A32 140Report 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:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph.ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
GLADYS LERCHBACHER
426 GUESS RD
ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541
EIN: 566000331 EH
StarLiMS ID: ESO42214-0004001 Date Collected: 04/21/14
Date Received: 04/22/14
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 1:15 PM
Collected By: J Smith
Well Permit #:
GPS #:
Inorganic Chemical 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 mg/L
Calcium < 1.0 mg/L
Chloride 22.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride 0.32 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium < 1.0 mg/L
Manganese < 0.03 0.05 mg/L
pH 7.5 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 96.00 mg/L
Sulfate 12.00 250 mg/L
Total Alkalinity 155 mg/L
Total Hardness < 7 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 05/01/2014
Page 1 of 1
Reported By: Arnold Hall
RECEIVED
MAY 0 5 2014
. -Si�e Evaluation Application
Fee Collected YES � NO . .- � ; "'•
(�c� �21v.°O� �,�2 Si�eS�
70 .
Date:
(j�-� }� 3 �,(..� APPLICATION FOR IMPROVEMENTS PERHIT
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1. Permit requested by: owner/prospective owner:
� _ _ agent:
Address: �'; � /,3-,,c �/ L�-p_. IFLi�.��G� �Vyl�� : 1'�J,
Home Phone ��: 3(, �_ ?.g �� Business Phone 46:
2. Name and address of current owner:
3. Property Description: Lot size: /f y�(���
4. Tax map ��: Township: �, �,
Subdivision Name:
S. Directions to propertys State Road �� & Road Names, etc.
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Lot ��: _
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width:
Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? t�-'' public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? j_ If so, identify location:
11, Type of structure or facility: Proposed: Existing:
Type of dwelling: House: _�/ Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms: �_ Garbage Disposal? Yes No
Basement? Yes _� No If so, number of basement fixtures: nonC
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for. the evaluation. G.S. 130A- 35(F)
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Signed Owner or Authori n Agent
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Permit Issued ,i�y/y�
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Permit Denied
Plat Observed �
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rACTORS — SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S
1. SLOPE (X) P PS PS �P�S �
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2. SOIL TExTURE (i2-36 in.) S S /_ S
(Saady, loamy, clayey, PS ``� P�� ��� PS j✓� PS
Note 2:1 clay) `�� U
3 SOIL STRUCTURE (12-36 in.) S
(Clayey soils) PS PS PS
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4. SOIL DEPTH (in.) PS PS � PS
U U U
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata� rock) PS PS PS PS
6. SOIL DRAI2IAGE/GROUNDWATER S S S
(bcternal & Internal) PS PS S� PS �
U U
7. SOIL PERMEABILITY S � S
(Percolation Rate) PS PS PS PS
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$. OTHER (specify) � G^9.�J"\ PS PS ' PS PS �
U U U U
9. SITE CLASSIFICATION ` �� C �
(See below) `, J
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable _
R.ECO2��IEIZDATIONS / COt R fII�ITS :
S�TE CLASSIFICATZ021 DLAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
cret areas, fill areas, wells, water bodies, slope patterns, etc.)
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' PERSON COUNTY HEALTH DEPARTMENT
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WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � � 2 Parcel # ��0
Zoning Township ..S' •
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Location/.
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Subdivision Name � Lot#.
Layout
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WcLL
0933
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As Installed
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area • G [S Size of Tank ��' '`e�" �'J
SFD Mobile Home Size of Pump Tank N
Business # of Bedrooms�_ Nitrification Line �/� �� `
Max Depth Trenches � � "
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' de us hang d.
Well and Septic Layout by
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Date �j- I 9-��7 Installed by �'�-�-�,�.� a°�� Approved by��;
ell Permit Paid WELL SYSTEM SPECIFICATIONS
3ividual Semi-Public Required Slab ✓
iblic Replacement Air Vent ✓
te Approved ✓� Required Well Log��W ����
ell Head Approved � Well Tag v�v ����
•outing Approved V C�v .DI
Comments:
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Date 9 l�l �71nstalled by �� w�� Approved by ./t/�� ��.`u-�c�,�
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. 7'he
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or
misleading statements provided to him in the application. Neither Person County nor the environmental health specia(ist wamants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
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lJltl,l, LOG
Date:--�=�=� -_�'� �.:;�
Owner: ��� h .T� . , . � . ;;::
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Location/Directions: �_�__t,� __ ---------- ` {�
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.�u �.V1S1011 ��1I11C: l/ — ---- • •
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Drilling Con�-actor: _ - .�_- �� � _ -�--------- ---_ ____�.___ Lot ## :
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Distance from , WFt.I, C:nNSTRUCTI( )N ::4'
Ner.ires t I roper � y Li� u� /S :'?:<
Pollution ���5 _ lli::c.�nc� froin Source of . ' � � `''
a � , :.
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Total.�Dep.th:. a-- Ft. �"icicl: � > ,• , i..
�-d_---._-- C�l M �� t�itic Water Level t� �Ft. '"�
Water B�earing Zones: llept}1 d �:� ,ti
Casin _ --Z----- _..--�-�—I't•-- Ft. ��t. :�:��.
g: Depth:� From�___to_ }�t. �
TYPE: Steel � -'� -- Dla�aicter: r � Inches :,''k•r
� Ga1v.11112GC� S[�(:] v . . �;.,
� Zf Steel, does owncr_:�pprov�:: yc:, No � � "•'
"Weight:�=Tl,ic�:ncss:._�_�/.Hei�ht Above Gx � '�'
Drive XeS o��; •
Shoc: _ � No .'—„Z2.__�7nches . ::��.
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Were Problems Encolintcrcci in Sctti�1b thc C��sins? Yes__ o ;
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f "yes give reasori: ,
Grou[: Type; Neat , a°��
S:��icl/C'cmcnt Coricrete � � � ,� ,
Annular. Spacc W�; �.,� 3 Inc}ics �.�!
Water in Annular S; �ac�: Ycs________ No �"- �;":.
Metho.d: Yun1 c c' � — - `�
Fx �._. __ ]'rc;.isuc-c 1'ourecl L---� �'
Dcpch: --- __________ . . . - , . . =..� ..
From --- �;,
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Materials Useci: N --- �- �t. . � ' . `;;;;:
�. Bags 1 ortl�uid Ccmcnt Wci t�oP.l ba�-� 1'�
If mixture (sancl, �r.:vcl; cuttin�s) - Ratio: � �' G' lbs:= ,,_,�; �
ID Platcs: Yes G --�---�10 '� r`��
No . � . • . , . ,
� 4 x 4 .slab Yes ✓ _ No � .. . ,��'
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Z HEREBY CERTIFY THAT TI-IE AI3UVL 1NFORMAr1',ION :[S CO ��
T�S WELL WAS CONSTRUCTED IN �,CCORDA,NCE y�r�T�-� RERE� �D T;
FORTH By�THE PERSON COUNT�' I-II��ALT�-I DEpART : GULATIONS;
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