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A27 57� The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT� No. �,..� Date �: - -� - �' `( ' } + f �� Owner: l� � W , L� �} C SSi•�� t��,- '�'�v C,�r� Location: — �� , f �t� t�l C-,�� l�!)ci. � � � cl �~i� ✓'s i � �: �)s� �t�� u` -' �, � Contractor: , Waier Supplp: Private �-�'"� Public ,,Sawagp�Dispos� acilities: No. bedrooms � � ^washing machin�ther sutomatic appliances Size oi tank: Nitrification line: _ lt}� Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. 5eptic tank should be pumped out every 3 to 5 years an� 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- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE IN�TALLATION IS COV- ERED ANB PUT INTO USE. �/ n^'� r� s�� Date approved:_ Sewage Disposal: By: Cert�cate of Completion Date Approved: � � �y:. Z�/� R ` :anan r "��a /, j ~� r rjf % �/,/{ t%'� '/ � I ,�L/ „"� .ir�,�-� or his representative) (OVER) Location of well and sewage disposal facilities sketched on back. NOTE:�°°� sketch of installation showing lot size shape, location of house, septic tanks, �s wate�� supplies, ��Note special problems existing on lot. Write in measurements in order that installations may be located � at later date. Note location of water supplies on adjacent lots. / _ ;'� ,/_,., � j 7 ��,,lrrt. (1) ; � i�b�4 -y....! r-�"�-._.-�.�t,^ . -._�._.._.. 1` I �� 1 �r��; �� , i�'� � ��. �� '�� i��li� . � ��:�� iJ�G � � �� ;ti --.__._...- -�-`^'+.. _ .. . . � " . . .� ;-�r. . . ,.� . . ' . .• �� ' . ' • ' . . . �� North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Sec�ion . INORGA1vIC CHENIICAL ANAL'YSLS REPORT Private well watcr information and recommendations � County: �f °�^ Name: ,��Ul� Sample Id Number: � � d,L - Location: Reviewer (`'°`7� � . ANALYSIS REPORT Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the federal drinking water standards. The pH is a measiu�e of the acidity of the water. Drinking water may contain substances that can occur naturally in water or can be introduced into the water from manmade sources. TEST RESULT5 AND USE RECOMIVV�NDATIOI�S Your well water meets federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering. . The following substance(s) exceeded federal drinking water standazds. Your water can be used for drinking, cooking, washing, cleaning, bathi.ng, and showering, 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 uon Ma esium Manganese Selemium Silver Sodium •Zinc H The following substance(s) exceeded federal drinking water standazds. We recommend 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. _ � Re-sampling is recommended in months. 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 detern�ine the source of the lead and/or copper. OTHER CUNSIDERATIONS Routine well water sampling for the above substances is recommended every two to three yeazs. Sample your well water when there is a known problem or contamination in your area, after repairs or replacement of your well, or after a flooding event. Contact your local health department for sampling instructions. � For further information please contact yoar county health department or the OccupaHonal and Environmental . Epidemiology Branch at 919-707-5900. � Revised January, 2011 � �lorth Carolina State Laboratory of Public Health O6 N. W?m�ngton St. Environmental Sciences Raleigh, NC 27617-8047 htto://sloh.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: ADAM C. SARVER Name of System: �� S PERSON CO ENVIRONMENTAL HEALTH WANDA DAVIS � 325 S MORGAN STREET 231 GRANITE DR. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES052212-0001001 Date Collected: 05/21/12 Date Received: 05/22/12 Sample Type: Raw Sampling Point: Outside spigot Sample Source: Ground Temp. at Receipt: Sample Description: Comment: Time Collected: 2:20 PM Collected By: Adam Sarver Well Permit #: GPS #: Inorganic Chemical 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 2 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper 0.14 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 4.60 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium < 1.0 mg/L Manganese 0.04 0.05 mg/L pH 6.1 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 8.30 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 18 mg/L Total Hardness < 7 mg/L Zinc 0.24 5.00 mg/L Report Date: 05/29/2012 Page 1 of 1 Reported By: �e�tG �Keol - --_-1-, �'�`� '�� ? �. % y_ 5�� Y ._,.� ��.; � 2��2 ��: