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A29 253� 52y �` ' 2�'i � (� �� 2Z ��, �� i ��Jv_� Yz�'�`� Tax i�Eao �• � �(1�Prj)c�c�56z� � Qarc2i �: � �_,�--�-�-�.��...,� I�''I�I�..� �� r—_--�'�—.�' = c� � �T�i' �L" �i�"' � .aa.�vaa�aaa�i-^-y�+ .e��_�.ea.11 77��aa.�.11�ga l�iPPi.iC�4]'1�N FOR S��VtC�S �i) Penr�:it r+ec�ar�s#�d lay: (flwnerlagentlpresspec�ive owner): �¢'� ,._ Horc :� �'hone: -� Address: 3�o Ilr� Busicu:�s Phone: ' -� � �o S Z) N�lri�a and address of curren4 awnar. _,.�A�?� 3�j 1Pta��;�4ciy Descre�tir�n: Lot size: cre� Tawnship: + e �� Din�c:t�ons to the p�operty (Induding road names and numbers): � �' na;l,��' .�.�1,�ly d�.Slnn �in � �ri►'n7 S�vi /)N1 Lot# o�� 4.) pr��as�d 13�e an Siruc�tu�a i�escription: answer�act� af the following questians: a} 1'rapased �,, Exisiing ,�, Type of Structure: �,�,,,�c.'nr�i �4- ) Width: Depth: b) Fdumber. of Bedroams: ... =� Number af occupants or people to be sarved: c) f�asem�nf:. Yes,,:,,,,_, No Wlli there be plumbing in the basement? d) <znrbage Disposaf_ Yes W. No. i . ;i) b!l��;r 5u�ply '�ype: Private �(new � or exist€ng___), Pubtic,,, Community� Spring � Ara any wells or► adjoining pcoperty? Yesi No � If yes, please indicate approximate location on the �site plan. Ei) Da�;�;; �/ouc �ra�erty �fle�tain g�reviously itlenti�Oed jurtsdlctional wetlands? Yes� No t/' f3LEd1�iF.i f��i� TN1E FOLLb1MiNG: ➢.A Pl.�►i aF Tf�E �ROP��RTX OR SI'i� PLAN MUSi 8E SU�MITTED iNITH TH1S APPL➢CA'��Old. 9''I�tiP�ERT'Y LlAfES �1FVC! CORNERS MUST BE CLEARLY MARKED. , �'��lE PR�E��SED LUCATIOM OF eALl, STRUCTURES Ml1ST BE ST�►6CED OR �Fi,ACGED. 9'3'S.�E S6TE IUIUST BE 3tE�4DIL`� ACCE551BLE �OR ARI EVAL.UATIC3M BY i!E HEALTFH i3E€��RTMIERli a iAF�. I here'sr� rnake appiicatiort ta the f'erson County Health Departm�nt for a site evaivation for the on-sit� sewage dispcsal :systerrr fo+• tf�e above-described property. I agree that the contents of this application are true and repre�ent ihe maximum �aciiitie�:� tu be piaced on thQ property: I understand if the site is altered ar the intended use changes, the permii shall ��e�omi� ir�� id. � ,� � /'\ + i't�I i✓ n if � 9i �`y� OJ ar Legak Date PCiiq, rev.Ofil2T102 �:�� I �' �� r `_ - ” �- - � ;0 �7 ��'� .; � ��, ��.��,� � �� . . �� . � �/�/�� -�. ��.�� :_� �/��' � NaII1e �'.�/� �,�.�;�'`=s`.�A Subdi�isio ' �" �� A �� ., � � ut3�.onz S te �ent .. � �r� �r� � . _ �� P��. � � .� Se�tion/Lo � � � �� ate � S�s��roa c�as��5�n�s r�szsa� ��xa ��aa�s �ssl,y. T''rse �aactor »Aus�',��Ia� i3ae .r�y��a j�azasr � �e�ag � i � t� ia��zs�� iraat pr+n�iea-�t-•r� is �ssaiaztarined : .%' .�,t,i..,� " � i ', ,�� ,i ` ,/ /,�I6 . �, . ; : . - / � . ;<% % .•." � `.° ��/G�' �� °� ��a�� `° ' %�� -��> , �� ,e �� a�� -n��'�� _� �. � �_ 'v- s � -.. _ _ _.:... + ---. �� , �� . �� ' � � - , -� � � . �_----� . / �' ___. �� - � �� _ - - '� � . . _ ,�``,' � e / �. � � . _ ,° .,�� . . ._-� � . � , .�.��j . � � - � �� . � � � ;� _:___ . ., i :� � � _.__ . ; __ __ -- �� s �`� r a� ��A .N ��. �► � : �° �'' �� '� ` , ,� � � . �r � , � �` , � � � ��s: _ � � � �,� :. - � � � L _ ,� . � �; . .