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A27 212� 1. 2_ 3 .: 4. 5. APPLICATION FOR II�ROVEtfENT PERNIT � � . DATE: Permi t reques ted by : J�_'�, �- �� /�y � p/ ` Home Phone �� /�� Address: /�SJ �,� L,�j N� �,2,, Business Phone �..;-�...._ ..._.._:. � Name and address of current,owner: S L� n�� Property Description: Lot size �. �9 �;Lc Dimensions: Front #<f° � Left +: Right Rear Tax map No.�� Township.: ' Block No. Lot No. . ' � Directio to p�erty: State Road No. & Road N mes, etc. ,� /�Q �..� .�� ,� ,� �' o � � r Y� u� 6. Permit requested-for: New••Installation v Repaired Additional Renovation re-using present system _.. ___�._._..... _. _ .,.. _ __ 7. Number of occupants of people served .3 z a � � 8. Dimensions of Proposed Structure: Width Depth '' _ H - - . .. 9. What t}�pa.(if anyj additions, expansions, or�replsce,�ent is a.�ticipated � X to the structure'or:facility that this seKage disposal sys�em is intended a to sexve? � ' , .. _ � . „� 10. 11. Type of water supply: fdell Yyes no: If no, name source of �.rater supply: . Are there any wells on adjoining property? If so, identify location. Type of structure.or facilit : Proposed � Existing Type of dwelling: House � Mobile Home Business Type of business Number of Employees_ Number of Bedrboms Number of automatic appliances Basement Number of basement fixtures 12. Clearly stake sll�carners of the property and the corners�of all structures. I herebp make application to the Person Countp Health Department for a site evaluatioa or existing system evaluation for the on-site seWage disposal spstem for the above described property. I agree that the conte of this application are true and represent the maxi.mum facilities to be placed on the property. I understaad if the site is altered or the in- tended use changes, the permit shall become invalid. Permits are valid for 60 months from date of issLe. Permission is herebp granted to enter the property for the evaluation. G.S. 130A-335(F) , �uC �i� LvD.�cJI /�4•G K/ � �, � � Si�ned Oc�n or Authorized Age t� � CORS - SITE EVALUATION `�LOPE (X) ;OIL-TEXTUR&• •(12-36 .in. ) �Sandy, I.oamy, clayey, Note 2:1 �clay) SOIL STRUCTURE (12-36 in.) (Clayey soils) � SOIL DEPTfi (in. ) RESTRICTIVE HORIZONS (in.) ;Im{�ervious Strata, rock) SOIL DRAIIZAGE/GROUNDWATER (bcternal & Internal) - SOIL PERMEABILITY ;Percolation Rate) . • • � AREA 1 S PS U S PS U S PS � u s v. PS U S PS / U S PS U S PS U s ►� � f • . r . � �, y �Q� � , •' , . i �Ok.� • , . � , � . �� • ��" , _. �l� l3 D AREA 2 S PS U S PS � S �s� � PS U PS U S PS U S PS U s. _ S"U �� r' � � � � A.REA 3 S PS U S _..` PS � �� U � S � PS � u G s PS U S PS U S PS U S PS U s S PS U S � S � s PS U S PS U S PS U S PS u AREA 4 jTEiER (specify) ps S PS pg ps I . U U U U 3ITE CLASSIFICATION - (See below) ' �OIL SERIES -- S- Suitable PS - Provisionall Suitabie U- Unsuitable :�MENDATIONS / COI II fENTS : . CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, �r:t areas, fill .areas, wells, crater bodies, slope patterns, etc.) E�DbYIAU T. L ON'G �� ,,� ��\ �...,,,� ;,...-1, , �;�I,�. . , •��.r;y:;i� 1` �I��. ��` � � \ `1 �� ,, f� � / ��, � 1�, • � I �^ �1 1��_p� \��Y �� '.'•.;1� . V ` � � �' �.. , �;^ � " �` - • ��: _ �_..,..,i' ;�, � \ ,-�„ � rri,,,� �'� -�;�: �; � ��_ �� t'r' �� ' a� �� `� � � � �� 5 �`.\ . r �� ti � � �� J b^� ��'t�, ,,3.� . \ �S,i� � `�,,�,, / �� r�� i ,'� . ,�,� �+� ,�, � � ,� / ' � ` . � �Z� A � . ��/� . c ?