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A27 168. z t' ' z Person County Health Department � Sewage System Improvements Permit Date: '��' � Z This Pe t Void ter 5 Years Pem�it # Ovmer: wi n�I/l��J�eY SR# �� Location/Directions: s��a���«� rr� : eG �c # Lot Size: Type of Dwelling: � Water Supply: Private: P�blic: Community: Bedrooms: 3 Gazbage Disposal Basement Basement Fix - � INFORMA D BY S8i11t8ti8i1: ovmer «[ep�esa►tative ,. REPAIR: REEV, Size of Septic Tank: ��� gAl19n�3Si�e of P�mp Tank: Nitrification Line: �� Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: ------------------------- Date Well Approved• Z-�'yZ Well should be 100 ft from any sewer system BY �.-�%� Sanitarian Date Sewage Syste Approved: Z- � �- 9 Z BY Sanitarian CERTIFTCATE OF COMPLETION ,,,� Conttactor. �' 1��;,�.�r� � �c�c /c. � ------------------------- � Sewage System location, installation, and protection must meet state and lceal � reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrificarion line must be inspected and approved by a member of the Person Coanry Health Depaztment before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched on back. (OVER) —_ --. r � Person County Health Department � Well Permit � Date: �- � a This Permit Voi After 3 Years � Owner• �,t 1E, � r�J �`l�i� ��Q- v SR# 13�3 � Location/Directions: Subdivision Name: � Lot # Drilling Contractor. � WELL CONSTRUCI'ION ►b Distance from Nearest Property Line� Distance from Source of P�' Pollution D D c�, Total Depth: f�_FG Yield: �_GPM Static Water Level �a FG � Water Bearing Zones: Depth !� S Ft.� FG �� Ft F� Casing: Depth: From �_ to_ ti� FG Diameter: b� Inches TYPE: Steel Galvanized Steel c� �— ff Steel, does owner approve: Yes�� No WeighG ,�_ Thiclmess: 1�_� Height Above Ground: � Inches Drive Shce: Yes ✓ No Were Problems Encoimtered in Setting the Casing? Yes No � If "yes" give reason: d Gmut: Type: Neat Sand/Cement ✓ Concrete ;4 Annular Space Width 3 Inches Water in Annular Space: Yes No v Method: Pumped Pressure Poured ti Depth: Fmm L� to .�d F� Materials Used: No. Bags Portland Cement _� Weight of 1 bag � lbs. If mixture (sand, grave , cuttings) - Rado: ,�_ to �_ ID Plates: Yes i No ►d 4 x 4 slab Yes —� No � I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. . �J � �-- - d Date � ZZ�q L Date Issued � Sanitarians Signature Date Completed Sketch well location on reverse side. ► , NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located " � �' . Site Evaluation Applicat'on Date: ���/ 9�� Fee Collected YES NO ,��- -rs � �-� APPLICATION FOR IMPROVEMENTS PERMIT l. Permit requested by: Address: � � Home Phone �� : ,�,`�"4- owner/prospective owner: L agent: +P.� s �✓)Ce_c��i �� • 2. Name d ddress of current owner: � s��v /c� _ . Business Phone 4�: � //�� r.ef �� � /� 3. Property Description: Lot size: �• �� 4. Tax map ��: ownship: ''2� /�*�� Subdivision Name: ��� > to � Lot ��: 5. �rections to pr gr State Road �� & Road Names, tc. � S. % � C�i"��s� /�.��1r � 11%x�r.�% ��. �/30� . 6. Permit requested for: New Installation: j/ Repair: Additional Renovation re-using present system: 7. Number of occupants or people to be servedc .: � z 8. Dimensions of Proposed Structure: Width: Depth: 9. What type (if any) additions, expansions, or replacement is anticipated to the struc- ture or facility that this sewage disposal system is intended to serve? , 10. Water supply private? � public? Other source? (Specify): Are there any wells on adjoining property? community? spring? If so, identify location: 11, Type of structure or facility: Proposed���� E isting: Type of dwelling: House: M i e Home:�%�� Business: Type of business: -�-� = Number of Employees: Number