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A30 61The Distr�ct Health Department Orange, Person, Caswell, Chatham, Lee Couniies Water Supply and Sewage Disposal -;.-. ; _ f�� � - ti -Da�e� ! ! �/' +,-.r� � .� �� �..,��r• t 1 Owner: —� l n � v� ,y �Y. 7 � . � < < � Location: �' ' 1;�..� Contractor: `� WaYer Supply: Private ' ' � Public _..—: r,- . Sewage Disposal Facilities:-#�o washing machin'e, , th autoi Size of tank: ' � � � �� �.;.�, �'� . ,�vt-t r t oo� Dishwasher, Disposal, : appliances ' � r Nitrification line: �-f�� + � ,.rt Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Above recommendations based on information received and observed soil condition. Septic tank and nitrification line MU5T BE INSPECTED AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE- PARTMENT STAFF before any portion of the installation is covered and put into use. Date approved• ' ' ' �x�,.n. �� Sewage Disp By:���- !}� rii; _-� � ��� ` ERTIFIGA�� J1P�.ET�O ���/ Si ned ` / �,� 'i .�` /j:,/ �� /���(a � %/ � �. Th ��S�r�c��iea�th D2p::rtmeri Countersigned • �-d� Ql�� = JG • -1 _� , f3� (OVER) : _ l 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 may be located at later date. ' Application Date: o� 1 Amount Paid: ca� .`��'�" Receipt #: 1 rl r1 l�'U �sh ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 if site visit re uired etl Permit e eplaceme t/Repair) $300.0 $200. . �-�.�?��J , 11 ����1 V ; .... .... _._. :_ �.����� lLaa.ra�rmr�*�TM*�an��m,ll ]H[a��mAi�a for Services Taz Map: �� Parcel#: �_ ,�,� m�� wo�-�e�r- Services Re uested ❑ Constructioa Authorization ee is de endent on the ty e of s stem ermitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant In r atio Name: Address: d� h al -�r �l � 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description; Lot Size: Subdivision: Address and/or directions to Property: ���'�`�` Phone (home): ' (work/cell): ��y �P �,� — % �'� Phone: #: �'yes' ❑ no Does the site contain an�jurisdiction�i wetladds'? " �� O yes ❑ no Does the site contain any existing wastewater systems? � yes O no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approvat by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) r� ���I��M�. rhah<< hcrm-�. a � L��� 4) Proposed Use and Type of Structure: ❑Residential " � ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: � Expansion of Existing System If expansion: Current number of bedrooms: f`r ❑ Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? ❑ yes ❑ no ONon-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: L�i'New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no Please note any known ground .water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional � Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. 1 also understand that if the information provided is inaccur e, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Sign ure (Owner/ Legal Representative*) * Supporting documentation required. �—�— / 7 Date Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any applicatian requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) Tax Map: � Subdivisioa: ���.sf ���.��� �- � � ���� 7��a�a�ro�ass�m�rn.��.Il ]HL�a�Il�]En. Parcel: �_ WELL�ERNIIT (New �,/ Repair _ ) Applicant's Name: Mailing Address: $ P� � ��. /�J . �4„�d(� M<<( . �ts.� c 2-��y� Phone Num6ers: $ 2g - y�{ t- 4R +tQ Lot: Per`nit Conditions: 1.) See aitached site plan for proposed well location. 2.) All applicable State and Counry regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.J Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: �� i�,,. a I� St('{,ac KS Permit issued by: � . Date: _ 2—! 3—( 7 i�Tew Well: HS/Date Location: 6"Z—� � Grouting: ����� Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Certificate of Completion 0[,iner: EHS/Date Well Driller: f�0.r✓��-�'�-Q-- Pump Installer: Approved by: Depth: Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: l�.�v��i'�+'3gf.�I���%\�SJi1`��� - - --i�firl�L^r1t`�R" • � � � .► '`� Date Sample Collected: '�-' � Date Results Mailed: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C DnvL.n.n 111!` 77C7� Phone:336-597-1790 Fax:336-597-7808 „Hcr„ : ��� s.� I�I��� �� ������ �-*'.�.v.asm+aa��a��.�esIl' IE-��f.11�Ila. SITE PLAN ' Name n � Tax Map# f} 3D Parcel# � � . Subdivision 3scti�n/Lo;# _ .�_ ��� ' 2- � 3 - f '7 Authorized Stz:e Agent �ate System components represent uppraximate contours only. The contractor must flag the system prior to beginning [he installation to insure that proper grade is muintained. . • Note: An Accepted systerrt rrlay be used in place of a conventiona! svs�em withvut per�nit authorization or mod f calio.n. � I ;��i�t no}� �oca�t. d�A;..�r';eld \\ ��,'�1 ��\,,�, � No� skre. (r� ne� (n�rat5 S {�� �YS�tm fi � � oca.{-i o� i���c, � y,%el � Perw���--� r 0 54�e�. � i� Gl.-� � is' d R - . �...,r., z � —�-�.=::.,.�.'� � ,( � _ _ —�a����:t �i t ,>>i ar� � ���,��n� � ?d ': i ;�. • ----- �r, �4 �"�� I,k c'! u� � I WELL GONSTRIICTi�N RECORD Thisfonnean bc�sed lnrsmgle a�e weI(s L Wdt Contra Informatioa: /J r-- � 1J ( /12��Z� �' � P Well CoaaacwrNamc 3.�,��" �- fi� NC Well CoatrrccocCemFication Numba Barnette Weli Drilling, Ino. �N� ' � 3G 2. Wdl Constrnetion Permittl: � YQ�� ae� (1tt al! app!lcrnWe xrll conttrndJonlu�ia' (f-� �ry 3. Nd{ Use (e6eck wctl ase): ���� ', OMuniapallPublic- aGeothaa►al (Fiea�B���S SnPP�Y) BR�dmtial WaRcr Snppiy {s�ngie) ❑Indvsuial/Canmaoial IIResida�tial WatcSopply (sUac� , ���� ', DGco�dwaierRan�a� QMui{erSmrageandRamvcxg ��3'�� QAquifer?fest �`� P OFzprrim1,u�lTuimot�,yr �Sl�uIdesxeConuol QGeoth�`nai(Close�LnoP) OTrrca E- - —..,. _.__,_-_��..u,�i ForiotamllJse�II.y- a,n��vdus�c��� 6�Z I7 w�� A3t� sawelt�ocabon: � _ �N4A 1 a S'�/��,v - -r� r�,�r^�ca�) !JJ{ �� �V���N�Oy_1G7L /l /-1-. - � 37s. Lati (IFweU fi �� 6.7s (ai 7 � ffi! ��� �. CuY. and T.tp / �'S � I J p�elT�aiGationNa(PR� de and Lo�itude ia degrealmiaatdse��s� a�� � �OC6�S1f�OCYI� 3 �_b�� N. 7�- a�'��2 �► the�II(sx C3i'��uaaent or OT�ora� < ,�epairtoanccrisangwe� I'lYes ar � ���� �Moit�rwrtlaw�� �" rC2l ta�a�cataa oron dsSoctQjs6tsloeac � nbadra+�Jwm. 9 Tmat',w�11 dcpt4 bdos+[and IQ S� �� 11. B i�.v t�= FOA I3� - -$ , � '�S Q � � �.otrr�xcasn�r� � .� ROM '�'0 R � 6;-7NNER CA.'SD�G OI�J � � . t� �. � R � n tt R a � R � C3 2R Y � 3Z Car� ° � i�.-�--�� 6 z -/ 7' � A''r7 A e a-' ' IibC ������ Br��,w�lx�,«����1,"��►°0°��,�_ xldr IStIXCACQaCA1D0 orlS! NGICQIC.DIOD �ellCo�tr�os Srar� abdiGaca �Y9/�reoordEar6earprwldad m die � owaer. y3.��smora8difsonmtwdl demils You a�aY use B�e tiadc of 8ds pag� f4 ism°'dc aad�iti�anal vxU sibe deta9ls or wdt �7aa� ddails- YuumayaLtio �addirimal Psgesifa�y'- SUB1H11TAL�STt1C1'IO� ?�4a. F�� � tlu4 fiam w�in 30 days ofco�nPlet� �vretl �icnU�B�a�wm� RGLilmmtaep��fl�W""��"'—•r� -P-- - � — - ' ]� Df WAttC �s�00Mti0D P�OR470$ Q �steva rulaw top of a� .Z� (�) 1&171� sav,tx cmta,Rak�b,1�TC zf�9-16I7 rca6oneoa�& a�a -+- 1Ah For Iaiei�as Wdt� Tn add�im to �� fotm oo the addtess � te dEstasoer_ C�) abo� at90 �m�T a eq►�► o€ this Tam atlhin 3o days of aompktmn c�. �ushv�tion mediad: a, t � �"-'-�'� V �OOL�tbe� ,�*, obts d�ea�b. �ee.)- - � e�fWater Qua��9.II�d ��� CsatrdPrngr�m, 1i36M� SaviaeC�sta',Rate��M�Z7�9-1636 'SR SUPPLYNSLLS ONF-Y_ � 24tForZt'abrrS�ydcIniecU��VeU� tnadditiontosmdm8�ef°r�Ata Methodotees� Btown2o ���� � atso tubdnt o� oopy ef this fo� vrithai 3a �js of �m� c�pk6pa �wr]1 �on � d�e cam[Y hnfd' d�omad °f the �5* ra6onm� HTH p�� 112 CuP ,�� x«u,c���'°a�"��°�-�O�w.oa�r�y � � _. _._.__..___. — -- - - --�----- ---------- -- _ �� ,.li���� ne d2partment of health and humen services :.T . � i � $ � E r . ; ,_,�,,� � � � � ; <— s � . ,� 4/� � ..{{���, � E � ; � r �. � � 1�.-�,`� �°` .� ; j "`Cr' � G F S` P;;�e i 11 ` E` �<f S`�J �� �� � i i,s i P f ���� ;, � i/ E F t r Vr--••,, p • �`; �'�.4 � s� � a �:^�.� � ^.. fy-.t !"�, -��- �� � t..� ,.—= � ~� {•� t � 'e. ` ��� :-' l�:: f � � F � r r ^i J�� Ek t .i r t [ �--,�' � \_ a .....�'' �..."� `'i..a i � �1' ��1' \• E � s € ` i ✓ a ^ � ��•i ��� �� � t,? k Ni ti For lnorpanic Chemical Confaminants � County: trSL � Name: d � Sample ID#: � fo Reviewer: , Q w�er � TEST RESULTS AND USE RECOMMENDATIONS 1. Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drink g, cooking, washing, cleaning, bathing, and showering based on the inar,�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 inoreanic chemical resu!!s onlv. Arsenic _ � Barium � Cadmium � Chromium ( Copper � Fluoride � Lead Uon Man�anese Mercury Nitrate/Nitrite Selenium Silver Maenesium Zinc nH 3. 0 a. Sodium levels exceed the U.S. Environmental Protection Agency's-(USEPA) Health Advisory level for sodium of 20 mg/1. The North Carolina Division of Public Hea(th recommends that only individuals on no or low sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inorganic 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. 0 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 determine the source of the lead and/or copper. 6. 0 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 inorFanic 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 Iron Man�anese Selenium Silver pH Zinc For more information regarding your we!! water results, please cal! the North Carolina Division of Public Hea[th at 919-707-5900. �� � North Carolina State Laboratory of Public Health 43012 Distnct�Drve �� ` Environmental Sciences Raleigh, NC 27611-8047 �� , " htta://siph.ncpublichealth.com �r�� , Inorganic Chemistry Phone: 919-733-7308 'cor�,,,�v Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER Name of System: PERSON CO ENVIRONMENTAL HEALTH ANGELA SOLOMON 325 S MORGAN STREET 857 POINDEXTER RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES083017-0027001 Date Collected: 08/29/17 Time Collected: 3:05 PM Date Received: 08/30/17 Collected By: A Sarver Sample Type: Raw Sampling Point: Well head Well Permit #: A30-61 Sample Source: New Well Temp. at Receipt: 1.5 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Cadmium Calcium Chloride Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate < 0.1 < 0.001 7 < 5.00 < 0.01 < 0.05 < 0.20 < 0.10 < 0.005 3 < 0.03 < 0.000: 1.00 2.00 m 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 Nitrite < 0.1 1.00 mg/L pH 6.9 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 7.10 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 36 mg/L Total Hardness 29 mg/L Zinc < 0.05 5.00 mg/L Report Date:09/07/2017 Reported By: Deddie .�tonco! Page 1 of 1 � _ , .,� -�. �� � I � ��� � �. y* � � � ��� � ��p ��6�.i1�3.�L1Y�tLr'�1L4iiNWYJ1 ��^�+'•4�Y���IL Date: �/ Z Z /� Name: (4 � �o n-� ,.� Address: � �M;c bF�, ,�o��i r� / Re: Bacteriological Test Results Dear Well Owner: Tax Map: 3o Parcel: �D � Your well water was sampled on �/,�,/� and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, 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 are naturally found in the soi;. Fecal coliform bacteria arz associated with animnal and/or human waste. ThE presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacterda are present in your water sample, the water may rot be safe for use. Young children, the eldef•ly, artd the individuals with conzpromised immune systems are especially vulnerable and their physicians should be not�ed of the test results. A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested prior to resumin� normal 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, . ���F�'w�e''� Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Em�iror.mertal Heairh, 325 S. Mnrgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1740, FaY 336-597-7R08 . •�,:. 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: ES083017-0065001 �(������ ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: ANGELA SOLOMON 857 POINDEXTER RD ROXBORO, NC 27574 Collected: 08/29/2017 15:05 Received: 08/30/2017 08:19 Sample Source: New Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncpublicheaith.com Phone: 919-733-7308 Fax: 919-715-8611 A Sarver Susan Beasley Well Permit Number: A30-61 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Date Total Coliform, Colilert Present o8/31/2017 E. coli, Colilert Absent 08/31/2017 Report Date: 09/01/2017 Explanations of Coliform Analysis: Reported By: Cindv Price C�.r ��.ce � 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.