� -� , � � � ��,'` 'C:5 � r� ��il � �� 1, � 1 � �.s" 1't- �+` �`� �''�t J.1� ♦ � � ;` <<� G,�',� ',,y .� ' �'"�'�� C,�,�� ,� �� . :, ,e `�� , �; �. �, �� ,. . �,� �, ,. � �� , �. � : �� .��#�� i� •+�M� �' � � � �� ~ �'.� •,�q''� C. � �, �"�„ ,`... �� '' �• ,� ,...._ \ . '"'`�. •�,��.� „� �. . � i�� `,, ,� '�''�' � �� .....�% J'� �`,,.� t�� -. � � �� ,��`� �s) �� / ,�"�.. �,;¢ �,/ � ,�.� G ;�, �Gs. .'/� /� �'`r„�. s .,p, `'�� ,,,'', C� '•�� , ��, , �� • � �� •a �� / �, � � C'� ?�' � = ti ,,� �,a � ��u o r,« � Ci� �;� � � '� � . '�•� � ��, � ��.4 0 0 Amount paid �� q.,2R� �� - �Receipt .4� ' � . � ,, t �."°2' ` � • • �'%� AP�'LICATION FOR S�RViCES W U � a l _J-�TO Date o,w . . ... .._.. ...__ __ _ mprovements Permit.(EstablishedlRecorded I.ot) _ Reinspec[ion of Existing System (Loan Closing) ImRxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) _ Permit for New Well Improvemen[s Permit (Addition) _ Replace Existing Well �.t:�. - r .:.t r'r . ,c, r x fs ��;:.x�" .?:r-,R.!'%Ix y.K& oj 4 w . �s� �x : ;�� yt^. y:y za 7 3�YeL =� '" # Y.�x�.�x��1 �� 'y�ater Sam�,e �.o be Collectec�� ,..�-�� S.F _ 5 K/ f(�2 F�h%C`�....i'an.eu l< a� 9Xr..� ' rr Y.�^^?e� a�M-3N.n... w�"�'^�.21'�f.w�s .>f ..... ..<. �a L;? �1-� -: , � . .: �?�.. ...N,�>,�.,..«s.,..xi��,,,—. . a .��-, . , ...« �.,...... _<.:. _.. . ...... . » _ Bacteria Chemical _ Petroleum _ Pesticide 1. permit requested by: Width: _ Lead ropos d Struct re: . C�'�l�b�G�C� I Y) ► t1 �I � MTr� �:�-a-��y � T� -` - 8. Wh�:��f'�Y, additions, expansions, or - replacement is anticipated to the structure or facility . �«-e-Q -��`�'�� ° G - that this sewage disposal system is intended to serve? ome Phone #: ��`�' i3� ''� H.�S usiness Phone #: - Sq�� ame and address of . Tax Ma� Parcel#: owner: 9. Water supply t5 pe: ' � private �. public ❑ community ❑ spring ❑ �, �,�� Are any wells on adjoinin property?Yes l�'No [�. /D If so, identify location:� � -�''`s . Lot size: l� 9 9 . Directions to property: State Road #& Road �{ , umber of occupants or people to be secved: 10. Type of structure/facility: Proposed: �xistirig: Q Type of dwelli : House: obile Home: [� Business: ❑ Type of business: � � Number of Employees: � ��C� �. }I��`� � umber of bedrooms. �� j�(� �;�$ 1 Garbage Disposal? Yes No Basement? Yes �No�7 If so, # of basement fixtures: CLEARLY STAI� ALL CORNERS OF THE PROPERTY AND THE CORNERS OF. ALL PROPOSED STRUCTURFS. __ _-- __ __ _. , .__: , .... . ,. .. ,.,-. .. . I hereby make application to the PerSOri COUIl�y, �Ie81th Depai'tmetlt for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are�tcue 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. I understand tliat before an Improvements Peimit can b issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no? delivered a survey plat of the property to the�Health,Dept. wi t hin 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void nd all fees paid forfeited -- ; u] : ' , Q � . ; z Signc� Owner or Authorized Agent � � 1 � `� ` � C/ , . Y�v �ermit Issued Signature Date -��,'��U� b _ . Permit Denied ❑ . : � . ' . , Plat Observed ❑ . .. . . .: : : :: ; . _ , __ • --- - .__ ---. _ . . ., . _. _ _... . . . ... ; . .._ _. . . � . .. - . .. , . , _. .. :.�- ..._ ....:._ .. ._ .. .,. , , .. . . . _ � -•- � ; ' . _ .. � _ _.�_ :__. . -_ . :t . . . _ _ • . .. � t � '. . _ Z � � .-. _ . ... _ _ __ _ .. - _ : : .. : _ . _ _ _ . : _ .