of bedrooms: � Garbage Disposal? Yes No � Basement? Yes No �If so, number of basement fixtures: 12. Clearly stake all corners of the property and the corners of all proposed structures. I hereby make application to the Person County Health Department for a site evaluation or existing system 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. Permits are valid for 60 months from date of issue. Permission is hereby granted to enter the property for the evaluation. G.S. 130A-335(F) ��-v� w �C�� „ Signed Owner or Authorized Agent , � r� � m � 0 Permit Issued � Permit Denied Plat Observed l� ��.� ` � G��,.r�.•�, � nW t'1 ec- � . ,_ ` � ^ � : FACTORS - SZTE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4 1. SLOPE (X) 2. SGIL TEXTURE (i2-36 in.) (Sandy, ioamy, clayey, Note 2:I. clay) 3. SOIL STRUCTURE (12-36 in.) (Clayey soils) 4. SOIL DEPTH (in,) S. RESTRICTIVE HORIZONS'�in. (Im�ervious Strata, rock) b. SOIL DRAIrIAGE/GROUNDWATER (bcternal & Internal) 7. SOIL PERMF.ABILITY (Percolation Rate) S PS U S � U S' PS U S PS U S PS U S PS U S S S PS PS U U s , n s, PS U S PS U S PS U S PS U S PS U S S PS U S PS U S PS U S PS U S PS U S S PS �T s / PS / � U (�y S ' D$ U S PS U S PS U S PS U S PS U S 3. OTHER (specify) PS PS PS � PS � u u u u 9. SITE CLASSIFICATION (See below) SOIL SERIES S- Suitable PS - Provisionally Suitable •..0 - Unsuitable R�COt�PiDATIONS / COI�fEPITS : SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, aet areas, fill areas, wells, �aater bodies, slope patterns, etc.) ' �. A� '~ . �r J � � \J • THE DISTRICT HE�LTH DEPARTMENT CASWELL - CHATHAM - LE� - PERSON COUNTIES OIRECTOR P0.ST OrFICE BOX 72B 7HOb1AS L. JOHNSON, M.P.H. PITTSBORO, N. C. 27312 • (919) 542�4641 � �� Site Approval Only • r � � � � � ,� �� To Whom It Tiay� Concern: A site and soils evaluation was done for you on a L � Z,acre tract located �t'�'3 �,,`, �0 1,.� _, (�,r �S�-� ui'�> L�- f_ t�l.l Cr.� A l�_D�A� .I�-Dk/1. LfJ�Q � S S�YC 2�, and was found to be suitable for a sewa�e disposal system . which can be permitted by the local healtti department. In order for the prospective buyer to obtain an im- provements permit, they must bring-a p18t of the property to the Health Department between the hours of 8:00 a.m.- 9:00 a.m. or 1:00 p.m. - 1:30 p.m., Monday through Friday. If you have any questions concerning this matter, please call the Health Department during the sa�e hours mentioned above. , Sincerely, �� � --s-. -__= — . •����r � • -- "-� : - • 0 ,2 � �� �� nc d¢parhnent of healfh end humen serviees ;�� � t � ��; � � � } � � - F-� � /�: r �-, � E C �-��� � ,n..�, .-� P � ; -, ; .€ fi � S�f! ;:�,5t �' � �P� 1 i I��� t� S 1t � �( j � �^� e k 's ��,f �' �J� � � t � i �,` i i f � �I{ i, � �, f F � G `�„""` t � F r� 5-� ^ l-. ':^t�^ � k ` i-- n ''' ��'j � Y � , �e. r�� ...� r,�:. r � �"i"� , 1 r•� 't �' � i �'� � < <�� t-� {�I_� � t �/A .,...,-�' �. '� `t _: � 't `.• �_.' �� E ! P 9 � � '•.✓ e l 1 �,; iI.? �_ i t,! � � �: For Inorganic Chemica/ Con�aminants County: ,� Name: f�4 5 .�,/Q�c Sample ID#: —((o Reviewer: � Oc v�� � TEST RESULTS AND USE RECOMMENDATIONS 1. Your w�l! water meets federzl drin.king water stardards for inorganic c;�emiea�s. Your water can be used for drinki g, cooking, washing, cleaning, bathing, and showering based on the inar�anic chemical results onlv. You may nave other water sampIing results that are not taken into account in this report. 2. � T'he following substance(s) exceeded federat 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 inoreaHic chemical results o�lv. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron Manganese Mercury Nitrate/rTitrite Selenium Silver Ma�nesium Zinc nH 3. 