�� SC3��: ,' � � � �� f # � „;�i �' J � �� G��m�- �' �� '"��- � � �a' � ?��-3�, �� 09/2/�3 �� .�� .�, . , � � � � � �� I-�".��-�i��mm �*�+ <��.,�n.11 �L��n.11�.11a Applican� Location: T�x M2� � ' Parce�l u . Su�bd'ivision ,� r.�� ..� .�• Fh�s�e Sect�ion' ot # Improvement Peranit Permit Valid for �Five ars No Expiration Type of Facility: v New ✓ Addition Water Supply –J�i�� # of Occupants of Bedrooms � Projected Daily Flow _��D g.p.d. Proposed Wastewater System: _ __ ��;��f�.� !-v/s"�i�.0 Type: ProposedRepair: —� /� � Type: �� jS Owner or Legal Representative Signatur . Date: Authorized State Agent: Date: The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewa�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). 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. Authorization to Consty-uct Wastewater System (Required for Building Pe��it) * See site plan and additional attachments (�J. �T� Proposed astewater System: �i'�,,,�� w�i.7t,,yD Type ��i ,(/ Wastewater Flow �.p.d. New � Repair_ xpans�ion T Soil LTAR. '� g.p.d.1 ft 2 Type of Facility: Od Basement _ Yes ✓No Wastewater System Requirements Tank Size: Septic Tank: DO gal Pump Tank: DOD gal Grease Trap: gal Drainfield: Total Area: OD sq ft Total Length �0 ft Ma�mum Trench Depth Zo in Trench Width v7 ft Minimum Soil Cover: �_ in Minimum Trench Separation: 9 ft Distribution: ____ Distribution Box Serial Distribution �_ Pressnre Manifold Specifications: � G/�/��,_..�/�/� ' Anthorized State Agent: Date: Pernut Expirarion Da e: The type of system permitted is Conventional � ccepted Alternative. I accept the specifications of the permit. J Owner/Legal Representative: G�i Date: .� / 07 F�� PCHD rev. 11/10/OS Sloped To Shed Watex NEMA 4X Simplex Control Panel 4" X 4" Presaue Treated 12" Separation II2CtriC'il COYI�Slt � .. �� 2Z T'!� F�'�f � �� IhutSealBoth I Ends Of Tha Cozu�it 'Z4" Minirre�m r. .� . , Threaded Gate Valve ; , . • .� , uruon { 6" Cover • ' � Acce�s Cover• • , ' . ; 1 � , • � _ � . — i •�� ' � ' ; '�� " . : �, Openin= Filled With � Zip Coxd Anti Siphon Hole ` i T�� luid C Gmu Iniet Fmm Septic Tutk Port eznent t �� g�� SCH 40 PVC Pipe � �� Check , Valve Higk Water Alarm Level ' (6" Separation� Hislt Level - Pump On -�.�,,,, ' �Vapox Lock ,, ,, �Dravndawn Hole _ . .,' � (Up H�11) � ' , Low Level -Pump OfF l'"'r �•. �. Pxecast Cozvcsete Taxik ' vcsa � ;.; (MatexialStrex�th>35001 � _.`, , ,, , .. .: , : . • . _ 4" Concrete Block , +' ' : . . '� , Cozucrete Risex .'�5° Separation . •, . , ;r ��. f• . -- ;r,��Portland Concrete Giout . �: Mutic - ' : . � Opening Filled With Supply ' portlan�d Cement Gzaut Line •. Outlet To Distnbution 2" SCH40PVC Pipe Float Wiret ' . r i Floats .. {...Remonable �•�. F1oat Tree , , : �. r . r � . �. ..��tiL• ..' . 00o GAZL�N PLTME' TANK � ?'� F��l � ��,Sf ��4.�� /�.r� .___,� �- , — cC � �TI�"IC�Y �.navns�aaanxa�aa�,mll 7HI�.�.11�]En Owner: �� ' 7 Tax Map: Parcel #: Z53 ate: Line Tap Tap (Sch) Tap Flow Line Length Flow / foot # Diameter(in) ( m) ;� (ft) 1 3 $'o • ! /a�' . o 2 a 3 3 4 5 6 7 S 3�D • 3 9 til 10 Z 300 ft of line x,65 g 1. per 100 ft = =100 =� gal 75% x�'� gal = 1'� gal per dose �1� gal per minute (gpm) = Flow Rate Friction Head Loss: l•�ft per 100 ft of supply line x O D ft of supply line =100 =/•'�8! ft •/ '78 ft x 1.2 = 2•?� ft of friction head Manifold Size: _? " Force Main Size: Z " PVC Total Dynamic Head —�ft of Elevation head + Z� ft of Pressure head +�ft of Friction Head = ��TDH -�-- ��i.si�-f�� Pump Require�m�e}��t,: �3 Z GPM @� ft of Head Drawdown: �..�gal per dose = 21 gal per inch =�_ inch drawdown per dose ��• r� �� :�� ■ Y � �\ ��t� -- . � . . . . � f:�+ � ..� I I ■[c�)l�o00 _0 11 II �I► �II ::::.:.. ..::..:..::.....::::::: .................:................ = = � � ' - � �� 2" min Schednle 40 P �! 9 macos �= p . 2" ifold Size I # Taps Maz No. Taps off one 2 FF] 3/� 6„ dp� 21 I �z � — . . ' Flo�v er Tss Size Moterial FTozv GP��t /z " Sched $0 5.5 ;, " Sched 40 7.1 �/, " Sched 80 1 �.1 9•, '. ScJted 40 12.5 �� I�.�' a ��T �—'� � c��1�T�� I��.a.�„-„ -,�-,.-,. ��..�.1i �L�.�.Il�. W��. PEi�'r� ��.�s� s�� r�� r �� sr� ��o�r �� #: _�� # _��_ To�p �.. �, ,. � _. �. .r: � - � ��. i� % , i i . % //ii .�, q, �� .� . i .� W.. � �• f / � / / / I . � �./ �� '�e o£ Wat�� Sa��lv: � Inclividual Communitp Public �.eau�ffie�ts• Site Approved bp � s � Grouting Approved by - � � Well Log �Iell Tag � -- �% f�,�►�P Air Vent � Y � Hose B� � Concrete Slab S✓ • � �J ��:i - 1 "�- , ; _ l. /� � •• i I`I � �, I i )'I - � r. �. � . ,�: . - r. :r: . L �See Att.�c$aes� Slte 5ketch�` Wells must be 10 feet from prop�rrty lmes. Wells must be 100 f�et from septic systems. . Wells must be ax least 25 feet from aap bu�ding foundation. Other conditions- - PC.��, zev. 09/07/Ol s/s � FER50N COUNTY ENV RO FAGE 12/05J2e87 10:17, {, 365977608 /( j1 � � � . �� n ,! ' . .•��••`. `"� � )•, • r.1A'+' 1�s.1�'�� .1..! A� . � -,, s L I r D / /1 {�( *` �' � ��{r�� (�0a'��'l �`' 1� � r � ` �� . 1l � r �..`.� r....r�ii_ 1\ �n�•i3c►,as�a�r►�aaa�:..a.�: 7�`��►�r,]1,�3ii• . �l � �� '�� .�, Groat Y.o� Ov�mer. � n i/ I.t iz s�¢ � Tax Myp� c Pucel #�.�3 Looation: !%� 3ub�ivisivr�; I.ot� � � J � Wa1 C� as�a Di�tamce Frva� aeu+e�t Proporty Line � 10 f�ct) Di�bmcs iro�n Sep�a Sy�am {Minicaurn 60 fqet) �.______ Tobl Deptb�: - r l,� ft�Y��d�_�0 __ �M� ater Lavel: & Wat�z �r�iug Zotu�. d R �- R R �. Catia�� Dopt�L From �_ to �6 R. Di�t: � i in �j►pa: (�lv�aizad 3bee1 �' `�"�- Weighr, j.3 : Thicla�ee�: /�� $eigbit abo�v�e C�touad ��_ ia Dt�ive 9�oe: ��Yc� �,_ No Arry �roblatu es�ootmtered while uKia� oasimg? _Yce � No lf "y�ess" giVe 1'Oason: Ciront: Ne�t SaadlCcmait � Coc►c�cete (3rtveUCen�t Azmuter Sptce Widtbt r�, �,�, i:t,ebes Wa#e�r ia Au�1rf p�ce Yes No Me�tbod of Cirout: Pumped Praaure , Paued i/ D�pth to Ft. M�� Uad: No. Ba� Portlrnd ces�oent Wei�ht of I Bag �� l�d� If mixture ( ve3� cuttinnBe) - R�io �_ 1� ut ID pLt�ee• �� No � a 4 slYb ____ et ` No Gboer: Depth: Il�ts Iustalkd: ,�„_,_y C�roia� _„ Inatslled by: �� I hareby aeztify ttwt ti�e a3�ave infa:matian is oorrect aad that thlt by tha Peravn Conmty Hea� DapYrttt�e�t ' ID R O Dats �r�,�,/ � �' �-..� Lopttion Dritv�ia; �i weu rvu oonatruoded i� �ccordanca wa,th regul�tiane est fartb �ip.�etun oSCoatr�+ctar lhtno� InKaih�nt � Iaitallstiva Can�ter• $det� Rs;is�atiMt Ne�ber: pumP � ft Sta�{c w•ser Lev�1: ft , Putt� fi�Iabe � ModeI: i��sp Sizc �nd �a�tfng: hp B�ca I lureby cartii�y Wat :his puaxtp was {nst�lled attr! tM q.ell heed. ccmtplated �ccoa�dina ro the Person Cot,nty Wstl isulee in affoct on thie date md that a capy of'��i: record hae bcert provida� bo thu �1 owner. Pu�p Iostall+e�t Sl�atlt�e_ __ .� , Ds�e: PCi� rev Ol/z7/4�4 �� `_-• v � � � � � � V � � J1d 7L^�.�T�.' � C[� TY!1 '-}'IY'}] (� ZL�. �11 � � �1.1L��%1. Applicant: Locaiion: N an � W ('SIP �� q ��o �� 5 3 �°1.1L°A.lI1VU�t1�°l�l J �C 'i��M Ti7� (�SE'UII��' P�O1�36ou�bo� � �6 t � a � p � o' O 0 0 � ' '-S� S .� .� d l � i � � (� -, o n /� ► �R �-t /" � G C i �'�'PS iF/' �S � � �; zr '�. � � �" t �'� i t:, � ? � Syst�m Type (In Accardancr Wiih Table Va}: �'b � THIS SYST�3ili �-dAS �E��I iI�STALLE� 9� CflIVIPl..IAiVG� UV1iN APP�lCA�L� NORTH GAR�L19�,� GERiERAL STATilTE�, �iU��S FflR SEiNAGE TR�TMEi�T AND DIS�OSAL, ��D ALL COi�d�13'iONS �DF � TF�E �IVIP4a0i��E�T �E}�9Vlii AND CONS�'RUCTION AllTi-{�IeI OiV. -` . �� _ 9-�� -d� , A thorized State Agent Date Installed By: � C6�li � Date: dg� I'�%�� . � �� 0 `� 5 � � � : � �o' . . �� /ao' L� � Jop' + T�Tf1-�. = ��a � S£�T�C; p�"S —loo� ST�,�3a-`f � S /ad /o� PUMP TRN �; P?S-/ovo P -r- Ss C� � /o�/a8 PREss �aE M.�tis Fo�D C�N7'�R aF RoAQ PCHD, rev. 07/29/Q� ,r a �� ° y ` ��' �/ O ��:�'�G 'p'��&� �Pl��`�� E��S�' � �� - � �-�J Ta� Map #��' 9�arc�! # a- S`� Sys�em Type (?a�ie Va) � OwnerlAQpiicant o� W�S�P Subdivision T�� f�y- 6sP v� ��P Address/Location S'/D �., r�� c��Ser,lPhase LDt # a�- i�� c�'C �.S`�"o �e R�. ' � State�ID/dateS7P-3 ,y os--oa-�� C2 �C1 �JC7b. 2�. Tee and Filter � � Bafffe Seaiant � Riser ifi a licable - Tank Outlet Sea1 Permanent Marker . Ptarnp �'ank � State D ate rt-�.5 0 �-� -o Ca aci I�o , al. Wate roof /Sealant Riser Water Ti ht �,a � ob; Paar�a� Check ValvelGate V�ive �larm (visable and audibie) Elecirical Components Rate (gpm) Approves� Pump lViodel Blocic Ur�de� Pump Pump Removal RopelChain 4� Law Pressure Pipe Appr. PiQe �liaterial and Grade Valv�s - y Trencfi �dth � ft. � Trench De th 2- o in. Trench Len th � av ft. Trenct� Grade � Trencf� S acin � Roc� De ti� and Quaii DamslSte dovvns �tc. Pressure Laterals � Hoie S�acinq � P�e. S1e�ve T�am-ups/P.rotectors ��quie�d' �eibac�z� From� Wells From Property line� Siructures/Basetnents �ic es / raina e a s Surface W�ters Public 11Vater Su iies Verticai Cuts >2 ft. Water Lines Ve�iicle�Traffiic - ----- -- � �Easements/Righf of �!V _ - Ot6�ee� ►�-� . Ease�nents Recarded -„ 'o y ert� e erator on N 11� Tri-Partate Aare�men� �ammen� vs�-l`�� N�� -S' g�:� /08_�� r � �c�d rev. 3/9 �/0'i PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT � - 22-13 $ -1 � � OB � �_ Z53 Date of Inspection System Installation Date Typ Tax Map Parcel # �D CIe��K.��er �r. Property Address Instxuctions: Check yes or no for appropriata itcr.is a.zd explain in space provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids:�_ Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps g:esen: & functiona! ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? ,� Inches of solids(pump/dose ank): <� Elapsed time readings ? Counter readings 7 Drawdown rate: YES / NO ❑ � ❑ ■ ■ � � �G Rr � ❑ J DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ / Evidence of effluent ponding in trenches ?❑ / Surface water effectively diverted ? � / Diversions/swales properly maintained ? ❑ � ! Vegetative cover maintained ? [,_�,�/ � Protected from traffic/unauthorized uses ? vLj / Distribution devices in goud coiidition " �r/ Field free of settled or low areas ? v� / � � ■ . ■ ■ PRESSURE DISTRIBUTION SYSTEiUI: Turnups/cleanouts/valves/taps intact & �,/ accessible ? l.�J/ � ❑ Pressure head properly adjusted ? []� / ❑ COMPLIANCE: Compliant Non-compliant Needs Maintenance - � ■ ■ REMARKS fanl< J'lUf QCC�SSr ��j be�a(,�J Aiil�iiTit7iVeiLi:.viviivic,iVT�: � L��i�h^ I✓1 Q��l ('OYId�TIOVI Application I3ate:. —G � Amoun� Paid: 7 �e@CP.Ij}� #: �i 3 cl 1 G �� C%7�� G�f � e � 0 Imprnvement Permit (Site Evalaation) �200.00l�300.00 (if> 600 gpd) L Ntobile Home Ftepiacement or Buildin� �150.Q0 (if site visit reqnirec� eIl Permit (lYe�r/[LePlacemen e�a ? �� s�� Tag IVIag: i�z9 �' � � �,_ � � .��.�,.� Parcel#: �S ._ lE��,.,,.�,, ��.Il IE�3[�.�D�. �Ot� �8Y'V1C�S C� Constructioa Antha lFee is denendent on � Repair' of Existing Septic SysEem AgpIication: No Charge/ CA Si50.U0 or �300.04 1} Applicanf In%rma�ion: / Natne: �t�lrs, ��Cn C(.�%�►�cr f•c�; 2G•�d�� i Address: n:Qt'ti >:t i �ir+u. t: �',�.��.� � � � �S iu 2} lYame and address of carrent o�*aer (if different t$aa �applicar�t): Name: hl; ll;� L �r�C„� �,ddress: � �,.�h�,r., l)� . 2''! �7N Phone (home): ��`��' �3LLL (worklcel l): I`'�"> �� r� �� Phone• '3'sr„ S9 � - � S? a 3) �roperty 3lescripfion: Lot Size: 1• 0 5ubdivision: '?h-c f nh..%��:%�ot �#: �-- �lddress and/or directions to Pmperty: r f:��;, �o.,iy► L,c.1C� t-�4 5�,. N_ �. � /�/w ,. . � -r-- p es 0 no Does the site contain any jurisdictional tvetlands? p yes ❑ no Does the site cot►�ain any existing wastewater systems? D yes t� no Is any wastewater going to be generated on the site other than domestic sewage? p yes � no Is the site subject to approval by any uther public a$ency'? p yes � no Are there any easements or right of tivays on this properry? (if `yes' is checked, please provide supporting dacwnentation} �) �roposed ZTse and Tyge of Structure: ��tesidentiat 0 Ne«r Single Family Residence Maximum number of bedraoms: CI Expansion of Existiag System If expansian: Current number of bedraoms: ❑ Repair to Malfunc�oning 5ystem WiII then be a basement? Cl yes 0 no �th ptumbin; fi�cunnes? ❑ Yes ❑ no ❑Non-Resideniiai � �pe of basiness: Total Square footage of Building: Maximum number af empIoyees: M2ximum number of sests: 5) water �uppiy. 0 New tivetl � Existing WeII O Cemmunity Well O Public Water Q Sprino Are there any existing wells, springs, or existing waterlines on this property? 0 yes � nu 6) if apptyfng for `Anthorization to Constr�tet', please indicate pre%rred sysiem type{s): Q Conventional ❑ Accepted Q Innovarive Q Altemative � Other 0�Y I cernfy thut the informarion provided above is complete and cofrect I also �derstmzd rhat if tl�e information provided is irtaccttrate, or if the site is subsequently altered, or the intended use chattges, all permits rrnd approvals shall be irrvalid. _ � Supporang documentarion required. SSG -IS� Date o permits are vaiid for eiiher 54 montl� or axe non-expir�g z��hen accomg�nied by an apprnved glai. a A compleied `�of Preparaiion' form mnst accompsny any applieation pequ�'ing a�ite evalnatiou. .. ,.,. „„�__ .�_.._.... L'we�imnrv�or�1'f7� T-TP.AN'I1 7ii1 .S� IVIAT�II St_ �UTCE l� ROXUOTO. NC 27573 {336-597-1740) ��,sf ��.�� - � � �� ° �rawn�r�snn�a�aa��.� g��.�.��n Tax Map: /� �� Parcel: � � � Subdivision: WELL PERMIT ��r (New _ Repair � ) �- Lot: Applicant's Name: l.e� i i �� c�. �� u�� C C+-) a'} � W i z a�--d S, Mailing Address: � 0 �.' 1 ea�r Wo�`4er Dti-, C � 7 7 �-} Phone Numbers: 36 3 2,�- G� �t (3 3 6� 5 8 3- G 6 3 G Location of Property: '-t q S- as�' h� �,�o� o`�ro \��c�� 'T�(Z � s!'�O Z'1n e Fa�rM ��bSe v� � T/ L Ct�o��r W�-}ey � �1�O�lS� OtJ CfL� — - Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: �New Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 5. Morgan St.,Suite C Roxboro, NC 27573 Date: �� Certificate of Completion �,iner: EHS/Date .�-5 Depth: � l'C� Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 North Carolina State Laboratory Public Health Environmental Sciences �icrobiology 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: ES102015-0066001 � �� ) �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: WILLIAM HUFF 90 CLEARWATER DR. ROXBORO, NC 27574 Collected: 10/19/2015 14:00 Received: 10/20/2015 08:19 Sample Source: Well Sampling Point: well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph. n caublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 H. Kelly Susan Beasley Well Permit Number: A29-253 Environmental Microbiology - Colile�t Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Darneice Owens 10/21/2015 E. Coli, Colilert Absent Darneice Owens 10/21/2015 Report Date: 10/22/2015 Explanations of Coliform Analysis: Reported By: Susan Beaslev , �� 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 Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: WILLIAM HUFF P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://slph. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 90 CLEARWATER DR ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES102015-0029001 Date Collected: 10/19/15 Date Received: 10/20/15 Sample Type: Raw Sampling Point: Well head Sample Source: Well Temp. at Receipt: 0.5 Sample Description: Comment: Time Collected: 2:00 PM Collected By: H Kelly Well Permit #: A29-253 GPS #: 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 < 0.001 0.005 �/L Calcium Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 5 mg/L 3�Z�I�'. 05 Mercury < 0.0005 0.002 mgi� Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L 7.3 < 0.0� � �� N/A Silver < 0.05 0.10 mg/L Sodium 9.20 mg/L < 5. 250 Total Alkalinity 50 mg/L Total Hardness 46 mg/L Zinc < 0.05 5.00 mg/L Report Date:10/23/2015 Page 1 of 1 Reported By: ��-�a