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A27 255Application Date: 3 �Z3 -) � Amount Paid: OCi .GO Receipt #: 1 G 7 4 7 �1�7�U An Permit (Site Evaluation) �300.00 (if> 600 �pd) or Building Addition 150.00 (1�f site visit Well er�init (New/RepIacement/Repair) $300.00/$20Q.00/$75.00 ��,sf ��.��i � � �� IE��s��¢�.11 IE3[ m�.Il¢lF� Tax Map: �_ Parcel#: ��,�_ �}-Z� - �S �lication for Services G"�� Services Re uested Construction Authorization (Fee is de endent on the e of s stem ermitted Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Infor�mN ion: �£� C Name: Address: � m D �� C a ' 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Address and/or duections to Property, _ Phone (home). �� , • 5� � _� � � (work/cell): "' � � ` � Phone: Lot #: � �n,1r ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure:. ��a ❑Residentiai � e� � � O New Single Family Residence Maximum number of bedrooms: / Occupants: � �zpansion of Existing System If expansion: Current number of bedrooms: h`` �' �`�O0'`� ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑1�1on-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well Existing Well ❑ Community Well ❑ Public Water O 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: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted � Innovative ❑ Alternative ❑ Other ❑�Y I certify that the information provided above is complete and correct. I also understand that if the information provided is inncc�rate, the site is subsequsn;ly altered, or the intended use changes, all permits and apprevals shall be invalid. a�gnature �uwneri Legai tcepresei * Supporting documentation required. ��a. 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. �1 n/i 51 Per��n C:nuntv Rnvir�nmental Health. 325 �. Morgan St._ Suite C. Roxboro. NC 27573 (336-597-17901 ConnectGIS Feature Report Page 1 of 1 http:;/gis.pe:soncounty.net/ConnectGlS_v6/D�wnlcadFile.ashx?i=_ags_ma�;26�)8i�dd9fa5c... 4/19!2016 � ConnectGIS Feature Report ;�` _��._: iC15 '.4'EB H �:511'JG Person County Environmental Healt� 325 S. Morgan S�eet Roxboro, NC 27573 = � r:., r�l ��"a r� � L}�9' ZS�j _, � �.�-- ��'' ;�i�r, �� J,: -�- i�_ -- --' 1 ` �� , �V � SE�rrG Ti1ri� /� � ��'STj� 'S �P��-f 1�� rl� �-t 5� 3376T //Io�c�D ' �i �:�� `.!i w��i/� i— � �/� Z�-�s' ,�.� 3373 Page 1 of 1 Person Printed April 19, 2016 See Below for Disclaimer �� oT�= � vk;a r�l �'c� �i2E.A' �1�T 8E �12�1:`� ,<<?�� ",r,a� � ��`�= .`""!�S � ��! ��` �7 971'.1 � ��,ii �_.}�,:. ;:. 2�9i9 'ti"_. 27'' ' � u : 2G Feet IOT;CE: Recently, we have had severai users report browser compatibiliry issues wiien trying to access our GIS website. Typically, the probiem stems r`rom users who hav� acently upgraaed to tne Windows 8 operating system or a new version ot Intemet Explorer. We were abie to resolve this issue by directing users to the Internet explore ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/intemet explorer/products/ie 9/features/compatibility-vie�- this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has bee repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system an otified that the aforementioned public information sources should be consulted for verifcation of the information in this system. Person County, Mobile 311, ConnectGi ssume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.persorcounty.n�t/ConnectGIS_v6; DownloadFile.ashx?i=_ags_map6490946a429 4/ 19/2016 .:' � � �—, 1 .� < �`�,. ,.. � :..:�:, c� � �� .��.��.� ��.�.��. Building Additions/ Mobile Home Replacements Tax Map #:� Pazcel#: �-a Address: Approval Requested for: Mobile Home Replacement x Building Addition G�r�E wr�, ��— �''u'.� � /to �� Applicant Name: �D�-c3 j �,,., ��c.� �Z�� S� Address: O P...d G ' Phone #'s• �%� �i � �'i � Permit Located: _ /L Yes No Installation Date: ro � Design flow: � (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: �/i4,/f i!v (date) (Applicant's signature if site visit is not required) —T Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net �� „�� nc d2partment of health and human services coun�: o Sample ID #: - 7:+�� tL yq ��„ ?,t3 ne S� �v Z, �<a .'gr � �yn � � S;a'�h� rt,�� p}.� e�qp �r � � yy� �k � � �� 'ui� �a'� ��2� ``�ati � '� '_� & � � f�� , . ��,,� � � � '� � �? �� '�f §'� * '3 t: ¢'`'�. ��;. ---�'., v� ,y'.r'� ,�` x y.s"�, � �`. �j i� Rr��a� ?' r' i � `�rjj M �1 %�.� M �x �' f3 ,�f� �„��ly ,S�.�w.� }�+'7 �'M �.sayy:+ {f� ri kT#, tt' S�d y[`�� y'`� �yyj� �i�{�',.�.� �cxa^ a .