0 a. Sodium lev�ls exce�d the U.S. Environmental Pratection Agency's-(USEFA) 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 has�� or. the inor�anic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, etc. 4. � Re-sampling is recommended in months. 5. 0 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 I S 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 inor�anic chemica! results onlv, hut aesthetic gr�blems such as bad taste, odor, staining of porcelain, etc. may occur. You may want te install a household water treatment system to address aesthetic problems. Barium � Cadmium � Chromium j Fluoride � Iron Ma esium Man�anese Selenium Silver pH TZinc For more informaiion regarding your wel! water results, please call ihe North Carolina Divfsion of Public Nealth at 919-707-5900. North Carolina State Laborato�/ of Public Health P•O. Box 28047 � ! 4312 District Drive Environmental Sciences Raleigh, NC 27611-8047 http://siph. ncoublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: THOMAS DUNEVANT 408 BEAVER CREEK PKWY ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES022217-0037001 Date Collected: 02/21/17 Date Received: 02/22/17 Sample Type: Raw Sampling Point: Inside faucet Sample Source: Well Temp. at Receipt: 1.5 Time Collected: 2:05 PM Collected By: A Sarver Well Permit #: A27-168 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 m/L Cadmium < 0.001 0 005 m/L caicwm Chloride Chromium Copper Fluoride Iron Lead 4 < 5.00 < 0.01 0.22 < 0.20 < 0.10 < 0.00: esium < 1.0 250 0.10 1.3 4.00 0.30 0.015 manganese < 0.03 0 05 m/L Mercury < 0.0005 0.002 m /L Nitrate 2.00 10.00 mg/L Nitrite < 0.1 1.00 _ mg/L 6.7 'A 5eienium < 0.005 0.05 mg/L Silver < 0.05 0 10 mq/L Sodium 8.60 mg/L Sulfate < 5.00 250 ma/L iotaiAitcaimiry 21 m /L Total Hardness 13 m /L Zinc < 0.50 5.00 mg/L Report Date:03/01/2017 Page 1 of 1 Reported By: .xennetl�i Greene �� � �..�.� � � � - � �.,..-., �� �x,.��" ��"`� 'Y..f' � � � � t ��� m�ntiv�ii �6 �rn �rn ���a � � t�:,�. � I�..� �e � �� tL �� Date: � / g /� Name: �rv, U��P✓G� Address: 0� -�� r CZ-��� v/ ? S'? Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel: l � � Your well water was sampled on 2/ Z�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted beiow: � No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results on[y. 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 bactEria arz associated ivith animnal and/or human waste. The presence of either total or fecal co(iform 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 sample, the water may rot be safe for use. Young children, the elde�•ly, and the individuals with con:promised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive for total or�'ecal coliform bacteria should be properlv 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 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. ' Since ly, , �'''�,� Environmental Health Specialist Person County Health Department � (re�. anoit6) Person County Environmerrcal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fae 336-597-7808 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: ES022217-0084001 � ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: THOMAS DUNEVANT P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://si�h.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 408 BEAVER CREEK PKWY ROXBORO, NC 27574 Collected: 02/21 /2017 14:05 Received: 02/22/2017 08:37 Sample Source: Well Sampling Point: Inside faucet A Sarver Susan Beasley Well Permit Number: A27-168 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 02/23/2017 E. coli, Colilert Absent 02/23/2017 Report Date: 02/23/2017 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.