� ._ - � ,. , S �- �� _ - �� . . G ._ _ . . _ . -. . ._ { . . . .. , _:.r , . _ _. --- _� ...._.�.. ....: ,,. � . . . .... .. . . _ . . - _. � : �� .. . .._ .. . ..._ �.;:. . ' . �. � , . . ._ _. . _ :. :. _ _ �. ,. . : � .: .:. __ . �e. - : . ._ : - . .. _ . . . . _ .:. ,_ - . ._ . . . , . . : _ . � � ; :t= . . . , . . ...... __..r �- � . � . , ��/3db . _ :: .., ..,.� ,: _.- --- ..._ .... . . - _ ....._ . .__...� _.__. - , . _ ._._ __.... . . , _ � . ._._ ... . . _ ., ,..�.� ...:.. s�.� s; �%"" r��"yF�„GTORS�SriE�!lu..tiA�7Q�rr��':• h�.gs°<� , x�,"��: � ��i�� r�t � �> ,9�-� �,�„� �s �- � j�RF3�i�r�� .i.��'.�'��.o.`x.�. x x�.. .�a�t�i ., w5!,�es��!� a .x . 5 .>x:z. rda .a :±e??'��ii !..:`?.1•.', > �. F..:.a �: _. �� z�.i'�<`�':+.�'..�.�'�'Rs��r ��''�k v��R'�x::�.... .. x"k-. . . I. SIAPE (%1 - . - PS PS - . t4 _ � . U �f V - U ;.�lff . i SOII.7'DCTIJRE02-16INJ S S'. $/� .- S.. / S . (SANDY. LOAMY. CIAYEY. NO7E 2:1 CI.A1� _ � - • . PS', . / � .� L ( . . , : . . .: __ _ s�G �' a,�T 5.s�� J'� o�_ ., � �' __ � .�, � �..I..; �. son srnucrvRe n:.M �Na S . . . S . s - . _ : s • . � _ ; ca�►r�rson.s� u" 5�lt u I'�/�'n"� v'v,,�u"" • u.�b�j , . s. SOILDFP7ti(W.) S � S _. S " - _ - . . . - . .-, . . . . . .. 3 �r � . y �/, ps /� //... .. /�{/) �1. � .. : . , . 6 �/ !i S. RES7R1C11VE HORIZ.ONS (iNJ . _ S . . S . . ... ... _ .. S . .'..: . . . 5:::_.. . , :,.., .,.... (IMPFRVIOUSSTRATA.ROCIC)_._.". . �. ._ PS , . " . PS . . .. , ., . - � .. " r . .. . . .. — i U b� SOR.DIWNAGEIGROUNDWATER _ _ ..._ ... . _ _._ _,. . . S : . _ _ : . S . , .- S _ 5:.._.: ,� _ .. . (EJCl'DtNAL k IIiTERNALJ - . . .. f v , V / . U � /U� � . , . U � 7: SOII,PERMEASII�TY S - S S (PERCOIAATION RAI� � , : U . � '. - � /J,/y � � . � . '. • � . ' • � . r : . . . . . , _ .c. _: r y U �• U . E. AYAILABIE SPACE i r S �. . S S . S. �, . , . � . PS �'f� pS � p$ z ' - • . V /V . p U . � . � � , 9�SIf6CUSSIFICATtON(SEEBAOVf� � �. ' � '� ' .. ::�':' : . , . SOiL SERIES ' : •: : : _. . . ; .. ; � ., .. . . , - . . . . . , � . . � ' . . ._. � � � . . � � .7f r J . . -.., .`:�.SSUITABLE PSPROVISIONAI.LYSUfTAIILE U-LJNSUTfAELE': r;..';. ,, t. � RECOMMENDATIONSICOIVIIViENTS. :``: � � � w� � �- � - � .:: , '';: � , i' �' SITE CLASSIFTCATIO DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas;-f ll �.=�: areas, wells, water bodies; slope pattems;'etc.� ' '"''"' - � C:VIMTPRO'1DOCS�APPSEC.S�1 FWANCEPC ;'; Application Date: � ` � � "d � � � Tax Map: Amount Paid: Parcel #: Receipt#: ��`� � �� .� �� - � � � �1��`� :�.� IF�.r'2'11`�Y^]LIl: .Y:D.IL7l.SYII']l..l.�Jl'1l.'�.21�_.IL 7E-1L.��.�2ll:a::.)L�.. . Application fo� �e�iee� � (Septic Svstems and Wells) G Improvement Permit (5ite Evaluation) $200.00/$300.OQ (if> 600 gpd) C Mobile Home dieplacement or �uilding Addition �150.00 (if site visit required) C Well Permit (New/I�eplacement) $225.00/$125.00 �ervices Ite uested G Construction Authorization (Fee is de endent on the e of sys 0 Permit Revision $75.00 ❑ Repair of Existing Septic System No Charge Important: di the infor`rtatian in the application for an Improvement Permit is i�tcorrect, fulsified, or• the site is alte�ed, t1:en t/ie Improvement Permit and the Authorization tn Construct shall become invalid ��ervices Re uested by:�nn,, Name: / �' lU :�i S Address: ! �' ��n�,4��.: � �✓�' :27.5�7 � Phone # (home): 33�- j�2�2 - / � � rf' (work/cell):3��-.S-�-S'3- i�� 2)1Vaane and address of current owner (if different than applicant): Name: Address: � �,,�/ 3) Property Description: Lot Size: ��_ Subdivision: �y, (�o�� Lot #: Address and/or directions. to Property: /,S'b''YV f��T��, S� w.•�,,�i,/ L`�iDfi�k' .F /33r1 r7�v .�.r'.�'f' —� . 4) Proposed gJse and T pe of Structure: Residential _�Business/Type: Other �- �ai'i- Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No . Water Suppl : Private Well Proposed Existing _) � Community ell: Public Water System: � � �� 3�i�c.GL � � Are there on the adjoining properties? No Yes (please show location on site plan) lYoPe: A comnleted a,�plication must also include: ➢ A plat/site plan of phe praperty that.shows property c�imensions and tl:e size and docr�tion of all proposed structures. ➢ A signed copy of the `Lot Preparation' fot�m ver�in; that the property is ready to be evaluated I ayn subanittia�g this applicataon to request sey-e�ices %om ihe I'erson County �IIealth Y)epart�ent. The nnformation providec� is �ccurate. I under§tand that if any site is altered or the intended use changes, all permits shall becoffie invalid. � Signaiur� (Owner/Legal Representative): �� -Ir ��e : ��7� �o�—C� 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-] 790) ' �, � U � a '�' ` � PERSON COLTI'VTT^Y�'r'IEALTH DEPARTMENT ' "� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT B 2227 Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shail be issued until Authorization for waste water system construction has been issued. Tax Map # �� Zoning Owner/Contractor �'�� v� Location/Address -s'2. i�Di'�-L , �-,�,,,.� Subdivision Name '� C�-�, Gre Lot# 1 SEWAGE Mobile Home # of Bedroorr Permits may be voided if Well and Septic Layout by_ � Comments: �-�►�„ (�n �„►. Installed by '�YS FICATIONS ize of Tank /j,� C-�.,,�; ' Size of Pump Tank_ t/� � � Nitrification Line_�� Max Depth Trenches_/� �� ;d intended use changed. �S" � � .t . i�i.� Sen .; u� h,� l� near [�' sef � �' � ' � _ ' Approved by� :t,. ! �/ ~ �77'11� �� " s�� 1 Go� 3s Xa � ''DV�T �f' ��f 1� 1 Iqy, . „ . — d 4�� e"o i�. � � -� � -�-- ell Permit Paid W LL SYSTEM SPECIFICATIONS Individual ✓ Semi-Public Required Sla� Public Replacement Air Vent Site Approved Required Well �� ,�-ri'" 5—� Well Head Approved Well Tag �� Grouting Approved �/. � 5�"S'0 � ,�/��,(�,(1, ` J� , Comments: Date �� Installed by �, Approved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleadi�g statements provided to him in the application. Neither Person County nor the environmental health specialist warraots that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l Person County Health D.epartment . Environmental Health Section � 'Tax ��lap #: /727 Parcei #• 2� Z Zoning: Township: �� !� n'� � - Subdivision: K�W�uz'l�� VU ��/� �� Section: Lot: �_ Applicant• � U �� ! �� ,u r �i-� - Location:. t� � �" �`L �� "-'"`, ov� � Vl �a,V' �f' �o� �s O eration Permit System Type (In Accordance With Table Va): �11� 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. _�/ /L �.'L .a � / J/�.I�i� / i � � , ..- . -. - .- Tax Map #: �27 � � � Parcel #• 2� � n�iq6'1bDY �•L��s 2�1 ?- On �S �100 0 ST✓�-l�� PCHD, rev. 10/12/99 � Person County Heaith Department Environmentai Health Section fL Zoning: Township: �f l i�� c[[�.