A27 13BApplication Date: — � 1—� lp
Amount Paid: 200� C�
Receipt #: �
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0
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building. Addition
$150.00 (if site visit required)
Well Permit ( lacement/Repair)
$300.0 $200.0 $75.00
�� � r ������T Tax Map: �27
�.� • ��- � � .���� Parcel#: �_
1[�,�,��,tr-��m�.n.�»�,e,�.11 1HI�:�.11 �:JM
�lication for Services
Services Requested
Construction Authorization
(Fee is dependent on the type of
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
'�1) Applicant I mation: ""�
Name: t/j,1� Gv TE�
• Address: ,2 �- l / LL o
,�� x.c���� ,�1,/� .��'S �¢
�2) Name and address of cur ent owner (if different than applicant):
Name: . �� ,q..
Address: ��
Phone (home): ��9� %9v�2
(work/cell):
Phone:
�
c.,,�s
�) Property Description: Lot Size: �%-7 Subdivision: Lot #:
Address and/or directions to Property:
❑ yes no Does the site contain any jurisdictional wetlands?
�s ❑ no Does the site contain any existing wastewater systems? r
❑ yes GL� Is any wastewater going to be generated on the site other than domestic sewage? ]_„ ��
0 yes L�-� Is the site subject to approval by any other public agency? �`�
❑ yes C�t� Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation) �a�(Y1 Q,'�i
4) Proposed Use and Type of Structure:
❑ New Single Family Res��3e�tti--
❑ Expansion of Existing System
❑ Repair to Malfunctioning System
❑Non-Residential
Type of business:
Maximum number of employees:
Maximum number of bedrooms: / Occupants:
; Current number of bedrooms:
Will there be a base es ❑ no With plumbing fixtures? ❑ yes ❑ no
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: �'New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
` 'on to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative er ❑ Any
I certify that the information provided above is complete and correct. 1 also arnderstand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�-
Signature (O�Cner/ Legal Representati
* 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 evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-17901
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1E��ra�a�co�anaam�rad�.l1 �IL��Il¢lEa
WELI,.PERNIIT
(New�/ Repatr_)
Taac Map: � Pa cel: � 3�_
Subdivision: jJ f A� Lot: �
Applicant's Name: _�Qv i� ln�; �, � ��
Mailing Address: 222`1 ; I � E}; � � P� .
G 2 5
Phone Numbers: - '1
Location of
Permit Conditions:
�
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 pot�ble water supp(y
Other Conditions/Comments:
ai�-i'J� � I( tef�a�KS
r
�
Permit issued . Date: _ 3- /�/-/(p
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
�Concrete Slab:
Certificate of Completion
Di.iaer:
EHS/Date
Well Driller: �/�Gti'vt�2 ��'�-
Pump Installer:
Approved by:
Additio�al Comments: � ('C6 �� V1 � Slc� �
Date Sample Collected: 5 � � ��
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnrhnrn NC �757�
Depth:
Grout:
DAbandonmeut:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
��/�c/,a
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����r�,�
ne department
of health and
humen services
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a Il t ` 6
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4._,,j � k l,� .....�` �r� �L.t i '��. t..l �JI \1 ! E e � E r ...i � �•� .�� E.. c �,� � : �i
Fo� lnorganic Chemical Contaminants
County: ArScv. Name: �� i�S
Sample ID #: � � 13 ►
� TEST RESULTS AND USE RECOMMENDATIONS
1. 0 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 inar�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 federa! drinking water standards orthe North Carolina 2L calcu(ated 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 v��ater treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inoreanic chemical results onlv.
Arsenic Barium Cadmium � Chromium �_Copper � Fluoride �Lead � Iron
Maneanes Mercurv Nitrate/Nihite Selenium Silver Ma;�r►esium Zinc pH
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 chemica[ results onlv.
❑ b. Leve(s 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 itrst 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,
coo mg, washing, cleaning, bathing, and showering based on the inoreanic 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
Man�anese Selenium Silver � pH
For more information regarding your wel! water results, please cal! the North Carolina Division of Public Health at 919-707-5900.
a
North Carolina State Laboratory of Public Health 43072 Di tnct Drve
Environmental Sciences Raleigh, NC 27611-8047
htto://siph. nc�ublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: ADAM C. SARVER Name of System:
PERSON CO ENVIRONMENTAL HEALTH DAVID WINSTEAD
325 S MORGAN STREET
2227 MILL HILL RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES051916-0067001 Date Collected: 05/18/16 Time Collected: 10:40 AM
Date Received: 05/19/16 Collected By: A Sarver
Sample Type: Raw Sampling Point: Well head Well Permit #: A27-136
Sample Source: New Well Temp. at Receipt: 3.5 GPS #:
Sample Description:
Comment:
New Well 1(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
Iron
Lead
Magnesium
Manganese
Mercury
Nitrate
N itrite
pH
Selenium
Silver
23.00
< 0.01
< 0.05
< 0.20
1.30 S
< 0.005
11
0.340 '
< 0.0005
< 1.00
< 0.1
7.9
< 0.005
< 0.05
9.60
250 m
0.10 m
1.3 m
4.00 m
0.30 m
0.05 m
0.002 m
�n nn m
0.05 m
0.10 m
Sulfate 12 00 250 mg/L
Total Alkalinity 104 mg/L
Total Hardness 130 mg/L
Zinc < 0.05 5.00 mg/L
Report Date:06/03/2016 Reported By: Deddie .�loncol'
Page 1 of 1
North Carolina State Laboratory Public Health
Environmental Sciences
IMicrobiology
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: ES051916-0102001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
DAVID WINSTEAD
2227 MILL HILL RD.
ROXBORO, NC 27574
Collected: 05/18/2016 10:40
Received: 05/19/2016 08:16
Sample Source: New Well
Sampling Point: well head
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htto://slph.ncoublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
A. Sarver
Angela Heybroek
Well Permit Number:
A27-13B
Environmental Microbiology - Colilert Pro�le Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Denise Richardson 05/20/2016
E. coli, Colilert Absent Denise Richardson 05/20/2016
Report Date: 05/20/2016
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.
V�+ELL CONSTRUCTIpN R�GORD
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SITE PLAN
Name v� �' V Tex Map# ` l Parcel#� r� )
Subdivisi / SecUon/Lot#
Authorized State Agent Date
System components represen� approximate contours oxly. The contractor mustJlag ehe system prior to beginning the
Installalion to insure that proper grade is raaintarned.
Note: An Accepfed system may be used in place oja conventiorsal system withoul permit culhorizvtion or modification.
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