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A27 213_ �e„t c� �T U�' �� c�s �a�/�9 - �- � w �. �e�� o�� _�: �� ; i i � ' t�pplica#ion Date: 'Z �1 D � �, � �6 ,� � � Tax Map: Amount Paid: v. �� a' Parcel #: . Receipt#: 0 2 � � �� S �� I�I�..� �� s�.��d�. - � � � ��-�- IL:.�ca-a,>nv-KD�a.St'I[71<C�+IC3L1C.:.�a.71 IE �<c:,aa.714::1�a . Application for Services (Septic Systems and Wells). 1) Services Requested by: � Name: S� d,�w n � r Phone #(home): 33b - S9 - ` Address: 1 ena v,l � (work/cell): 33L� - S0�- 3�2.5-_ e td � % 2)Name and address o curren owner (if different than applicant): �� —��,�,�- C0� Name: e, o wo� 5�d d Address: ` � 2 3) Property Description: Lot Size: 3 ct� Subdivisi Addyess�nd/or directi4ns� o Property: � 5�� nn;��S .� 4) Proposed Us and Type of Structure: � Residential �_ Business/Type: Other_ Number of bedrooms �_ / Number of people served (seats/employees): _ Basement: Yes No �. (with plumbing: Yes No _, Garbage disposal: Yes No � 5) Water Supply: Private Well %� (Proposed x Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No _ Yes %� (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of tlee �sroperty that shows property dimensions and the size and location of all proposed structures. . � A signed copy o, f'tlte `Lot Prepa�•ation' fornz verifying tltat tlte properry is ready to be evalaiated. I am submitting this application to request services from the Person County I3ealth Department. I understand that if the information provided is incorrect or if the site is subseque tly altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): Date : /` �/'�� 10/08 Person County Environment� l Health, 325 S. Nlorgan St., Suite C, Roxboro, NC 27573 (336-�97-1790) ' � � i �� _� � .��y 1 , 1� 1 y` ' � ' � �' �/ � 3 � ; �•.�`r^`��' ^'�. ---• . �. �� ' �'"_, 33�i� �[.� �^+ �";"+ <Es�.�.�s. ��. Arrplican� C� P .�a /o � . ,� I.003'tIIOII: �'r$`^�'a (1�J To�n Y, Wj�S`�'la � o� �l'��— bP a/Y' ,n c�� . - �'cs1II < a . � �V IG�%sl� �`� � �� UO 0 �' ° ^ D o � ;1 L v ?�' Iaaapravement �ea•mit ��rsni# ��l'ad fo� �'3�e �� o �aration � `Orj ✓QiP Type �of Facility: ES R S�� Neur �ddition '�7ate� ��apply `� P f I � of Oc�ants g # of Bedrooms Projecte3 Daiiy ow ' S O g,p.d. -- �--� Proposerl Wastewater System: Co � v(� i'o � u�� Type: �—+'i— Propose�i Repair: a cc� ' � Type: , . Permit Conditians: Owner br Legal Rsprese Authorizsd State �Agent The issuanca of this pe�it by. the Health Deparnaent in does not guarante� the �ss�sa of other pezmits. It is the responsibility of the � a�plicant/properiy owner to in s�e ti�at a11 Person Couaty Plaimiag and Z�niag anci Biu7.ding Inspeciions. requirements are me� �inis �aproveffiesat �ermit is �zbjest to revoca�ion ii the sife pIan, piat o� t�e intended use c3�anges. TIte Imp�oveme�t �ermit is mo# a3%s#e� by a c3�ange in ownerslaip of the �roperty. �his permit was issu� in cn�pfianca.vvit� the provisions of the Nort9� C�roli�.a `Liaws rzrid Rules for Sewrags ?'reut�nent ra�d �isnosal Svstems' {15A 1�TC?�C 1�A .1900). iYeitlier Prxson �oun#y nor tiie �nviran�aesatal �eaith Spe�ialist' �arr�$s tIaat the se}�tic tank systemma ov�1t cuntiatue ta fnnc#ioq satisia,ctmrily in tiie futare �r'that tlae wate.r supQly w�71 remain�potatsle. - .... . " � A�nt�ori�taon � C�Bstra�ct �as#�ater Sys�em (12e�n�� for �uiiding Per�i.t) * See site plan and additional attachments� (_ j• . Propase Wastewater System.� ^ � F�� /�''c �� i� v/� 7"� Typ�cT Waste�ter Flow T�:p.d. New �i� Repair Expansion� �� Soil �TA�t: O•� g.p.d.! ft Z Type of Faciliiy: � !