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N.gj.; �0 �.O/ Q�.. / f. \ .s, � . f` � 1rf� i. . .— , O�O/.W . � . �� "�� a � L-� (?�CJ i�� a m � The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMP OVEMENTS PERMIT No. �� e Date y' - ' � Owner: �' a Location: ..SIZ - 1 f �.� Contractor: �► r d Water Supply: Private y� Public �(�t]il�� - Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal, � washing machine, other automatic appliances Size of tank: Nitrification line•�� 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- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED ANB PUT INTO USE. Date approved: Well: Sewage Disposal: By: ^ Signe Sanitarian Counter- signed (Owner or his representative) Certificafe of Compleiion ; ' - I ,� Date Approved: � � By: � " ��"` � ;�r� Sanitarian (OVEft) Location of well and sewage disposal facilities sketched on back. NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations ay be located at later date. Note location of water supplies on adjacent lots. �' � `` (1) �`�° �� ` . �_� i' �2� 'i�n /�� / 1 \ / � f /� s1?� Ii5� �3 � � � H O � � w V ¢ a Improvements Permit (Established/Recorded Lot) Improvements Permit (Unrecorded Lot) _ Improvements Permit (Mobile Home Replace) rovements Permit (Addition) �'--1�-9� of Existing System (L.oan Closing) _ RepaidReplace existing Sep[ic System _ Pe�nit for New Well _ Replace Existing Well 1. Permit reques[ed by: owner/prospective owner/agent: M� ��K� x. �«ss«� Address: C� 8� 3�•ti��t� � k i� �.=e'[ (� n- �J., .. o., o., r.l (' 21 S-1_� ome Phone #: q i p s`l9 �1�c�'S usiness Phone #: 9 �� S q`? i�� t ; Name and address of curcent owner: Description: Lot size: � •�-4 ��•�-� , Tax Map##: � � � Parcel#: 10 9 � Township: ��TJ��'- . Directions to property: State Road #& Road iames, etc. 7. Dimensions or Proposed Structure: - -w�a�: � ' I1 ��h � . Dep � \ 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? �_�_�:-c A�1� 2 �sa�s LEas E�"�i RcoP 'to Sca��,�c.�c �,�s�• .Cu-~ o`r' v rJlx�.f.. i�o.N.J 3c.=4� �-►cnnc. �s's�r (+''..c.f. ►� `., K� : E c..5 0.+1 J S N5.3(il.� S o.J � G. F"� - 9. Water supply t}•pe: private �public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ ,If so, identify location: 10. Type of structure/facility: Proposed:a�Existing: ❑ Type of dwelling: House: ❑ Mobile Home: 0 Business: ❑ Type of business: � 8� ��'`-� �"�Di-� — Number of Employees: 1 Number of bedrooms: ..s�— Garbage Disposal? Yes ❑ No L� .. Basement? Yes ❑ No C�If so, # of basement fixtures: 6 Number of occupants or people to be served: � ► CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL 7?ROPOSED STRUCTURES. I hereby make application to the PeI'SOri COuriiy Health Department for a site 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 pennit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of ttre property to the Health Dept. I understand that in the event I have not delivered 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 application shall become void and all fees paid forfeited. W � f��_ 9 ` f.�✓,� � ��i z"� � �� pecmit Issued ❑ Signature Date Permit Denied ❑ � Plat Observed ❑ ,�..�''�'d""`s' y i � txss�tBK�x`k ¢ �£3�`�' kx.. �" ' 2.: - � �� A3tFl� 2 j � r ,.�-A 3 � �y�„�,`�s-�f."�se+�`��1 � E��?°a,�w:'y� :+'r� r�w,.> .aq.,: , . ..s`,Fi�CTOK5-5ITE�1lI.UAIIQ�i��r,,,e�s..cx�sx..�,[�:rs �s �;3�a.�.�'�� <>a,.. 'F e:s.�,a ....... . ..>...�..:. w<ir ._ . . .. . ..,., _., I. SLAPE f9F) . S S S PS PS PS � U � � v 2. SOII.TFY.TVRE(l2•36IN.1 S S S S (SANDY. LOAMY. CUIYEY. NOTE 2:1 CiJ11� � � ' � � U U � V 1. SOIL Sl'RUCil1RE (12•36 IN.1 S S � S S (MYEY SOILS) � � � � U � � � S S S S !. SOIL DFPTH (IN.) � � � pg U U U U S, RESTRICTIVE HORRONS (iN.) S S S S (iMPFRVIOUS STRATA. ROCK) PS � � � U V U U 6. SOQ.DRAINAGFIGROUNDWATER � 5 S S S IEJCTFItNAL& WTF.RNAL) PS PS PS PS ' U U U U S S S S 7. SOQ.PFRMEASAl[Y � � � ps (PFRCOLAAiION RA7E) U U U U S S S S E. AVAII,HBLE SPACE � � � � u u u v 9. SiTEMSSfF1CA770N(SEEBELO� SOIL SERIES SSl71TAHLE PSPROYLClONJ111.Y5UTCABLE U•UNSUTTABLE RECOMMENDATIONS/COMMENTS: ..