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The District Health Department
CASWELL - CHATHAM - LEE�- PERSON COUNTIES
Water Supply and Se�,wage Disposal
IMPROVEMENTS PERMIT N .
Date [ 6 —1 - �'�—
Owner: �0.Ui� L� • �i o� t �/S
Location: S 5 t! 3� .�(r�z /,z „�,� 5� �(�'!
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Contractor:
Water Supplp: Private ✓ Public
Sewage Disposal Facilities: No. bedrooms �-3 Dishwasher, Disposal,
washing machine, other aut matic appliances
Size of tank: � Nitriflcation line: �Od `�3
Other disposal facility: �--° �-�' �-1-�^�C1�u Jt ��t�..,. ��c�u�
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 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 AND PUT INTO USE.
_ ,
Date approved: r' 3' 3` _
Well: q'- 7�
�y,���, Sewage Dispos 1:
' ` BY:�
Signe - � d . � (%c .�ti.�
Sanitarian
Counte -
eigned '
( wner or his represe ve)
Cerriiicate of Completion „
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�','� `'..,.Date Approved: �� By:
S i arian '
. (�L� � (OVER)
�� `�-\ Location of well �nd sewage disposal facilities sketched on back. �
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
'suppl�es, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location oi water supplies on adjacent lots.
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DATE ISSUED:
OWNER: �Q U�'
ADDRESS: �-
DRILLING CONTRAC
WELL PERMIT
11-Chatham-Lee-Person Counties
L Q n
ATE DRILLED: i� � COUNTY: I"-Q-✓�JO n
ADDRESS
WELL CONSTRUCTION
Distance fro Ne est Property Line Distance from Source of
Pollution
Total Depth: t. Yield: �� GPM Static Water Lev Ft.
Water Bearing Zones: De�:�F�. Ft. , -��/��__Ft.
Casing: Depth: From to ( Ft. Di`V !er- �'�'�_Inches
TYPE: Steel Galvanized Steel
If Steel, does owner appr Yes No
Weight: � Thickness: � Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting the,Casing? Yes_ No_
If "yes" give-reason: i-/
Grout: Type: Neat % Sand ent: Concrete
Annular Space Width Inches �
Water in Annular Space: Yes No
Methodc Pumped sure Poured
Depth: From to � Ft.
Materials Used: o. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand,�avel, cuttings) - Ratio: to
ZD Plates: Yes�. No Chlorination: Yes No
4 x 4 slab Yes ri No ,
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I HEREBY CERTIFY THAT THE ABOVE INF A ION IS CORR CT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W H EG[i IONS SET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. H E ,
Signature of Contr tor Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO INSPECTION:
�,'. � a a � Q .N�-,-,�v��-/
S�nitari 's Sig�ature Da e
Sketch well location on reverse s�d�O � ablisk�3 y�ef�x�et�
points. ',n�� ,(S vf�jl;•`
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Application Date: �� 7 �' � � Tax Map:
Amount Paid: l�b—�— a• s Parcel #: .
Receipt#: G,� l � ( (
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Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
�$200.00/$300.00 if> 600 d) Fee is de endent on the e of s stem ermitted
obile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Services Requested by:
Name: _� � V� � c� P�' S
Address: �y p N� 55 P � I �-�a �� 12d •
Nurdl� M�IIs, NC Z7541
Phone # (home): ,3 � („ - `rj � �{ ' 0 � O �
(work/cell): 3 3(o -� p�f -/ Z 3 0
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) PropeMy Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: Same n s ti
4) Proposed Use and. Type of Structure: �� / 4� �u ����, � j
Residential � Business/Type: Other 2C ( l.�J G' ,
Num ber o f be drooms 3 / Num ber o f peop le serve d (seats/emp loyees): 3 9� SGYee nP� - r y
Basement: Yes _�_ No (with plumbing: Yes No �� poYG�
Garbage disposal: Yes No ✓ �
5) Water Supply:
Private Well ✓ (Proposed Existing �
Community Well: P.ublic Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A comuleted anp[ication must also include:
➢ A plat/site plan of the property that shows properly dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid. _
Signature (Owner/Legal Representative):
Date • / �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map #:�_
Approval Requested for:
Applicant
Address:
Phone #'s:
Parcel#: � �
Mobile Home Replacement
� Building Adciit�on
Permit Located:
Instaliation Date:
�(� — 5cs4 — r 230
!/ Yes No
�-23�Ro
Design flo�,v: 3(a � (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �,' 2"�� (date)
(Applicant's signature if site visit is not required)
Comments:
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Envi onmental He th Specialist Date
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SI'I'E ��TCI-i
Name a � i �� . . � Tag Map # %i �t� � Pa:tcel # ��` ��
Subdivisio � Sec�ion/Lot#
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A�.tho.�ized Sta.te Agent Date
System components ne�resent upproximate �contours only. The contractor snaust, flag the system prior to
begin�ing the installation to ansure that j�ro�bergrade is muintained
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North Carolina State Laboratory Public Health
Environmental Sciences
�iicrobiology
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: ESO40516-0108001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
Name of System:
DAVID ROGERS
P.O. Box 28047
4312 District Drive
Raieigh, NC 27611-8047
htto://sloh.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
370 HASSELL HORTON RD
HURDLE MILLS, NC 27541
Collected: 04/04/2016 11:30
Received: 04/05/2016 08:57
Sample Source: Well
Sampling Point: Kitchen sink
J Smith
Susan Beasley
Well Permit Number:
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Susan Beasley o4/06/2016
E. coli, Colilert Absent Susan Beasley 04/06/2016
Report Date: 04/06/2016
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.
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
DAVID ROGERS
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sloh. ncaubtichealth. com
Phone: 919-733-7308
Fau: 919-715-8611
370 HASSELL HORTON RD
ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541
EIN: 566000331 EH
StarLiMS ID: ESO40516-0031001 Date Collected: 04/04/16
Date Received: 04/05/16
Sample Type: Raw Sampling Point: Kitchen sink
Sample Source: Wetl Temp. at Receipt: 3.4
Sample Description:
Comment:
Time Collected: 11:30 AM
Collected By: J Smith
Well Permit #:
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
mium
Calcium
<0
0.005
Chloride < 5.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
<
4.00
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Manganese < 0.03 0.05 mg/L
Mercury < 0.0005 0.002 mg/L
< 1.00
< 0.1
10.00 m
1.00 _ m
pH 7.2 N/A
Selenium < 0.005 0.05 mg/L
Sulfate
ness
< 0.05
7.80
< 5.00
34
0.10
Zinc 0.47 5.00 mg/L
Report Date:04/22/2016
Page 1 of 1
Reported By: Deddie .r'�toncol