� Subdivision:�� C�'e�� Section: lot: �_ Applicant: IVIu�rUl� ��i��J Location: � •� �G C�O�%�+� � • l0� �`� `�� eration Per �mit 1. LOCATION AND SEPARATION DISTANCES A) System meets .1950 setback requirements B) Distance from system to any welis � �I/�7��5 �U�Gf�i- � �W VI�i��S ��- f'�OtGiYt II� C) Distance from septic tank to foundation�� D) Distance from system to property lines �/D' 2. SEPTIC TANK B) �C) D) E) Visually inspect the exterior walls and top of the tank _� Visualiy inspect the interior walis, baffle, tee, fiiter, riser, lids, air vent, bottom, and water tight outlet _� Date of tank manufacture — �—iq2- Tank seriai number ' — 0 Liquid capacity of tank �QOU gailons 3. SUPPLY LINE TO RENCHES A) Grad e ' (1/8 inch per foot minimum) B) Material su ply line s constructed from ��0 p� C) Diameter � � D) Length � � E) Distance from tank to drainfield/distribution device � 4. DISTRIBUTION DEVICE(S) A) Type . B) Is Device water tight C) Distance from the distribution device(s} to the trenches ►�l � D) Is the device on a leve{ foundation � � E) Does the device pertorm according to its design specifications F) Reco�d the inlet and outlet elevations 5. NITRIFICATION FIELD A) Trench depth ^Z inches�5�'tf'��V�G� �� B) Trench width __��inches C) Distance between trenches z� � Ol� G�� D) Number of trenches I E) Length(s) of trenches Sr'P I/� ,W 1 UIGi F} Aggregate depth �,�_ inches G) Aggregate material and size � H) Record septic tank outlet elevation ( 1} Trench grade � (< 1/4" per 1) J) Step downs a. Minimum of 2' of undisturbed earth - b. Proper rise over step d wn c. Solid pipe used _� d. Elevations of step dow�_��' `ecord elevations and show on as buitt) �� See "as built;' plan o attached sheet. PCHD, rev. 10/12/99 4' Date: ' Owner. Location/Directions: � Subdivision Name: Drilling Conbractor: PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG SR# Lot #�_ WELL CONSTRUCTION v Distance from Nearest Properry Line 1 v Distance from Source of Pollution ( G a Total.Dep.th: I_� Ft. Yield: �� GPM Static Water Level a.S� Ft. Water Bearing Zones: Depth � Ft. F� Ft� Ft. Casing: Depth: From 6 to 2'� Ft. Diameter: Inches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Y�s No Weight: Thickness:� � Height�Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: Grout:, Type: Neat Sand/Cement / Concrete Annular. Space Width Inches Water in Aruiular.Space: Yes No Method: Pumped - Pr�ssure � Pour� Depth: Fr�m O to � C� Ft. Materials Used: No. Bags Portland Cement If mixtuie (sand, gravel; cuttings) - Ratio: ID Plates: Yes � No � 4 x 4 slab Yes � No i �- Weight of .1 bag_lbs. to I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TH AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERS0�1 C^vui�`T1' HEALTH DEPARTMENT. ' c �C� , _ ' nature of Contractor D< « � � 3 S a � � � . � y�� ...�..., Y �-r^ � � �.d. *7 �� h,'�"�Ir''aD71ii.]L7in.cL7CJ3,.'(E�t.� ,111L�<�11.11.t�� uiiding Additions/ 1Vdobile �ome A�eplace�ents Tax Map #:�% _ Approval Requested for: Parcel#: ca�/p? Mobile Home Replacement _� Building Addition � Applicant Name: Manii�, � Li� jv1�rri � Address: �' -� o1C%�rZ� { t� 2"757 Phone #'s: Permit Located: � Yes No Installation Date: 5-3-�o Design flow: �8u (gpd) Current Contract with Certified Operator on file (if required): �1I%- Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: (date) (Applicant's signature if site visit is not required) k�'��.,� .c� f�� S��- /�-0� Comments: Addition/Iteplacement Approved - l �11m � i�.� Environmental �Health Specialist ��alo� � Date � 1 ! � *.. � �� '^�� ./ � �J �. V � � IE��n.�n�c-on�a.nvca��a.��.Il IHI��,Il��a Date: /C� / 3 /�� • : � � r.l � �' ' �� ' � :�:. '��. �!�i �' -' _y � Re: Bacteriological Test Results Dear Well Owner: Tax Map.�� PT.rcel: �/� Your weti water was sa�npled on �i�/�, and tested for both total and fecal colif'orm bacteria. Your water sample test results are noted below: � No coliform bacteria were detected in the sample. Your weli water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in t}�e sample. 7ota1 coliform bacteria are nzturallv found in the soil. Fecal col f�rm. ba�teria �.re associated ��r.t!: animnal and/or human wasie. The pcesencs of either total or fecal coliform bacteria in wzll 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 not be safe for use. Young childrer,, the elderly, and the individuals with compromised immune systems are especia[ly vulnerable and their ptiysicians should be notified of the test results: A wsll th.a_> tests positive for total or fecal c�liform bacteria should be preperlv disif fected und r�tested 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. Sincerely, �� Environmental Health Specialist Pers�n County Health Department (rev. 4/2�/16j Person Coun.ry Envircnmental Health, 325 S. Morgzn S.., Suite C, Roxberr,, P:C 27573, ?hone: 33u-579-1790, Fzuc 336-�9i-7S0"s North Carolina State Laboratory Public Health Environmental Sciences fUlicrobiology 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: ES092016-0059001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: TERESA PARTRIDGE 1337 ROBERTSON RD ROXBORO, NC 27574 Col lected: 09/19/2016 14:30 Received: 09/20/2016 08:15 Sample Source: Well Sampling Point: Kitchen sink P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slah.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Angela Heybroek Well Permit Number: A27-212 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Cindy Price o9/21/2016 E. coli, Colilert Absent Cindy Price 09/21/2016 Report Date: 09/22/2016 Explanations of Coliform Analysis: Reported By: Cindv Price CJt-1� ;�it�,ce � 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. �� T�� nc department of health and human sarvices �� ,�u� �..,� d �S sa� .:°S ��:� ��+:rvs�+ :,' � J 6� � }�.-s+ w � � � "'v,) � � � n = � �.�� ,�- � � � 3 � ,.� � ��:; � �: , �"-� `"� f :,..� �-k� � �� -� � �;�� .� a � �- � E �$ p � �a "s d c: �s1� �s.xx._q }�` � 7i�ca� � �. � �i x � p � j� � �� f�� a' � �a,.�� 5# ' � e-o-;. a �3 7s�.,r.:+ t;s3*' �r.r3 °�a,w". iA a> u,,:a ,-:a 43 w .4 � Y � � c �3 For lnorganic Chemical Contaminants County: Name: � Sample ID #: — Reviewer: TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic c%einicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results on[v. You may have other water sampling 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 inor,�anic chemical resu[ts onlv. Arsenic Man�ar Barium I Cadmium I Chromium Nitrate/Nitrite I Selenium I Silver Fluoride � Lead � Iron Ma�nesium Zinc pH 3. [[�a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium 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 ii:nrQanic c/temical results onlv. �. Levels 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 frst 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 chemica! 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 Ma nesium Man anese Selenium Silver H Zinc For niore information regarding your we!/ water results, please ca!! t/1e Nortle Carolina Division of Public Health at 919-707-5900. 0 North Carolina State Laboratory of Public Health 3�12 D stnct Drve Environmental Sciences Raleigh, NC 27611-8047 htta://slph. ncpublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: H. KELLY Name of System: PERSON CO ENVIRONMENTAL HEALTH TERESA PARTRIDGE 325 S MORGAN STREET 1337 ROBERTSON RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES092016-0044001 Date Collected: 09/19/16 Time Collected: 2:30 PM Date Received: 09/20/16 Collected By: H Kelly Sample Type: Raw Sampling Point: Kitchen sink Well Permit #: A27-212 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 Calcium < 1.0 mg/L Chloride 31.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate N itrite pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date:09/29/2016 < 0.05 < 0.20 < 0.10 < 0.005 < 1.0 < 0.03 < 0.0005 < 1.00 < 0.1 7.9 < 0.005 < 5 130.0 199 <7 < 0.05 Page 1 of 1 N/A m m Reported By: Deddie .r'�tancol PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Taz Map #: � �� Parcel # �� Zoning Township U�1. �� V' - � �� r �� i_. _ i_ L�� t Locatlon: ��res Subdivision: Section: �� pe of Water SupplV: Requirements: Lot: �_ Well Permit ✓ Individual Community Public Site Approved by ✓,�,�� '�D Grouting Approved by ./. �?9,t� i-�', �GO Well Log o/.�� -��.� Well Tag Air Vent Hose Bib Concrete Slab � 1 / 1.ii►1 � Well Approved By: Date: **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: i''�S PCHD, rev. 11/29/99 �plicatlon Date: 4�� 6 Tax Mao #• �� . Amount Paid• �� a � 3 Recei �� q k 6 I Parc.sl �• � � I ��y�r � �� ' � �C � �T�T'�� ..�a-.m��-,.-� .e�.��.a �a.m.a.�. _ APPLICATION FOR SERVICES . � 1) Permit requested by: (Ownedagerit/prospective owner):r�� j�� S.�`�'�� Home Phone: �3 t, � Address;/ o oB�2r �n� Business Pho : � / � P A[�3r2o N G 2 7 S-� 2) Name and address of currerK owne� 3) Property Description: Lot size: -log Township:QL u�''� �L Subdivision:�� Lot# �-- Directions to the prope►ty (including road names and numbers): �,f�i t,J�z� � o.'t'oH.c1 W� .vsr z 4) Proposed Use and Structure Description: answer each of the following questions: �, i a) Proposed _, Exis�ng , Type of Structure: O �YF'3 u i L1� � �v G Width:�l� Depth: �� b) Number df Bedrooms:' - Number of occupants or people to be served: � � c) Basement Yes_,, No Will there be plumbing in the basement? d) 6arbage �(sposal: Yes _, No _ 5) Water Supply Type: Private �(new _ or existing�, Public_, Community . Spring _ Are any wells on adjaining property? Yes�„ No _ ff yes, please indicate approximate locatiori on the 'site plan. . 6) Does your property cor�tain previously identifled jurisdictional wetlands? Yes_ No� PLEASE NOTE THE FOLLOWiNG: ➢ A PLAT. OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L�NES AND CORNERS MUST BE CLEARLY MARI�D. �, `➢ THE PROPOS�ED LOCATION OF ALL STRUCTURES MUST BE STA�D OR FLAGGED. ➢ THE SITE MUS'� BE REk1DILY ACCE3SIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. � � I hereby make application.to #he Person County Health Department for a site evalua�on for the on-site sewage disposat system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed o� the property. I understand if the site is altered or the intended use changes, the permit shall or Lega! Representative Z � Date PCHD, rev. 06127/02 � � " �� . , � y� ~ , � �✓ '�.1� �� 7Cn`�-71:t�a[D.7rn.lrnr�l.�mt'�.�A.� 11. JL��U.J11�.ICA. Building Additions/ Mobile Home Replacements Tax Map #: aoa� Parcel#: a�3 ��'� ��-� a Approval Requested for: Mobile Home Replacement X Building Addition �c. ��' x ao' Applicant Name: ��le,s �, �s�o� _ Address: I �''� 'Ro�.sa�s.�� 'Rz �x��o� %uL Phone #'s:t?��1� ��7 -��a �33to- 55� -��A� Pernut Locafed: x Yes No Installation Date: ► �-� �15 Design flow: �(oc� (gpd) Current Contract with Certified Operator on file (if required): ��_ Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: 5-1-�a (date) (Applicant's signature if site visit is not reguired) CS Comments: �`1td �a n��- o� n,w� �- � �,�• ��- �9��, —4-�G1� WQ;c�4- O'�Z �r1Si�d��- Mo.�Qrr.qxJr C�Ol S�LfJ�'L ��h¢.S W�� 1 . ir. � _ _, � .,n � � o - ZS �i- ��-. S fi � inr-. —�, � ition/Replacement Approved � ' anmen e lth pec' ist 11/15/OS 5- I�cxQ Date ��y;,�� `LJ'�_ �l "" � `�.1� � 1L � lE�-�u-�,�,r„-„��.11 ]H[�m.Il�]]� Na.me �1e�. c�. �Aa�� S divis' 12;��t� � Auth rize tate Agent SI'I'E SI�E'ICC�I Tax Map #�.Parcel # a�3 Section/Lot# a s- �-o� Date System cnmponents represent upproximate�contours only: The contractor must, flag the systemprior to beginning the� installation to insure that propergrade is maintained — Cv�Qc r��- ( � -{�`� � �t � �r � - �' > >S ��- o� G, ..—� �i- T��OL��sn ,�,� � -j � �� l�� *.S� '� ��cale: /l� � � �v �S� o Q o � N+o-oc7� r�c111,�,k �,l�j G; ,''k'str �\ cx�� Sz1� gQ�l;� �,nQS, _ heo„�� c..�e;5�, �- Q� ��,�.- �,-��. v„� s��j-�,.,... �,.�,� � �sz c� CcS=,�s-. CY�d C�,u�. �r�,,,� i +G; �v�2 oF SQ��'� . PGHD, rev. 09/12/01 r;-... . .� . . _ � :.. .,. �.. . _ ,..:..,._,- . , .. .._-,,..... ..",_ __._�.......�...,,. ._.. . . ��v.�.. _ . . .-__"._ _ �... I_ . _....__ -. . �'_ . -� , _ . . ._ .._"_ ___ __ r' ;. __". . . _ �FLE6'CM1L' frAV LI ,,: . , �� . '�. �.;, ��Y ��„ �' • � � 0 � C:D1Yit� T. �.or�� 1 � � '�. ,�� y v /"�\ r"�'nr�, . . � �, `�,i �, . �� a�`��a �'�., •� �, �; . ,r �`� ��°,�' �, � 1 _ A � � � � �i �i� �� , -�,,` � 1 �1 `� ' n, r � � 1� r '� �,.�.. �� , � ' �� 0 �!� ��!4 AC. �� II.9� Ac'' M� li _ ' F+ : _ ; �� son County Health Department � ^ �, Sewage System Improvements Permit CI- �' g'This Permit Void After S.-Y s Permit #��"a3 `'� � Date: /�. Owner: ' � � e ^ SR# ___ _ .. f n I K `I i�1 1.UL� � Subdivision N e: K' ' Lot Size: ' Type of Dwelling: Water Supply: ,Private: ,►__ � -- P�blic: Community;. Bedrooms: �— Gazbage Disposal _ ` Basement Basement ' es : ' INFORMATION CER'TIFIED BY ' � owner o esen uv Environmental Health Specialist: REPAIR'---- REEVALUATION�---------- Size of Septic Tank: �� jns Siz� of Pump Tank: Nitriiication Line: �-�-�"� � � Depth of Stone: 12 inches Max Depth of Trenches: Alternative System: Conv. Pump LPP Pump . Remarks: :; . .: „ ; , : _ Date Well BY Date S � B 1 should be.100 f� from any sewer system �� s . ital Health Specialist � �`yERTIFI�A F MPLETION ►-� Contractor. � � ---------------------------- �� . Sewage System location, installation, and protection must , meet state and - local � regulations. Septic tanlc should be pumped out every 3 to 5 yeazs and shall be maintained by Qwner in such mannei as not to create a, public health haiard. Septic tank , and iutrificadon line must be inspected and approved. by , a member of [he Person County Healt� Department before any portion of the installation is covered and put into use. If Rj . the site plans oI intended use cfiange tlu� perniit is subject to revocation: ; ' J (G.S.130 A-335F) . ; ; . _.. _ � L.ocation of sewage disposal sewage system sketched on back. ' � (OVER) .._ � . .. ��"��/'�' �1C��/�CG� �� ' . � . - `�z0