�. Jf h��, y.4 :i'+.'K.' h..q;ga�'' �v�3it'�i � �t� 1��..rG"�, S�T.,4� � :C� :i � � .d� i} � 'Rfl:r� K � ��"a�� 4� � . � i� F For lnorganic Cl�emical �ontaminants Name: u TEST RESULTS AND USE RECOMMENDATIONS 1. � Your well water meets federal drinking water standards for inorganic c%emicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemica[ results onlv. 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 inorQanic chemical results onlv. Arsenic I Barium I Cadmium I Chromium Nitrate/Nitrite I Selenium I Silver Fluoride � Lead � Iron Ma�nesium Zinc nH 3. [�. 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 iiinr�anic cl:emical 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 I S minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample atthe well head to determine the source ofthe lead and/or copper. 6. ❑ Tlie 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, 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 � Magnesium Manganese Selenium Silver pH Zinc For n:ore informatioi: regarding yaur we!/ water results, please call the Nortle Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 3012 D st�ct 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: DAN LAWRENCE 2831 SEMORA RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES053117-0042001 Date Collected: 05/30/17 Time Collected: 11:30 AM Date Received: 05/31/17 Collected By: H Kelly Sample Type: Raw Sampling Point: Outside tap Well Permit #: A27-255 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 (l01 0_005 ma/L K�� Chromium < 0.01 0.10 Copper < 0.05 1.3 __ _ e < 0.20 Iron < 0.10 0.30 Lead < 0.005 0.015 esium 10 anese < 0.03 Mercury < 0.0005 0.002 N itrate 1.40 10.00 Nitrite < 0.1 1.00 mg/L pH 7.3 N/A Selenium < 0.005 0.05 mq/L Total Hardness 130 mg/L Zinc < 0.05 5.00 mg/L Report Date:06/09/2017 Page 1 of 1 Reported By: .xennet`i Greene �� . � � � � � �/ �� n.�nson�an�nca�ira��,� ��.Il��ia Date: �_/ � /�Z /i. :�, /. . � �� r'.. /.1 �I .IIJ"�/!I / ♦ Re: Bacteriological Test Results Dear Well Owner: Tax Map:�� Parcel: ZS� Your well water was sampled on �/�O /��, and tested for both total and fecal coliform bacteria. Your water saniple 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 bacteriological results only. V Total coliform bacteria were detected in the sample. � Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in tl:e soil. Fecal coliform bacteria are associated w:th animnal and/or human wasie. 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 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 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 Deparhnent 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, �� sG%� Environmental Health Speciatist Person County Health Department (rev. 4/20I16) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences �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: ES053117-0090001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: DAN LAWRENCE 2831 SEMORA RD ROXBORO, NC 27574 Col lected: 05/30/2017 11:30 Received: 05/31/2017 08:27 Sample Source: Well Sampling Point: Outside tap P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sloh.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Susan Beastey Well Permit Number: A27-255 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present O6/01/2017 E. coli, Colilert Present 06/01/2017 Report Date: 06/01/2017 Explanations of Coliform Analysis: Reported By: Susan Beasley 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. JUN-14-2017 14:15 FROM-HEALTH DEPT . , , v' ., � •� 3363226099 T-004 P.001/001 F-841 PERSdN CaUNTY HEAL7H DEPARTMENY 355Q SC7►UTH MADISQI� ��VD ROX�OR�, NKIRTH CAROLINA �i573 BACTERIdLIOG1CAL WATER SAMPL� ANALYSIS Name �f �wner or Tenant � �.1�„� � ��l_� Address �� J�,�r4�: ,� �"�• Caunty � � Collected By _ -kd� I�Z.+�'� Date C�ilected � Time Collected �;a0 Source: �NI►e�! ❑ Spring ❑ fath�r Location: �' tlousa Tap p Weli T�p ❑ Other ❑ No Charge �Charge � •��rrMa��a��t�at�sssrr��a��r��*�w��rr��a�r�r� ,r,vwrr*x*x**ir##�,k*xrt�r**�ie*,r�r�r,r*trrr*,t*,tir#+i��rr+r�,rw�r,r,rw,e,►wrrrrsrr*,r****}###}*##�F Total Coliform F�cal/E. Coti Results Present L■� 0 Repat^rted B Date Reported IPD � � ` ' �� --- Itepar# Call�ed n YES � MO Called T� � �� Absent � i l' � �� / � � � �� /+ �\ �1/�� l � � V �� ' �n�nso�a.n�nca�na��m.� ��.��in Date: _�/ � /�Z s � /i. :i. /, % . � , �� .-� �s.1 �i :�i3'�/i o,� I ♦ Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on �/�D /�Z, and tested for both total and fecal coliform bacteria. Your water sample test results ai�e 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 bacteriological results only. t� 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 baeteria are associated with animnal and/or human wasie. 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 sample, the water may not be safe for use. Young children, the elderly, and the individuals x�ith compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive or total or ecal coli�orm bacteria should be properlv disinfected and retested prior to resumin� 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, �� LsC%� Environmentat Health Specialist Person County Health Department (rev. 4/20i16) Persan County Environmentai Health, 325 S. Morgan 5t., �uite C, Roxbom, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences �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: ES053117-0090001 � �� (�� (�� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: DAN LAWRENCE 2831 SEMORA RD ROXBORO, NC 27574 Col lected: 05/30/2017 11:30 Received: 05/31/2017 08:27 Sample Source: Well Sampling Point: Outside tap P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://sloh.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H Kelly Susan Beasley Well Permit Number: A27-255 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present Os/01/2017 E. coli, Colilert Report Date: 06/01/2017 Present Explanations of Coliform Analysis: os/o1/2017 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. � Il � � . ,� � �� '^�� J �. V � � �a�a�nson�an�nca��n��.Il IHI��.11�ll�a Date: l�v l�l !� Name: � � !l !G Tax Map:� Parcel: /7i Address: ��' n/��. �Q,�� a�s7� Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on �/�/�, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: x 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 bacteriofogical resu[ts only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. "lotal coliform bacteria are naturally found in the soil. Fecal coliform ba�teria are aSsociated with animnal 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 sample, the water may not be safe for use. Young children, the elderly, and the indivrduals with compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A well that tests positive�or total or ecal coliform bacteria shoz�ld 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 Deparhnent 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, �� .�� G� Environmental Health Specialist Person County Health Department (rev. 4/20i 16) Pers�n County Fnvironmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone� 336-579-1790, Fax 335-597-7ROR . 0 13yS PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant � l)� � Address �5'�Q -��-�Itii County � Collected By ��Z,�� Date Collected i0��?7 � l� Time Collected �� C� Source: �ell ❑ Spring ❑ Other Location: House Tap ❑ Well Tap ❑ Other o No Charge �Charge ..............................................................................� *******�******************************************************************** Total Coliform Fecal/E. Coli Results Present ❑ ❑ Reported B Date Reported ��y' � � Report Called ❑ YES ❑ NO Called To ��`�"�"� Absent i� �� 1�� y � � � �� ' aa�na-o�n.n�aa3na��.� ��.Il��n Date: l� /�/! 7 • �/� v • � � - , � � .+ �i ��. �� _i i Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel:�S Your well water was sampled on Ce /!2, /!7 , and tested for both total and fecal coliform bacteria. Your water sample 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 bacteriological �esults only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria aze naturally found in tl:e soil. Fecal coliform baeteria are associated with animnal and/or human wasie. 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 sample, the water may not be safe for use. Young childrer., the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be no#�ed of the test results. A well that tests positive for total or ecal coliform bacteria shozsld 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 conta.ct 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, C��%� Environmental Health Specialist Person Coun�y Health Department (rev. 4/20i 16) Person County Environmental Health, 325 S. Morgan St., Suite C; Raxboro, NC 27573, Phone: 336-579-1790, Fau 336-5Q7-780R 6�D PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant � '� �� e-� � Address 2�� c.il,'l,Dn� ��. County � Collected By - Date Collected �� ' Time Coilected '�„ .CJL� Source: d�'Well ❑ Spring ❑ Other Location: �' House Tap ❑ Well Tap ❑ Other ❑ No Charge �Charge ..............................................................................� ******************************�*************************************�******* Total Coliform Fecal/E. Coli Results Present ❑ ❑ Reported B Date Reported .� � I � � `� Report Cailed a YES ❑ NO Called To �� Absent r� ,; 0