�i� • ' P�r., ' ams �ullies, wet areas, fill r :- PERS ON COUNTY HEALTH DEPARTMENT �� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tat Map # A�� Parcel # � � Zoning Townshin �� C r �,_"_ _ .,� _ _ . _ �� Location/. Subdivision N � � � � �e� b n � �--.�, -� - S.R.# vy��,� � � PermiY Void after 60 months. Permit Void if not Permits may be voided if site is altered or i Well and Septic Layout by � . Vitrification Line / R�y G��e Vlax Depth Trenches � �, J{ • in compliance with zoning regulations� a�� ed e ange -f� c,��.� /X 3/ a u ,�o,., o f c�S�,,.� 6 �,.�� .I�l, �. Date Installed by Approved by Well Permit Paid ❑ Individual_%. Publ ic � ell Head Comments: WELL SYSTEM SPECIFICATIONS ni-Public quired Slab _ lace Air Vent Required Well Log Well Tag T Date Installed by �{ �l� ��i Approved by /�/ V � 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 condifions on the property or for statements in this report that may have �esulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants 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.1.0 North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Darbyshire, Sue Ann Address: 683 Blalock Dairy Rd Roxboro, NC Zip: 27574 County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Ste C Roxboro, NC 27573 ATTN: _ (336) 597-2371 Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: Type of Analysis Private Courier: 02-33-15 Collected By: J SMITH Date: 4/27/2009 Time: 7:51:00 AM Location of sampling point: Outside spigot Remarks: - ` � Parameters Results Units �` Date Analyzed: Alkalinity as CaCO3 18 ` mg/I =4/28/2009` Arsenic <0.005 mg/I 4/28/2009 Calcium 6.9 mg/I 4/28/2009 Chloride IC 16 mg/I ' 4/28/2009 Copper 0.55 mg/I ` 4/28/2009 Fluoride <0.20 mg/I 4/28/2009 Iron 0.11 mg/I 4/28/2009 Hardness as CaCO3 (Ca,Mg) 27 mg/I 4/28/2009 Magnesium , 2.4 mg/I 4/28/2009 Manganese <0.03 - mg/I 4/28/2009 Lead 0.021 mg/I 4/28/2009 pH 5.1 Std. units 4l2$/2009 Zinc ' 0.38 mg/I 4/28/2009 Date Received: 4/28/2009 Today's Date: 5/8/2009 Report Date: 5/8/2009 Ref: 5847 Login Batch: Reported By: Sample Number: AB88568 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 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 North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Darbyshire, Sue Ann Address: 683 Blalock Dairy Rd 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 Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: Type of Analysis Private Collected By: J SMITH Date: 4/27/2009 Time: 8:06:00 AM Location of sampling point: Outside spigot Remarks: _" Parameters Results Units ' �`Date Analyzed: ` Alkalinity as CaCO3 16 mg/I 4/28/2009 ' Arsenic <0.005 mg/I 4/28/2009 Calcium 6.9 mg/I 4/28/2009 Chloride IC 15 mg/I 4/28/2009 Copper <0.05 mg/I 4/28/2009 Fluoride <0.20 mg/I 4/28/2009 Iron <0.10 mg/I 4/28/2009 Hardness as CaCO3 (Ca,Mg) 28 mg/I 4/28/2009 Magnesium 2.5 mg/I 4/28/2009 Manganese <0.03 mg/I 4/28/2009 Lead <0.005 mg/I 4/28/2009 pH 5.1 Std. units 4/28/2009 Zinc <0.05 mg/I 4/28/2009 Date Received: 4/28/2009 Today's Date: 5/8/2009 Report Date: 5/8/2009 Ref: 5846 Login Batch: Reported By: �(��, Sample Number: A688567 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria aze 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 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/l (as N) Not less than 6.5 units 5.0 mg/1 North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Rateigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Darbyshire, Sue Ann Address: 683 Blalock Dairy Rd 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 Collected By: J SMITH Date: Location of sampling point: House spigot ATTN: (336)597-2371 3/30/2009 Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: Type of Analysis Private Time: 9:30;00 AM Remarks: . e= ._ _ . , Parameters Results Units � Date Analyzed: Alkalinity as CaCO3 18 ' mg/I °3/31/2009 ' Arsenic <0.001 mg/I 3/31/2009 Calcium 6.4 mg/I 3/31/2009 Chloride IC 14 mg/I 3/31/2009 Copper 0.10 mg/I 3/31/2009 Fluoride <0.20 mg/I 3/31/2009 � I ron 0.80 mg/I 3/31 /2009 Hardness as CaCO3 (Ca,Mg) 26" " mg/I 3/31/2009 Magnesium 2.4 � mg/I 3/31/2009 Manganese <0.03 mg/I 3/31/2009 Lead , 0.031 : mg/! _- _. 3/31/2009 pH 5.3 Std. units 3/31/2009 Zinc 0.08 mg/I 3/31/2009 Q�u\�C5 �� t �� ` � i�� Date Received: 3/31/2009 Report Date: 4/21/2009 Reported By: Today's Date: 4/21/2009 Ref: 4512 Login Batch p�03QQ78 r�� Sample Number: A68740 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 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 Noith Carolina I}ivision of Publio Healtli � •� � Occupational and Environmental Epidemiology Branch, Lpid � 1 INORGAI�IIC CHEMICAL ANALYSIS RE ] � Private well water lni'ormation and recommendaHoa� County: ��-i�.i��1 Name: �i i� 0 � $�`cfi?�� . �t�C�:�DVED i:lckmcad 6wnty Nui;th Ce.� E�+rxcr�sr�asi C7ett�h ��6�Ct� Location• � Reviewer /w`z� �r ANALYSIS REPORT Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the federal drinking wa�r standards. The pH is a measure 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 man-made sources. ('These recommendations are based on inorganic chemical analysis only.) TEST RESULT5 AND USE RECOD�VVIEENllATIONS Your well water meets federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering. Arsenic The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, 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 pmblems. The following substance(s) exceeded federal drinldng water standards: We recommend that your well water not be used for drinkinQ or 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. Iron � 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 1 S minute sample at the well head to determine the source of the lead and/or copper. Contact your local health department for re-sampling assistance. . OTHER CONSIDERATIONS Routine well water sampling for the above substances is recommended every two to three years. 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. Contact your local Lealth department for mor� lnformation or go to httn://wvvw,eai.state.nc%nUoti/hsfactshee�html • � �. � 4A , . � �� March 10, 2009 North Carolina State Laboratory of Public Health ' Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Darbyshire, Sue Ann Address: 683 Blalock Dairy Rd Roxboro. NC Zip: 27574 County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Ste C Roxboro, NC 27573 ATTN: (336) 597-2371 Source of Water: Well Source of Sample: Type of Sample: Raw Type of Treatment: Type of Analysis Private Courier: 02-33-15 ; Collected By• J SMITH Date: 3/30/2009 Time: 9:30:00 AM Location of sampling point: House spigot Remarks: Parameters Results Units Date Analyzed: Alkalinity as CaCO3 18 .` , mg/I 3/31/2009 Arsenic <0.001 mg/I � 3/31/2009 Calci u m 6.4 m g/I 3/31 /2009 Chloride IC 14 mg/I 3/31/2009 Copper 0.10 � m9/I . 3/31/2009 Fluoride <0.20 mg/I 3/31/2009 Iron 0.80 mg/I 3/31/2009 Hardness as CaCO3 (Ca,Mg)` 26 mg/I 3/31/2009 Magnesium 2.4 mg/I 3/31/2009 Manganese <0.03 mg/I 3/31/2009 Lead 0.031 mg/I 3/31/2009 pH 5,3 Std. units 3/31/2009 Zinc 0.08 mg/I 3/31/2009 �� Date Received: 3/31/2009 Today's Date: 4/21/2009 Report Date: 4/21/2009 Reported By: '��./ Ref: 4512 Login Batch. �j903QQ78 � Sample Number: A687408 U PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant ue /-F n l.)(�rh�1 Sh�rP Address ` n c� �r County�i rson �— , Collected By �S Date Collected 3-3v -oq Time. Collected q� 3 a Source: ell ❑ Spring 0 Other Location: � House Tap �Well Tap ❑No Charge harge 0$ther ��*��*��*��*��*�**�*��*�*�**��**��****��*��***��*��*�*��**�*��* ��*��*:�*�*�*�*��**��**��*�*��*��**��*�*�� Total Coliform FecaUE. Coli Results Present Absent C� ❑ ❑ �" Reported By � � �y �`� ��tc5 � ,�� 5� ., lf � � 5 J�o.\ ��, c, � � . ��.a �,� C�' bactreport - 27- Oq -{-oo� 1.�" �(raw � �S ,� ��,. � e6d Sa� les u �