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A30 83% ' � � , J � • ' � � ' / ` =, -� �, .-, �s L' � � �� v a � 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� �(�'! � � 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 „ � ' ��_ �','� `'..,.Date Approved: �� By: S i arian ' . (�L� � (OVER) �� `�-\ Location of well �nd sewage disposal facilities sketched on back. � L C�� _ i A t 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. � �^ --- — _.. _._._,_._...._ __.. _.___.._..�_._..._._._ ! l _.___.._.___,_____. �_ _ ., ._ —._._.__,_,_ � � .._ . .._--" � . .;: t � ._.__..____.._.._�_.__ _ __..�.c;..._---___ �' - _ ._--.. a 0 -� 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 , � • . e7�G7 �-. •��m�l-�` • �" r�������r��-,� �t��r.r.�� R�,���■ � -- ,,�„�� [•�r�7l�ir7�IL��' L�fi�l'�1� �'� ' �� 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;•` ��.�.. � �. �. ����F, � -� � /' � /��-,;- _ _ , ; , - �1J' �' - �, - / �._ _!` . _ � .y . , ' '. � r` � --: � . � �� � � ' , � �" � � Application Date: �� 7 �' � � Tax Map: Amount Paid: l�b—�— a• s Parcel #: . Receipt#: G,� l � ( ( �--���.�� ���� �� - - _ � � ����� � anvn��a�n�•-+►++ mua�,r�n.� ��r.e+.m.Il��in 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) � � �� � . �: . � �7 �T ;� . \mn`ti � 3. d� �1✓ � � �. 4 1i � J3...:,l.�.a.��.�<��.iJ�.mi�:.«✓��.�.� ��i��.��lC+� � �ann��aaa� �da�a��aa�/ PV����flce �t�a�ae fl�������san���� 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: ���fln�o ��1������� r-������r�� r-- �,,� � - 2-II Envi onmental He th Specialist Date 1 ? / 15/OS .����J.�� ����/ �� � ,/^� ^_ t/ \/ ��� l�,m�u-�,m,r,.-„���,�.11 ]HI��.11�ll-b SI'I'E ��TCI-i Name a � i �� . . � Tag Map # %i �t� � Pa:tcel # ��` �� Subdivisio � Sec�ion/Lot# s� � -� ' ' 7-il E-'��_'.�- , �� _ 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 � ?-� � �� y�� ,.y�y,w,� �� ��. w� e� - y ,r+ � d t�%� � f� � ��. ° �.� � � . f1�` ` �� �€ �z'.:. � 7-s r� � � :".':� :,. � � '� �.�• ��r ?, ,.� � - .�p , �,� . � ,y$, � '" n °'�a- �e '`g": � � t� � `� � �;' ^a�` ° � 4 � ^a.« �;:; � E�"� :� r,�z,, v,+� � �'s `�` _�li� - __ �� �;; s � � " -: " Q-ti-'x'"��"' �'�"�r- ; � ; � � �` �'°' ,�g � � : - � � x e `, tt<<a.: v� � � - a. . r_ ..��'� > , �. � �% ',f . p�i � ' � .-�1 s� .'�{�� ",�„�.'�'. �, � '.��. � � h° I� � J �,' 4 . . 'w; �-4� ' ' '�� �� <. f' � �„a;. .�� M y ��`a :�A" �„ ��' Y��.�`g '� '1 ;,:.^..>. � � � R „� -� - A � �- - � �- F.. � :� d�. 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C71 ^.�p � ~���,�w���_�,,,_'i.�-n `s'�' j ie �rk� � �.z � �,. � s _•. � �^ � 7� ` � ' � • 'i� � . �t'e � ° � 7ai- ,,,i, ar . ;,. °� �� z, .: � � . .. � — � ,-� +�"�'. ;.��m„� '��"� €- .;�' � � � �� � �� � � -»� �, Y' _ , . � r„ , �' �s. r`� ��� '� �'�S � i ��` � � �I +� �"�a, a � ,� � a: � I �.. x ����. : i x�t��'. sY�'' �_,.�.'Y � � ...y�a+� �• . .«'�'-�� d ' .�".s-l��}d��£ ..'.k�« �".. . `, 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