A32 76� � 1?— �� ) �11G�� �l � Tax Ma � 3�
Application Date: � � f P�
Amount Paid: .� -";z,�� � � ���� Parcel#: %�^
- — ���
Receipt #:
ITd..an.�e �iscD�ca�rnn.c;�rntE.�nll .IHL�:�.1LA:lla
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
1Vlobile Home Replacement or Buildir.g Addition
$150.00 (if site visit required)
Vb'ell Per�rit (New/Replacement/Repair)
$300.00/�200.00/$75.00
cation for Services
Services Re uested
Construction Authorization
(Fee is deaendent on the type of
P�rmit Revision
$75.00
Repair of Ex:sting SeptEc Systcm
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: ,Q
Name: � ,��,., 6 � �U _
Address: /. p� �,�/a /K�� � —
���� /1'1i//r Lt/� 2 �S `1 � _
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): ��� '�� Y- y� s s
(work/cell): 4/q - 7� `� — � � `� J
Fhone:
3) Property Description: Lot Size: (��'R- Sub3ivision: Lot #: ` � 7S ��
Address and/or directions to Property: ( S� i�o l� Q ��1rd� 11�� ��� �
❑ yes o Does the site contain any jurisdictional wetlands?
J�jces ❑ no Does the site contain any existing wastewater systems?
❑ yes �o Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �'no Is the site subject to approval 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)
�/a4) Proposed TJse an�] Type of Structure:
� ❑Residential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expans�on of Exi�ting Sy�stem If expa.lsion: �urrent number of bedr�oms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
Non-Residential 2(y ��2� � CO� Y �p�'�'
e of busine�s: Total Square footage of Building:
Maximum number of employees: ___ Maximum number of seats:
5) Water Supply: ❑ New well �Existing Well �7 Community Well ❑ Public Water ❑ Spring
Are there any existing wells, sprmgs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
�/(� 6) If applying for `Authorization to Construct', please indicate preferi•e� systein type(s):
[\ ❑ Conventional ❑ Accepted ❑ Innovative 0 Altemative ❑ Other O Any
1 cert� that the information provided above is complete and correct. I ulso understand fhat j the ir for-rnution p-rovided is
inaccurate, the site is su uently altered, or the iniended use changes, all permits and approvals shull be invalia'.
�% �/f �Gi� (p�17" /�
/�//r //[. _
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 32� S. Morgan St., Suite C, Roxboro, NC �7�73 (33b-597-i790)
Application Date: Ip-�O-G 7 O� Tax Map: _
Amount Paid: � (56 , 0 O � � � � - � � � Parcel #: '
Receipt#: �j ('j � 4 �Y(- � °i, -�
>-j� ��-,�.5 f" ���.���
3 G � _', = ' �`�- � � � 1� �C' �
�.. �C:'��.n:a.wai. a�4.a �av. na.a. �c� ss-n. ti::..r�.Il I�-3C .c-.cn �1.+t1�:a.
Application for Services
(Seotic Svstems and Wells)
�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
0 Well Permit (New/Replacement)
$225.00/$125.00
Services Re uested
❑ Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No CharQe
Important: If the information in the application for an Improvement Permit is incorrect, falsified, or tlie site is altered, then the
ImprovementPermitand theAuthorization to Constructshall become invalid.
1) Services Requested by:,Q
Name: �. s a / ar �e-r Phone # ome): 3 3 G'$`t"J - 2�t (�{
Address: U Q !o (work/ e 1. � I q) ?��j -�5 a d
'd / Mis G �L�SI
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Properly Description: Lot Size: � Subdivision:
Address and/or directions to Property: -�Cc.,�( p, �C<rC��L
4) Proposed Use nd Type of Structure:
Residential �_ Business/Type: /Ul0 d�.i ` 6� � Other
Number of bedrooms ,;,,,;�.</ Number of people served (seats/employees): �
Basement: Yes No �/ �(with lumbing: Yes No _,
Garbage disposal: Yes No �
5) Water Supply:
Private Well � (Proposed� Existing _)
Community Well: Public Water System:
Are there on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property tlzat shows property dimensions and the size and location of all
proposed structures
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the P son County Health Department. The
information provided is accurate. I understand that if any si is ltered or the intended use changes, all
permits shall become invalid.
Signature (Owner/Legal Representative): u ' Date :/d / � �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
' �1�� `� i �1a i* ��1.�� �.1� �
,yy � �y�
��w ��1' � �'�� 1L ��
���.s�„-„ -�,�, ��..�.�.11 I�-3C��►.�1�
a�x . ap : . ' arc� : .