-�-1� �L �S� Basement _ Yes � o � � , �as�e�aa�er �gtste�. �3.es�a�a�e�aen� � '�a� Siz�: Se�i�c '�aaa�: � dD U�d �mm� 'Tank: n% �%� g� iig�se ia��p: a k � g�i �rain�e�d- '�o#�ll A,re�: � (� � �� Total �,r�g#la s� T �t � l��t� ��nch i3ept�a � 3 ��i� �remcia'9�adt� �� 11��a Soni C�ve�: � iai iYlinina�a'�r��c� Se�ar�tiom: �� g oc � �fist�i�utaon: �i§tributio�a �o� l�Serial I�istr�ntiom �ss�are i�a%id �pe�cataons: � �' i � � 7�"C "`� � J -� `}— l`-r �r � l � /► � " � i� G�t P S o� �t d)�►�—� 5 1 So j I, -- �v�ao��d st�ate Ag�#: � — Date: O ��Q % - Perrmt Exp' on Date: _ o I o9 -- 2-c� l__� � The ��e of system permitte3 is � C nv tionai Acc�tea Alternative. I ac��t �e spe��fications of tiie P��- l � J ��e�l�.��1 �zpa-��J:a�ive: Date: d � �� ' . C� rev. � 1/10/a5 ��y,),�� `._-.. � � � � �� IC, ��-a.d-�L��-�aa��-�-��La �.�.11 II-3I «�m.]1�11-� ' • • . . /... ��► � i i � �►�. � • . � � ,/I I �i� �1 Tax M�p � % P�rcel # Subdivision Ph�se Section Lot # # of Bedrooms Op��at�o� Per�n�t System Type (In Accordance With Table Va): i�i THIS SYSTEM HAS BEEN IIVSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATME(VT AiVD DISPOSAL, `�.AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION �� AUTHORIZATION. �/. �/ A thorized tate Agent Installed By: �i - �� s .�- Q� �2��'�. z/'g /0 9 Date Date: 7�q�a9 �-�-�_ .E. �y�M� C�7 ' S� 6<o%L' 7�'1 �T5 i000 G` % " 5� it�Z 1 ? �S^o� _ �r,s� `�CILL� g� yL.. _ 70' �tTaMs IZ-7s�.�� PCHD, rev. 07/29/04 0 � S�a�"fC �'��lK I��i�ON �i�E��.iS� (T�pe t! - � Tax MaQ #�� Parc�! #�1� Systern Type (Tab1e Va) . Owne�lA��iicant � ��/ Subdivi5ion AddresslLocation � Se�lPi�ase Lot # � � , State IQldate �',g ��L•z Capaciiy. �'S /'On o � Tee and Filter Baffle � Sealarrt Riser (if appficable} Tank Ou�et: Seai PeRnanerrt Marker - � Ptatrep Tank ta e Capaciiy . . gal. Waterproof /Sealarrt - Riser . � Water Tight � .. Pump- �beclt Valve/Gate Vaive � : .; � - � . � t�-sip on o e . . .� �oats/Swiict�es �: : � � , . Alarm visabie and audibie) � E3ectrical Campo�erits - . s Rate pm Ap roved Pum Mode1 Biocic Under Pump Pum Removal Ro elChain 'on �ys#em Seriai Distribution � ' Low Pressure Pipe � ARpr. Pipe Material and Grade ; q T�+enct� 1Mdth ft, Trencfi. Depth � in_ � Trencii Length a f�. Tr�encf� Grade Tr�encf� S acing . Rodc Depth and Quaiity � - DamslSte owns etc. � � Pressure Laterals �iole Spacing � o e �ze .. . . _ � . Pipe Steeve . � - - . � . Tum-upsfProte�tors �Required Se�ac� . � � From 1Nells �. � . � Frnm Pmperty lines � � __: .Strvcturesl6asemerrts.:: � �.� � �tc es ra�nage � ays. .. . _ : . Surfar�`Waters � - � - � Public Water Sup (ies Vertica! Cuts �>2 ft. . Water Unes Vehicle Traffic Easements/Rigtrt of rtV� � Ot9�er. Easements Recorded . 1 �ammer�ts� � � � � pcnd rev. 3113I�1 �� a L. - �' 5 � '�✓ S \ j � �`a`7` . l� �, - q� � (� � � Z C. 7 = �9 � �� ao�' � �O � �� '�� = �� 5 3 �t" � �N v, * � �� !'Ra�b ;, 6. G,�,�� /� � G� ��,� �� 1��;1�.��:1� � :::.. ��\ `, .,. � ��71�°IC� \ ]E�..ny-�,.�,.,..,��.m.11 ]HC�.mR,6Ila. \ SITE S�ETCH . , \ - \ � \ Name G.• � w 4 �O� �o !a� � n Ta$ Map # � � Patcel # � ` � � \ Subdivision Section/Lot# � / �`I'/o . \ - _ . _ ' ' _ _ _ T _ � � :�� Authoxized State Agent � ate � � . � Syste�sr camponeuts reprerent aji�rozz�nafe•casrtours only. The coniractor mussflag ilia systen: prior to �� beginning ihe installation io insure thatpro�5ergmde r.s maintained \ � ' i �, < � .,� � . � �'a� � , -: � , �. \ . \ . \ ` • ...1. � � �� .��. ! `\`..` ty '�; �� . Q� `\ ' ` 1 1 �� -_ �. i � Ro� os � � t ' ----_.___ _ _ �� .;, .� ,, �rn�rj� ��,�r �`�- ° �c' N �-C�}�E : ��.�C�O� ( �o' �, � '�'� ��M�s�t- �a,,l ;.� q$—% ►-, c �i ps o� y�� i �io-,s I �ip , . a 4� ,'..�-'� ` i ��` ., �� . .�•.