in this report. 2. 0 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 inorganic cl:emical results onlv. Arsenic � Barium � Cadmium � Chromium Copper Fluoride Lead Iron Manganese � Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH 3. ❑ a. Sodium leveis exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sediam 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 uinrQanic c/temical results onlv. ❑ b. Levets 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 inorFanic 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 I[ron � Magnesium Manganese � Selenium Silver pH Zinc Fnr more infornsatio►t regrrrding your we!! water results, please ca!! tl�e Nortli Carolina Division ojPublic Health nt 919-707-5900. North Carolina State Laboratoryof Public Health 3�2Dst?ctDrve Environmental Sciences Raleigh, NC 27611-8047 htt�://sloh. ncoublichealth. com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: BRENDA BARNETTE 197 WAGSTAFF CARVER ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES032216-0033001 Date Collected: 03/21/16 Time Collected: 2:00 PM Date Received: 03/22/16 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A27 -104 Sample Source: Well Temp. at Receipt: 3.5 GPS #: Sample Description: Comment: 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_ Chloride Chromium Copper Fluoride I ron Lead Magnesiur Manganes Mercury Nitrate Nitrite pH Selenium Silver Sodium 14 < 5.00 < 0.01 < 0.05 < 0.20 < 0.10 < 0.005 3 < 0.03 < 0.000: 2.40 < 0.1 7.2 < 0.005 < 0.05 9.40 < 5.00 4.00 m 0.30 m 0.015 m m 0.05 m 0.002 m 10.00 m 1.00 m � 0.05 m 0.10 m m 250 m Total Hardness 48 mg�� Zinc < 0.05 5.00 mg/L Report Date:04/06/2016 Page 1 of 1 Reported By: Deddie .�tonco!'