Su;a.d!ivi s�ia:n
'�� �s�e S�ctian:Lat'�
���ait �a�id �or ,� �+ive ��
Type �of Fac�ity: c� 01�
# of flc�upants �� # of Be�
Praposerl Wastewater System: �
Propos�d Repair:�-iah-,n� Ac'�
Permit Conditions:
�pravea�ent ��rr�it
_ �+i'o �pi��iaon
.�.�\ ��a v,�, Neur � Additian _ i�aie� �n���y liVel
� Pi�ojecte� Daiiy Flow ,��_ g.p.d.
� Z ( Tyge; �_ c r
C��lo �fc�l c�.e%i� �� z F �� c,r ('iY�r,-� f� Type: �
(�wner br Legal Representative Signa�ure:
Author�zed State�Ageut��Sn,�a c ��
�e iSc�7anc� of this pemut by. the Health Depariment in does mt guara�tee the iQ��_A�+s� of othel p�. I# is the responsibility af tlae �
�P��P�Y owner to in s�e ti�at all Person County Plannmg and Zaning and Bu�7ding Tnspe�ons re� are met. 3'his
�nnproves�nent �'Qrmit is snl�ject tu revacation if the site pIsa, plat or the intended use chaaeges. The Ymprovemeat �'�x�t is not
affes#e� bg a ci�ge in ownersiup flf the property. T7�is permit was issned in complianca.with the proviszans of the North Carolina
`Laws and �les for Sew�age Treadnent aad ]Disnmsal Svstems' (35A 1�iCAC 18A .1900). 1Veither Pessou �onnty mor tiie
Enviranuaentai Heaitii Spesialist' warrants tbat thg septic tank syst�m ��11 cantinue tu function. satisiactonlg ia ths fu�mre or'that
the water supply w�11 remain-potabie. - -- . . � . " .
A�tdao�iza#ion to Constru W�stewater System (Recynire,sl for ��ding Pe�muit)
* See site plan and adc�itional attachments i�- � z�7D� - �
c� -
Propose Wastewater System: Z�pe �q Wastewater Flow�g:p.d.
New � Repair Expanson � � So�l LTA13..�J e��� g-p.d1$ 2� .
Type of Fac�7ity: ��, �, r,�,`T m', lx., c) �e I I� nQ Basement _ Yes ,,,� No � �
.,
�asteevat� Systea�a� l��n�emen#s
ian� Size: Se�#ic T�nk: 1�� � �p Tank: 1�� gal �Grease irap: � gal
�raim�eid: Tota1 Ax�: � s� � -�'otai i.ength �a�'Z �t � �um Trenci� Deptin �� . in
Tre�c� �dtd� �_ ft 10��'iniimuffi Soi� C�ver. � 0•• in 1VTanitmnm Trench Se�aaa��ation: 9 ft
�istrA�ntion: �i�iribn�iion �o� Serial �i�tri�ntao�a � Pressase 12a�oid
Spe�cations:
�nthori�e� St�te Agsnt �j��
Permit Expiration Date:
Date:
The type of system permitte� is Conventiona.i � A.cc�te3 Altemative. I ac��t the spe�ifications of the
P�� � -
�D��r1���i ��prese�tive: � V�� � �k�t-L-�- Date: Q i ( � � C.� �
' pG'� rev.11/10lQ1
���'?,�� ����`l..J�
�.._. . " _ � � �� 1��
E.�-���--����.:t ��[�.�.�.,� Owner. va5�n� i� r�e r
Ta.Y 11�Iap: �?� Parcei #: r1(o Date: �► ��1�� �
�,ayae �a� �a� (�ac�a) �� �'%� �e ���g�ia �o�v / �oot
# fl�i�eter(�) . ( yn) -. 'g�) �
i � � I . �l -- r7 , o . �
Z 'I ��� 7v
3 'i2 =�-la �• 1 8D n.�
4 '�z � �, ic�
5
6
7
S
9 �
1� . .
<�� ft of Iine x 65 gal. per 100 ft=�ty5c� ��46a ; 100 =o��,sgal
75% x� iy ,� ga1= (C�O. g�i pe� �ose ��, gal per minute (ggm) _�ow ��e
�rnction �ead
g,a�: t.`7$ ft per 100 ft of supply line x�� ft of snpply. line =100 =_�_ft
i.3 ft x 1.2 = I- l� ft of friction head �. .
��a�a s��: a"�I .„ �a� �� s�: a „pvc
�otal.IDyn�saic �ead =� ft of Elevation head +,�,_ft of Pressnre head + a ft of
Fricdon Head = `�i TDH
Pump Req�airr�e�t: 02�_ GPPiI @� ft of Head
Drawdown: Ilo I gai per dose � 21 gai per inch =�_ inci� dra.wdown per dose
:,, . . . , :r: :.��1:� , ,, � �� :.�. , �.
a
_ 4 - �
a�ta�����■cs - 1� . , :
. . , , ,, i . ,: .,
,.. �[i�11�0�0�
: �-o-�-�-�. �-�-.,-� �-a-<-r-o-o :->-�-�._._�-�-.-�-�-�-o-._.._:-,
(1 II 1R I1 > .............��.....«.....�..•
:.... :... ..... i�aa��•.ai��:���������a�:�+s���*
� � � � � ' i .,,._. . �J 'L ' :1 : : Y.