� ' --_ ' �---- o, % 26„ �,,/ �� 5E,,5�' . Must install septic system on contour. Must not install septic system during wet conditions. Septic system must maintain all proper setbacks. . Any questions call Environmental Health Dept. � 336-597-1790 � r� �� V� � � � � �1.! �. V � � ��av�nmon�anvra�n�n.��.Il ��.��Ila Date: _�/ /2 / 1�� Name: �%' � f Tax Map:� Parcel:� Address: �! .1 �, 2�� Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on /J i 3/�, and tested for both total and fecal coliform bacteria. Your water san�ple test results are noted below: � 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 bacteriolo�ical results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total col�orm bacteria are nzturally found in thP soil. Fecal col form ba�teria are asseciated �x:th animnal and/or huma.*� waste. The preser.ce of either total or fecal coliform bacteria in wzil 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 children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well th�t tes!s positive for total or,fecal col;form �acteria shozrld bs prope; l disinfecte� a�zd retested przor 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 f ushed oat of t►'�e system, please contact the Heaith Depariment to requesc 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, �� Environmen al Health Specialist Pecson Counr,� Health Department (rev. 4/20l16) Pers�n Cour.ty Environmer.tal Heal?h, 325 S. ".4organ St., �uite C, I:oxSoro, :v'C 27573, Phone: 335-5i9-17y0, Fax 330-597-7808 -4 North Carolina State Laboratory Public Health Environmental Sciences fVlicrobiology 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: ES100416-0070001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JENNIFER SOLOMON P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slqh.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 118 JOHN D WINSTEAD RD ROXBORO, NC 27574 Col lected: 10/03/2016 11:00 Received: 10/04/2016 08:24 Sample Source: Well Sampling Point: Outside tap H Kelly Angela Heybroek Well Permit Number: A28-213 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent 10/05/2016 E. coli, Colilert Absent 10/05/2016 Report Date: 10/05/2016 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. ��c � r� � F j�f' �°� � . ti �� t" � e� � � d H ��`S`,�,,"� �Y� x� . �� }" �� :: � 'r�. �� 5�� '��.� �� ..��«'�Iv 4 nc dGpartment '� :K�s`� `a�'. #3 fa s � ,yr� a �.-.�s' �"''S� r'�'A.�`� °v-�.-�• ��,r'�"'� �9'� 1� "�`' � � � �F r"�y of health and ,� ��.s � � � s � �'� i `h � .�;;s r, � a E� r �! � � �'�,t � `�,� �c�� ' *� � human services �a,� � � .� �,�: `'t�� vti� �� `� `��,o� �? ..�' �.:� � � '� ?! � � �z� � � z�. � '� ' For Inorganic �hemical Contaminants County: t� Name: i . Sample ID #: �— n Reviewer: . l TEST RESULTS AND USE RECOMMENDATIONS 1. Your wel I water meets federal drinking water standards for inorganic cliemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�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 federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina Division of Pub(ic 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 results onlv. Arsenic I Barium I Cadmium I Chromium Nitrate/Nitrite I Selenium I Silver Fluoride � Lead � Iron Ma�nesium Zinc �H 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 tlie innrQanic c/temical results onlv. ❑ b. Levels 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 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 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 Manganese Selenium Silver H Zinc For n:ore informatio�z regarding your wel/ water results, please call tlre Nort/e Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 3012 Di t�c�Drve Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncpublichealth.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: JENNIFER SOLOMON 118 JOHN D WINSTEAD RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES100416-0025001 Date Collected: 10/03/16 Time Collected: 11:00 AM Date Received: 10/04/16 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A28-213 Sample Source: Well Temp. at Receipt: 2.0 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 Calcium 7 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L � Fluo < 0.05 < 0.20 Iron 0.44 0.30 Lead < 0.005 0.015 Magnesium 4 Manganese Mercury Nitrate Nitrite pH Selenium Silver Sodium Sulfate < 0.03 < 0.000 < 1.00 < 0.1 6.9 < 0.00: < 0.05 6.10 < 5.00 0.002 m 10.00 m 1.00 m n 0.05 m 0.10 m iotai riaraness ;�;� mgi� Zinc < 0.05 5.00 mg/L Report Date:10/07/2016 Page 1 of 1 Reported By: Deddie .�toncol" � �-��, ; � �� ..r..,, � � .�^ � � � � � � ��a-��n.�r��a.n�.��rn.�.�.� J��.m..11�.1�.n. '6��+ �,�, �'�ER1VII�' (1`devv Repair� 'Tas l�Iap: � � 0 Parcel: oZ � � _ Subdivision: � Lot: Applicant's Name: G �' a � � �S �� S�' �� "' v'' �—� Viailing Address: I �} ll��.�v +� �P R�. � �bv�J� NG 2-757 Phone Numbers: (o -S �9 - �9�� 3 3 �o -Sb 5� -��5� �a /S� w --� � ��-� � L� fl, t.,.� � -, S� 4 � � ��- b� � ��, 1�e�mit Conditions: 1} See attached site plan for proposed well location. Z) All applicable State and County Negulations gouerning construclion and setbacks apply. 3) Permits expire S years from the date of issue. Other Canditions/CommenPs: See S��P S?'L"�Q?�"c �j - ]Pe�-sni# �ssued by: �Y� Daie: �/%a��0 9 C�+ R'�'�$+'��t�T�+ �i+ C�l�IPI��+'�'IO1�T New Well �nspection: EHS/Date Location: �w oa- � Grouting: Well Log: WeII Tag: Pump Tag: Air Vent: Hose Bib: Casing Heighi Concrete Slab �D 9 Liner inspection: EHS/Date Installer: Depth: Grout: Well A�andonmeat: EHS/Date Completed: Method/Nlaterial(s): _ V6�eil �rille�: � � °� S'�� I�icense #: �'� � � Pump Instailer: }i a r�; S � �,�; ;, cP License#: �a!� '?� i dVell Approved by: � Date: �5�d- %�C> r'/ Date Sample Collected: GS��v Person County Environmental Health �25 S. Ulorgan St., Suite C Roxboro, NC 2757� Date Results �Iailed: ' � Phone: 336-�97-1790 Fax: 336-597-7808 sil�os ! �+��` ', sJ � �� `�,,,J�� ' - �.' � ' �'� � "� a�svaa�+ca� �+�*��an. ��eaIl��a • :� oa (��r � � �,� � oZ. _____ ��9! � �:.�.� � _ � 5......��-L. iA� (=N1�RIi�t�! �" � U ` � �'% Well Log Taac Itiiap � Parcel # o�� Location: /.S X c..� <-� C�R� t� h�+� �-�s � N ss,� d� CQ3 r�,. a;1�3o � 1�-c� � � o+ u� t c�-k- b c fia re Subdivi�ion: Lot # Q o�c�.. WC�I CODeb QC1�OII ��ace From nearest Propaty Line (Miaimum 10 feet) _�o Distaace from Segtic System (Minimum 60 fees} �a Total Depth: � OS ft Yield: GPM Static Watct Level: a � ft Water Beari�g Zones: Depth 5 2 ii � sd� fi _3050 ft ft P vC - 7 4 � 5: �� Castng: g c� Dspth: Fram �- (_ to R 3 ft. Diameter: C� (�y in Type: Gatvanized Steel P 11 G�-- 5-� t t( '�a8h�5 R- �. Tbichiess: Height above Cxraund: �_ ia Drive Shoe: __�/ Yes No Any problems mcountered while setting casing? Yes ✓'�to If "yes" give reasan: Grnot: � Nrat: SandlCement Cancrete Gravel/Ce,ment Annular Space Width inc�es Water in Annulaz Space Yes _ No Method of Gzout: Pumped Pressure Poured Depth to F�. �Ixter�ixia Used: No. Bags Portland cement Weight of 1 Bag _� Pounds If au.xture (sand, gravel, cuttings} — Ratio to ID plates: Yes _ No 4 x 4 slab _ Ys� � No Drilling Log Lacation Drswiag From . To Formation �� 0 hAl� � (� �3 C7 r ti` ' r i q S r�a�,�c 5�9 SU r�fl 1� o b 5 G r,�,�� ..._.______. I hereby eertify that the above information is correct and that this �+�vell was constructed in aceordance wzth regulations set forth by +he Person County Health Qepaztrnen� Sigaature of Cuntr�tctor `��.-�/l�-� ID #� Date `,�..' 10 - o�j PC�-ID rev 01/16.'t3�,