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A27 337, , � � . . . � �� /, � Amount paid �%� n C� .�2ece�pt � � le�"1 v � �� 5� .� Fy O � � a w v ¢ a Improvements Pecmit. (Established/Recorded Lo[) Im�ovements Permit (Unrecorded Lot) improvements Permit (Mobile Home Replace) Improvements Permit (Addition) _� � Date �� Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System _ Permi[ for New Well _ Replace Existing Well 1. Permit requested by: . � 7. Dimensions or Pro�osed Structure: ownerJprospective owner/agent: l� �► �a G Width: 3� Address: • S � Depth: �D - 8. What type (if any, additions, expansions, or replacement is anticioated to the structure or facility �� d that this sewage disgosai system is intended to serve? Home Phone #:s �_�� , ) p �J C usiness Phone n: S`�' 7�SS 4� 2. ame a d addre�s, f current owner: 9. Water supply type: C• private� . public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No (�. If so, identify location: 3. Property Description: Lo[ size: . Tax Map#: �� "7 .,% � 10. Type of structurelfaciliry: Proposed: �Existing: Q ParceI#: � �� Type of dwelling: Township: ' U.. House:�1 Mobile Home: Q Business: ❑ 5. Directions to property: State Road #& Road Type of business: ames,�tc. Number of Employees: � ,J o r Number of bedrooms: �_ � Garbage Disposal? Yes ❑ No �l . Basement? Yes ❑ NoII If so, # of basement fixtur�s: 6. Number of occupants or people to be served: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORri�x� ur aLU PROPOSED STRUCTURES. I hereby make application to the Pet'SOI1 COunty He31th Depat'tment foc a site evaluation for the on-site sewage disposal system for the above described propercy. 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 invaiid. I undecscand that before an Improvements Permit can be issued, I must present a survey plat of the proper[y to the Health Dept. I understand that in the event I have not deIivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this appl' tion shall become void and all fees paid forfeited. Signcc� ner or Authorized Agenl F, � Mnn 4VJ � a w U � a B 3159 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # �� Parcel # ��J' �J� Zoning Township (� �', U p� �-{ • � � Owner/Contractor Q. l C�' �-` � Date �_ ��-9q Location/Address �'-'ln1 'r � l�c��`5 5-k,r� P.� �"I � Mc�.�.�,r; c:� �C�.n : P l5� ''-I �Fcz � Subdivision Name ��j�� S.R.# Lot# 3 SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area � .O � Q-C SFD 1/ Mobile Home Business # of Bedrooms�_ Size of Tank �(�Yj;�1 '��(.i„aQ,�dr{Kl�l Size of Pump Tank Nitrification Line ��`x3 ' � Max Depth Trenches o� 4�� Permits may be voided if s' ' altered or in ende e cha ged. Well and Septic Layout b Comments: �/y/2 Date / a- 99 Installed by � B�, Approved ' '��..� _ Q n, . �� ell Permit Paid 0� WELL SYSTEM SPECIFICATIONS ite Approved�� dell Head Approved �routing Approvedy Comments: �IDate Semi-Public Required Slab teplacement Air Vent � � - - l�D Required Well ,/ '� �� Well Tag � Installed by 7 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 misleading statements.,provided to him in the application. Neither Person County nor the environmental health specialist warrants 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 � �. �1��-�.�� u�r�� . �. LOT 4 DANTOM SUBDIVISION N � � S86°39'32"E 330.59' �� / �i . � � � �� r 1 . OO�AC . �� LOT 3 DANTOM SUBDIVISION �� 332.12' N86°39'32"W LOT 2 DANTOM SUBDIVISION 1 I W � o � rn � � N I � � I O Z 0 �- � I i i / � Person County Health Department n Environmental Health Section �� „� Tax Map #: M- � � Parcel #: Zoning: _� Township: a//�� / // Subdivision: ' ! Section: Lot: � Applicant• � � �. �,�1�, Location• � Operation Permit System Type (in Accordance With Table Va): Ca� ve 7%- 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 AU ORIZATION. � ,� � �- a 9 99 Authorized State Agent Date s T �� '�S loa o s��6 �ya 9- �-��99 y��'� �,;�. Tax Map #: %�}�� Parcel #: �.� � PCHD, rev. 10/12/99 Person County Health Department Environmentai Health Section �r �, �� Zoning: Township: ,� i ve / Subdivision: �►/� /% l�i Section: Lot: �_ Applicant: C��jn �-_P,�)��.�7'�cS Location: Operation Permit 1. LOCATION AND SEPARATION DISTANCES � A) System meets .1950 setback requirements B) Distance from system to any welis f C) Distance from septic tank to foundation D) Distance from system to property lines ✓ 2. SEPTIC TANK � A) Visually inspect the exterior walls and top of the tank B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet f /}� C) Date of tank manufacture _-�7 D) Tank serial number �5 � a" E) Liquid capacity of tank pp " gallons 3. SUPPLY LINE TO TR CHES A) Grade Lco(c��""'i(1/8 inch per foot minim m �� B) Material supply line is constructed from 0 C) Diameter Y �` D) Length E) Distance from tank to drainfield/distribution device 4. DISTRIBUTION DEVICE(S) A) Type ,, ((�/ B) Is Device water tight r v T � C} Distance from the distribution device(s) to the trenches D) Is the device on a level foundation E) Does the device perform according to its design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD �i A) Trench depth �_ inches B) Trench width 6'' inches / C) Distance between trenches D) Number of trenches � n E) Length(s) of trenches / oJC F) Aggregate depth � inches G) Aggregate material and size H) Record septic tank outle� elevation look C� �aw;,.�,,. I) Trench grade t�/C �_rs,�•,.� (< 1/4" per 10') � J) Step downs a. Minimum of 2' of undisturbed earth �� b. Proper rise over step down.� c. Solid pipe used � I�A,a;� d. Elevations of ste downs co �`(RecoYd elevations and show on as built) See "as built" plan on attached sheet. PCHD, rev. 10/12/99 �� l � �a� � V�� 1.J � V �� m►.�nsonan�a��n.��,� ��.Il��in Date: �/_�/� Name: _�1 GiG>> ��ll'c�f, Tax Map: �� Par�el:�r� Address: __[ 2�-�' � l t t�1 �1� . '��.I��. ��7� Re: Bacteriological Test Results Dear Well Owner: `�our well waier was sampled on � i�/ff�� , and tested for both total and fecai coliform bacteria. Your water sample test results are notzd below: K 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 bacteriologica! results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. 1'otal colif'orm bacteria are naturally found in the soiL Fecal coliferm b2�ter.� a.r� asse�ia:ed with animnal and/er 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 childrer., 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!rt tests positive for total or ecal codiform, ba�teria should be properlv disinfected and retested vrior 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 Heaith I3epartment 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 Persoa County Health Department (rev. 4/20/16) Person Ceunty Environmeatal Health, 325 S. Mc:ga�n St., Suite C, Roxbo:o, ?JC 27573, Phone: 330-579-1790, Fax 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: ES071416-0068001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: RICKY CRABTREE 125 COLLIN DR ROXBORO, NC 27573 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 httq://siph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Collected: 07/13/2016 10:00 Received: 07/14/2016 08:19 Angela H broek Sample Source: Well Well Permit u ber: Sampling Point: A27-337 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Colifofm, Colilert AbSent Denise Richardson 07/15/2016 E. Coli, Colilert Absent Denise Richardson 07/15/2016 Report Date: 07/15/2016 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. �� 1� nc department of heaith and human services � � � � ¢ T �� F f`t P �. �@' � v � ,�"''�a �� y� ��t X�� `�w i 5 � 9a^.� a i v'"c�y` �?,�-'+ s�' 6 � ,�'"re' f��"� r3 °ay� °v'� �. { �� _xi uu-k ', ��; � tS q ��:� €? � t � � t� ,� i; "` ¢g �` � t� °"s .� ':E G �,ww..� �.• �'�c..r ,i� � �+�" 'a' �: .» td � a �:e.s�` m � :: `� � d 4'»r � �a,.� � � + � M � 4 ir>: ^s.j L , � i j � � '� 1 � A � »� � �� 5� j� E � .«�.E � k 1 <j � �t �_€ � �` �� '� �" � .n: z.�r.r. : �, �.P.. x.��'� �.. ar:�� .� � �....� �, w.,a.� x: :� &. -'`b sy�' � c� �..r� �:, a � �:�� :3 ., i'a.Y.,% For Inorganic Chemical Contam�nants County: � d� Name: G Sample ID #: Reviewer: TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your wel I water meets federal drinking water standards for inorganic c/temicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical resu[ts 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 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 resu[ts on1v. Arsenic Barium Cadmium Chromium Co er Fluoride Lead Iron Man anese Mercury Nitrate/Nitrite Selenium Silver Ma nesium Zinc H 3. [✓f 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 iiiorganic clremical results onlv. [�b. 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 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 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 n:ore i�rformation regarding your wel! water results, please call t/re Nortli Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 3�12 Distnc�Drive Environmental Sciences Raleigh, NC 27611-8047 http://slph.ncqublichealth.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 RICKY CRABTREE 325 S MORGAN STREET 125 COLLIN DR ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27573 EIN: 566000331 EH StarLiMS ID: ES071416-0053001 Date Collected: 07/13/16 Time Collected: 10:00 AM Date Received: 07/14/16 Collected By: Sample Type: Raw Sampling Point: Well Permit #: A27-337 Sample Source: Well Temp. at Receipt: 7.0 GPS #: Sample Description: Comment: � New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic Barium Calcium Chloride Chromium < O.00E < 0.1 < 0.001 3 < 5.00 < 0.01 ).010 m 2.00 m ).005 m m 250 m Copper < 0 05 1.3 mgi� Fluoride < 0 20 4.00 mg/L Iron < 0 10 0.30 mg/L Lead < 0 005 0.015 mg/L Magnesium < 1 0 mg/L Manganese < 0 03 0.05 mg/L Mercury < 0 0005 0.002 mg/L Nitrate < 1 00 10.00 mg/L pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date:07/28/2016 < 0.1 7.9 < 0.005 < 0.05 65.00 < 5.00 125 9 Page 1 of 1 ,� 250 m Reported By: .xennetl�i y'reene ��:i,:;urv c:�,�,�v�� i:rvv.i.itc�ror,::rrt•r�i. iu:ni,��i� ' • IJl{I.I. 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