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CASWELL - CHATHAM - LEE - PERSON COUNTIES �
Water Su I � •
PP Y and Sewage -Disposal-�
IMPROVEMEN'tg pERMIT No.' ` -'
Date _3 � --7 ._ c�.— � --
owner: _ O:� �f 1-f 1 e ) -j
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Location: __� r;
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Contractor: �� �w • �
Water SuPP1Y� Private _ / _�--�""'
---- Public _________
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; � j : � _;,�^J, �,_� .1= i -�+ �/ ` � c�' 'u` :��.
Sewage Disposal Facilities: No. bedrooiris � '.
washing machine, other auto�matic appliances Dishwasher,
Size of tank: t�:�r.�r') �;: i;' Nitrification line• ��.�r�"
� ',
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB By A 1VIEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY pORTION OF THE INST
ERED AND PUT INTO USE. .. ��TION IS COV-
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Date approved: j' ,/,;' n � i�/1i�AA�.`-
Si ne' � ��" /���•�
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Well: � �Sanitarian
Sewage Disposal:
By:
Certif'icate of Complelion
Date Approved: �2J•-lS �
Counter- �,' �,�� ? �
91gllE'd A'1/G ,4.Q. ' / � �
(Owner or his representat� e)
(OVER)
Location of well and sewage disposal facilities sketched on back.
.. . \
Site Evaluation Application
Fee Collected YES �
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Date:
NO
APPLICATIOId FOR IMPROVEMENTS PIIiMIT
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1. Permit requested by: owner/�rospective owner: f nos
agent:
Address: ��a90 �1 Q�i �N m1 �5 �d • �bX�
Home Phone ��: �gq-qJq� Business Phone ��:
2. Name and address of current owner: �nY�� �� £�
—— ... �1 �1_ �...�i_ Ll� ,. _. ..� i
3. Property Description: Lot size: � Qe(r�?� �,
4. Tax map ��: �� � Township : ��a-� t� � Y F'2
Subdivision ame: � � Lot �t: _
5. Directions to property: State Road �� & Road Names, etc.
. � . . n � _ , � . . _ (�_ �1_ 1 h��
6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system: ✓
7. Number of occupants or people to be served: �.
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 dispos 1 system is intended to serve?
n . � , , ., e-- - __ / �__� �- - -. �
10. Water supply private? public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11, Type of structure or facility:
Type of dwelling: House: _
Type of business:
Number of bedrooms:
Basement? Yes No
Proposed: Existing:
Mobile Home: Business: _
Number of Employees:
Garbage Disposal? 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.
Permit's 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)
` �17�� //�� �� � .
Signed �wner or Authoriz�Agent
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (X)
2 . SGIi. TEXTURE (i2-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTIJRE (12-36 in.)
(Clayey soils)
4• SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata� rock)
. SOIL DRAI2dAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMFABILITY
(Percolation Rate)
8. OTHER (specify)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R �CO2�SEI1llATZONS / COMMEDITS :
S:�TE CLASSIFICATION DLAGRAH (Include: Soil areas, property lines. roads. streams, gullies,
Wet areas, fill �reas, wells, water bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEp�TMEN A � 10 5
WELL AND SEWAGE SITE, LOCATION I1��R T
Tax Map # �} �d Parcel # / � �, ��MENT PE�T
Zoning Township F ���
Owner/Contractor �}�,.-c.�z.,�' �;L LU�t
Location/Address ` ���„r Date 3_ g_ 9s-
� . ., �, �
�—�z.`�s.`'Ez �
Subdivision Name � 2/ l� Lot# s•R.# j�c� �, j
_ ./S
Layout
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�, � ' �2 v�, y���`�' �"".,�'.�,
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As Installed
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SEWAGE SYSTEM SPECIFICATIpNS
Repair Lot Area 3�-� Size of Tank ��
SFD �/ Mobile Home Size of Pump 7'a� jy� � ,��"�
Business # of Bedrooms 3 Ni�t �'ficati9n Line r,�.� o. . �
l��ax l7"epth ren� P� c x3 ��� ���
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by(� ' ` ,��,p��
Comments:
Date3_ g-�S Installed by I�o.�,,�.�„�'�,�,,� Approved by d
Site
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WELL�YSTEM
S¢mi-Public IRequired
t�eplacemen Air Venti
Well
Well
�llate / Install� by ,� / A roved b
This report is based in part on information provided the homeowner or hisJher representative in the appl��t�on submitted for this
environmental health specialist is not responsible for false or misleading infortnation contained in the apP�i�t�o� ,I,he environmen�j hea,t�j� s
st tements prov ded to him in the'application Ne the rPerson Coun r nor the environmental health a ecialist �y U�ted &om false or misleading
�, pecialist
continue to function satisfadorily in the future or that the water supply will remain potable. � ��� �at �e septic tank Sy�� ��1
OFiIGINAL
c:�'�°�*►v�sarn Ol/95 rev.1.0
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
� Q i�s ��'i�e�
Name of Owner or Tenant � r
Address 5 �� � � `� rJ [P � '� � County � � � � � ��
,
� �-� �� -� ,�� c. -�,� � �' �
Collected By �' _ � �
Date Collected � � � C1 <
� Time Collected ' �' � �
Source: Well ❑ Spring ❑ Other
Location: House Tap OWell Tap ❑ Other
pNo Charge • �iarge
�*��*��*���������:�����*������������*���*�*��*���*��,������*��*�*�����*������**�
*�**�**����*�����*����**������*�*��������*����*,�*���**���*�������*��*��*��*���
Total Coliform
FecaVE. Coli
Results
Present Absent
❑ �
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Reported By 12 �
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bactreport
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North Carolina State Laboratory of Public Health �j(T� � j
Department of Health and Human Services �� h'
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047; � ��
I i �
!;l ` �
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM I�� Q� it
wl
Name of System: Snider, Charles Source of Water: Well
Address: 5290 Hurdle Mills Rd Source of Sample:
Roxboro. NC Zip: 27574
County: PERSON
Report To: Person Co. Health Dept. ATTN:
325 South Morgan Street Ste C (336) 597-2371
Roxboro, NC 27573
Courier: 02-33-15
Collected By: J WILEY Date: 12/9/2008
Location of sampling point: Inside tap
Type of Sample: Treated
Type of Treatment: Wtr softener
Type of Analysis Private
Time: 11:00:00 AM
Remarks:
Parameters Results Units Date Analyzed:
Alkaliniry as CaCO3 154 mg/I 12/10/2008 '
Arsenic <0.001 mg/I 12/10/2008 '
Calcium 60.8 mg/I 12/10/2008
Chloride IC 5 mg/I 12/10/2008
Copper <0.05 mg/I 12/10/2008
Fluoride <0.20 mg/I 12/10/2008
Iron 025 mg/I 12/10/2008
Hardness as CaCO3 (Ca,Mg) 165 " mg/I 12/10/2008
Magnesium 3.2 ` ' mg/I 12/10/2008
Manganese 0.65- mgA 12/10/2008
Lead <0.005 , mg/I , ; . � 12/10/2008
pH 7.3 Std. units 12/10/2008
Zinc 0.09 ' mg/I 12/10/2008
�
Date Received: 12/10/2008
Today's Date: 12/23/2008
Report Date: 12/23/2008
Ref: 17387 Login Batch:
Reported By: I�J�-�-fu�w� `�
Sample Number: A682521
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hazdness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
L
�i ��\
rato of Public Health `\ �' %
North Carol�na State Labo ry /.��, ,��
Department of Health and Human Services �=`,- R�=
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-804] co
,
�= > � �
INORGANIC CHEMICAL ANALYSIS - NITRATE ONLY
Name of System: Snider, Charles
Address: 5290 Hurdle Mills
Roxboro, NC Zip: 27574
County: PERSON
Report To: Person Co. Health Dept.
325 South Morgan Street Ste C
Roxboro, NC 27573
Courier: 02-33-15
Date
Collected By: J WILEY
Location of sampling point: Inside tap
Remarks:
Parameters
Nitrite as N
Nitrate as N
ATTN:
(336) 597-2371
Results
<0.10
<1.0
12/9/2008
Units
Source of Water: Ground
Source of Sample:
Type of Sample: Treated
Type of Treatment: Wtr softener
Type of Analysis: Nitrate
Category:
Time: 11:00:00 AM
Date Analyzed: '
mg/I 12/10/2008 �" , ;� '�
mg/I 12/10/2008p�'J = � � � ���7
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J
a.J '
. . _.. ... . . � .�/ .
. . .. � . �...� .� . , . . ...
. . , a..,,<. � ..
EXPLANATION OF RESULTS:
FosterlTherapeutic Homes: Nitrate-N level acceptable if less than or equal to 10 mg/I
Private Well Guidelines: Nitrite-N level should b�< 1.0 mg/I and Nitrate-I�L< 10.0 mg/I
- i'
Sample Temperature on Receipt: 5•0 � C ���Q,� ' ,,�0
Date Received: 12/10/2008 Report Date: 12/23/2008 Reported By: Iu:�L(-c�,��(,�l
Today's Date: 12/23/2008 Reference: 17435 Login Batch �8120�3Q `,4� Sample Number: AB82569
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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 regazded as a complete report on the water supply.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
,� �-o- i ��
� �', µ .," 'r>p P.O. Box 28047
��a� i< � North Carolina State Laboratory of Public Health 306 N. Wilmington St.
��-`�: .�'�� Raleigh, NC 27611-8047
,: - Environmenfal Sciences http://slph.state.nc.us
"'� Y�y�,�,�Y �2� Phone: 919-733-7834
Certificate of Analysis Fax: 919-733-8695
�,��
�" �%
Sample Group� ES121008-0004 �! �
Report To: Name of System: ,� Q
PERSON CO ENVIRONMENTAL HEALTH SNIDER, CHARLES 'l' �
, p� c�
5290 HURDLE MILLS RD. �e'�` �;�
325 S MORGAN STREET �`'"'� v
ROXBORO, NC 27574 4-j
ROXBORO, NC 27573 "�r � � �
� � I
Attn:
County: PERSON Well Permit #:
Sample #: ES121008-0004001 Ccllec:ed: 12/09!2008 J. B. WILEY
Received: 12/10/2008 14:42 MNICHOLSON
Sample Type: Water Sampling Point:
Sample Source: Temp. at Receipt: 5.5 DEG C
Location Code: GPS #:
Sample Desc:
Comment:
Category:
Client Sample #: 082301
Treatment:
Air Volume:
Organic Chem - PESTICIDES Method: EPA 508
Pesticides Drinking Water
Analyte Result RL Units Qualifier(s)
Aldrin Not Detected 0.1 ug/L
Lindane Not Detected 0.02 ug/L
Trifluralin Not Detected . 1.0 ug/L
pac
Report Date:
Not
1.0
12/29/2008 Reported By: J.
Page 1 of 1
•• N.C. Department of Health and Human Services
'��• '� Division o£ Public Health . PE$T�C��ES
State Laboratory of Public Health
P.O. Box 28047, 306 N. `�ilmington St, Raleigh, NC 27611-8047 �
Environmental Sciences Analysis Report
Name of Owner, PatientG n Q�IPS S �P �'
Or Supply: _ �`'1 ,�, ,
Address: 5 a'9� � v.-a �P /v1 i l�s ��J
1`� o y�jv �p Zip: �'� s%�
Telephone # � �a c�- d �1,�
County: � �S p �'
...........................................................................................�
Report to:
Telephotf 8 n C l�ijl �,n„ `y,,,� �
. u��w
Addtess• `S� C
o ro,
Collected Bp:_cS��'�«� �/`E'-ri" W (�P �r
Telephone n � S� 7' � .� ��
Date Collected: ' ��vy( O �
Analcsis Desired: � S � ( G ( �P
Date Recei�•ed: 0EC � O �oo� �
/�� S �
Date Extracted:_ / 4� �� f�S��
Df�iS Form 2364
Laboratory (Rev.06/99)
E_anlrpt
Date Reported: D�� � `� L���
Date �nahzed�/a �o� ��
Reported By: