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A28 166�� „I'�� nc department of health and humen serviees i�g ' ` � � ;! ! f" r' �,.., � ,s r �5 -� r�' 4S l ` 1 �' S E � [k� ' T s .� Fi'�'`r � .� . + �''ti6 � < E �f ��s s Li `!� �f 5�� ( � l 6 � i 1/% i t ! ��{ e��/ i fl �: �--•� �,Y � p ;,"` 1.�� ;�� , r.. t �,.�,� e--;y.•m� J�k � �.-.� a�t 1{' i ,t �p�� t.� '�---,`� F �\, `�...,.d` t.�� ''L.•' i ��l ��' l�.F ! E e� i i�•�/ d^ 1 '•` +�_J: f., l 5�_.? k i��v �or lnorganic Chemical Contaminants County: •,n Name: �SSi i S� — Sample ID #: ��-�-�-�� Reviewer: . � � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorga�ic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results 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 inorFanic chemical results onlv. 3. ❑ a. Sodium levets exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or !ow sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inorPanic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, 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 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 inorganic chemical 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 Iro � Manganese Selenium Silver p Zinc For mo�e information regarding your we!! water results, please call the North Carolina Division of Public Health at 919-707-5900. � � _. � - r - � � � �� '�wr�.�,� '�r7'""Y`�'�""'+..` � � �..!' �� 4�� y y ��p LL�4�JFN.J4L4fA'q:+'�LYiiM9G+�Y� �/��`�ilb�5V1� Date: 2' / �2Z �� , Name: �.S'Si i �S —" � Address: • '-E- ." ��7�7T Re: Bacteriological Test Results Dear Well Owner: Tax Map:�3 Parcel:� Your well water was sampled on l/�� /�� , and tested for both totai and fecal coliform l�acteria. Your water sample test results are noted beIow: � No coliform bacteria were detected in the sampl.e. Your well water is safe to use for drinking, cooking, washing dishes, bathing and sho.wering, based on the bacterialogical results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria arz naturaljy f�und in the soil. Fecal colif�rm bacteria arz associated with animnal and/or human waste. ThE presence of either total or fecal coliform bacteria in well wat�r may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminaGrd groundwater may be entering the well. If coliform bacteria are present in your water sample, the water �nay rot be safe for use. Young childf•en, the el�'e�•ly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be not�ed of the test results. A well that tests positive for total orfecal coliform bacteria should be properlv disinfected and retested prior to resumin� normad 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, t �Q,v�r-e,( Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person Coimry Em�ironmerrtal Heaith; 325 S Mor;an St., Suite C, Roxboro, NC 27573, Phone: 336-579-1190, Far 336-597-7808 • '�.=: 'ti `w + . . ► 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: ES013118-0081001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JESSICA WILSON 145 SMITH-HILL LN ROXBORO, NC 27574 Collected: 01 /30/2018 14:20 Received: 01/31/2018 08:26 Sample Source: Well Sampling Point: Outside spigot P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sl�h.ncpublichealth.com Phone: 919-733-7308 Fan: 919-715-8611 A Sarver Susan Beasley Well Permit Number: A28-166 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Absent o2/01/2018 E. coli, Colilert Absent 02/01/2018 Report Date: 02/02/2018 Explanations of Coliform Analysis: Reported By: Susan Beasley f ,. ,�.. � 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. North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis � �� P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sioh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Report To: ADAM C. SARVER Name of System: PERSON CO ENVIRONMENTAL HEALTH JESSICA WILSON 325 S MORGAN STREET 145 SMITH HILL LN ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES013118•0026001 Date Collected: 01/30/18 Time Collected: 2:20 PM Date Received: 01/31/18 Collected By: A Sarver Sample Type: Raw Sampling Point: Outside spigot Well Permit #: A28-166 Sample Source: Well Temp. at Receipt: 0.8 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 Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury N itrate N itrite < 0.001 11 34.00 < 0.01 < 0.05 < 0.20 0.32 < 0.005 6 < 0.03 < 0.0005 < 1.00 < 0.1 0.005 m m 250 m 0.10 m 1.3 m 4.00 m 0.30 m 0.015 m m 0.05 m 0.002 m 10.00 m 1.00 m Selenium < 0.005 0.05 m Silver < 0.05 0.10 m Sodium Sulfate Total Alkalinity Total Hardness Zinc Report Date:02/12/2018 12.00 < 5. L3 49 < 0.05 Page 1 of 1 250 � � � Reported By: Deddie .r'�loncol - ,� aiicaiion �ate: ,�,�� Amount Paid: �ec�iat #: � �` ` . _ ... ...� ... ....: ...... -, . T�x Map #• ��'" Parcai #: 1 � �D P�rson Cauntv Health Department. . . . Environmentai Health Section :,; 1 �,�� "_.,,.�. APPLlCAT10N FOR SERVICES ° , '" `' ` IF THE iNFORMATION IN THE APPLICATION FOR AN IMPROVEMEiVT PERMIT IS FALSIFIEQ. CHANG�D. OR THE SiTE IS ALTERED. THE9V THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALlD. 1 Permit requested by: (Owner/agent/prospective owner): �► ��.r �� i't, Home Phone: �'1- •l �,L L Address: t�( S S.,, ,'� �� u l a,..�_ Business Phone: �xba :� n.� � �.! "� �--- 2) Name and address af current owner. _,� r�l �. 3) Property Description: �ot stze: •L2�R�7�ownshlp: v� i e. '� � Directions to the property�(Includinq road names and number �T`/ � � ��p —`-� L ��(lCiC, 4) Proposed Use �rrd Structure Description: answer each of the following questions: . a) Proposed �� Existing � % b) Sticic Buiit �, Modular a, ingle Wide 0, Doubie Wide fiY � f c) Number of Bedrooms: � d) Number of occupants or peopie to be served: Z e) Basement: Yes 0, No yes, # of sement fixtures: '. � �_: '� r �_. . . _ ._._.... r.^..'�''.:^�;Qtd�..a�;: �'�'S ❑.,'�O - _ _ _: . ... .. . .: ---- -• '.... - v.,.__ _ . �.._. � . �.�� _ . � .. .. g) Dimensio�s of Proposed Structure: Wdth:� Depth: 5) 1Nater Supply Type: Private �new � or existing [�Public �, Community �, Spring 0 � Are any weils on adjoining propertyt Yes ❑ No Cxif yes, location / !� ,8�' Please Indlcate Desired System Type: (systems can be ranked in order of your prefeience) _Conventional _ilAodifled Converitional _ Alternative. Innovative ✓ Other (specify): � T�i �JC �i C , J CLF�RLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATiON i . . f� � � � I hereby make application to the Person County 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. 1 understand if the site is altered or the irrtended use changes, the permit shail become invalid. i understand that as applicant, i am respansible for identifying and marking property lines, camers and making the site accessible for the personnei of the Person Courrty Nealth Department to condud their evaluations. I understand that I am responsible for notiiying the Heaith Dep rtment ifi my property contains any wetlands as designated by the Army Corps af Engineers. � � Owner or Legal Representative Date PCHD, rev. 10/12/99 �f� PERS�N COUNTY HEALTH DEPARTMENT SEWAGE DISPOSAL � �M�,. IMPROVEMENTS PERMIT NO. " "'"1 ��xf Issue Date: /'i - �wn� � � j � -�� ' 1 �v+� .. � �/'i'71 V I/ � �- '4,� Owner: �� Locatio �_,/'� Septic Tank Contractor: ,// �'�� 8uilding Contractor: �. � Water Supply: Private Public �r Al1 wells should be 100 ft. from sewer system. Lot Size: � 2 �Q C ✓r� Sewage Disposal Facilit�)ies�•��jo. bedrooms f Size of tank: �j7�]��G,/,�.Y Nitrification 'line: �-v Y� g�=- Other disposal facility: • � Water supply and sewage disposal facilities location, installation'and protectiion must meet state and lacal regulations. � Septic tank should be pumped out every 3 to 5 years and shall be mai.ntained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND APPROVED BY A MEMSER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE.INSTALLATION IS COVERED AND PUT USE. T IS PERMIT VOID AFTER 3 YEARS. � Date Well Approved: � Siga d BY= Sanitarian Date Sewage Dis os p oved:_ Counter- BY= signe. ✓ (�- (Owner or hi representative) Certificate of Completion > Date Approved: / � � �� . gy; anitarian (over) • Location of well and.sewage disposal facilities sketched on back. � 0 :� DATE ISSU: OWNSR: ADDRESSx DRILLING � � IY1lC�tIdE.� �ARti��, ��l�O� Person County Heal£h Department Well Permit :I��(p',/A DATE DRILLEDs��W�_COUNTY: �r'�s'�' NAME WELL CONSTRUCTION Distance.from Nearest Property Line Distance Prom Source of Pollution Tota1 Depth: Ft. Yields �S GPM Static Watar Level Ft. Water Bearing 2ones: Depth Ft. � Ft. Casing: Depth: From�_to � Ft. Dia�ler:�nches TYPE: Steel Galvaaized Steel If Steel, does owner ap Yes No Weight:� Thickness:�Height Above Ground: Inches Drive Shoe: Yes No Were Problems Encountered in Setting the CasingY Yes No � If 'yes• give reason: / Grout: Type: Neat Sand C„@ment Concrete Annular Space Width � Inches Water in Anaular Space: Yes No � Method: Pumped Pr u e Poured Depth: From �to p Ft. Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. if mixture (sand,. 4�favel, cuttings) - Ratio: to ID Platess Yes� No 4 x 4 slab Yes No � DRILLING LOG De th Froin To Formation Descri tion _, � � P` S. � � ' • — I HEREBY CERTIFY THAT THE ABOVE INFaRMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE TH REGULATIONS SET F TH BY THE PERSON COUNTY BOARD OF HEALTH. PERfI V�I� :FT�THREE Y RS. � Date � �2 Date Ia Sanitarian's Sigaature Date Completed Sketch well location on reverse side. . � Yerson County HeaZth Department �xisting Sewage System Report For: �bile Home RepLacement Addition Requestee: ��''�� -� 1 ��.�m ; -�.. � ; I I L�4 ��Y bl�� ! v��5 �_� Location/Uirections• � 1�TI � �t��tD�'� � �� Home P'hone#�/� 72Z2 Business� _ -'Pax Mapx �Z ' < b�o n_ _ nn -�- � � � ��.� . -. . O riqinal Permit Lvcated Septic System Desiqned �'or: � _ . Etesidential 13usiness Other (specify) � Bedrooms �_ # Employees Other llate �nstalled � �,��_ Water supply /�� Type ot System Nitrification Line `-I Y)'X�' — Tank Size Certified Operator Required On site wastewater disposai syste�n showes na visua].ly apparent malfunction on �� ermission is granted to: ��^ (.t� ►��T� Accordinq to the attached site� plan. �