���r
iOV��aO�
Sias
3"
diold 5S� / � Taps
D�z Na Tags off on�
lucs 'h ,or �
��» {�
4 =
9 �
aa;-
�nw prs'TaP
Si�.-z _Llarerial �o:v G�'�
:c'• Sclied 30 }.�
: � �cned =0 I " ` �
;�, " �ci:�ci d0 %0.1
i =�. • � �riteu 10 I -
�
. �
/
� i � :
�'•_�'�.`►:� �:. � �.. �� ��-.. .... �... ..:�:r: .� � . ' :.. .
� ''r. � � �1:J ���
�., o • ' .. _. n n
._,a.��7�IC'�71�.7Ch71.,({:IL'Il.�a�.�. �.cf�.Sl.Jl.�.lt9.
Building Additions/ Mobile Home Replacements
Tax Map #: �7 2 Parcel#:� Address: �� ��' �� �
; �sY�
Approval Requested for: Mobile Home Replacement
� Building Addition
Applicant Name:
Address:
Phone
���6''� �rl�^Cr
V
Permit Located: l� Yes
Installation Date: —Z! -o
No
Design flow: � � D (gpd)
Current Contract with Certified Operator on file (ifrequired): N�t
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on:� �%��"�--- f date)
(Applicant's signature if site visit is not required)
�
Comments • �Q'�'�' s S % �.-, � � � �� � � 2 6 � �C Z 6 (S1' ,r - � �-�1- ,
Addition/Replacemea�t Approved
En irorunental Health Specialist
��- ( �-z�( �p
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.nersoncount�net
ConnectGIS Featw�e Report
f q �
� ���� _
Page 1 of 1
Person
Printed June 17, 2016
See Below for Disdaimer
; , ,� `� �� _ � � � ��.
:� � �, � � � ,
aa � � �`.-,R
' ~� � i,,-�< ; �� � � � �
^ , `�� � \ � � � � �`�� � i: � � $ �; ,
.. . .. a� @a � ,
a
: �� � � �✓ � 3, � �
� e . �;� . x . �
a _ I � � s �^� .
w �
� � �
�� �. �. . 9 �" = ,
� 1 �
.A � � - �y � � �. t
� $� �� �':i .. ,�� � �.
a +p .
�''� . �� � R } eeb•�
». � . `
_ � _ � ' . . ,--¢e . ,
. J.,� . � _ � ` ., .
` �
/� �� � : • _
. . . �. � � 4 ,1 �a , �_ .
`n' � g
. . � I ��� ��� �� . ' 's �. �. ..
. . .A._`1�'�� �����w � .. , ' . , � ... _ .
{ � � f
� � � � - �
y, � . , ...,
� � � � � � �
, .
1 -
� �� �a .
�.
. •• '•�. k .'�
� , � � � _
r ,�„ � �� �
,
�� � �
�� � ' .�� '�. � '� 1 � � ° x .�� ` ��
. , ,
�, �
�`'i � �� ' � �
�: �
� �� � � ,
;�3 �,a - i a z
� �� � "' _ ';,
£,
, �
%
� . `,,�
�' ��
,
. � , ..n . i &:
�: - �< . - .... , : ..� =: � .. �:� � ; �.
� � .. � : � � z � - a�E �.
.� � " � �� � � �� �� �
� � - '�'� � ,_
� � � � � ��" � � �
� '`� ' ,� , � ��`
. . .. . . � � ��h ..
j� t � ; �
� i � , .�z � � .
�
� � � � � � ���:
n �"" ��, � 6 � � � '���,�,
\\ � , i ��;� � � �
>�. �
� ,
� � _ � a1"
� � -'
�. � .
�� ,`. .<� � � � w � �� � � �
.; � ,�
r�` �' ��n �' �. �°` �
�� � � B
e . -
• � -�
:r . . �' - . . . fl " < . a, ...� . . �
. e .
�
. � � � .. . . . ^, . . �� " e.. .- .
� �
�"�. _ �u<...< _ i . . ' . 'l, s" `
�
�
�
_ � _ . . . �. � .
` � �
_ . . `'.' . . S'. �� � �. � \�
[ lii J --� � � . � . .. . . .
�i `�� . .. . ..
"`'' � 60 Fcet :
� � . �� ; _ �� �`�� n �"� � � � � _ �..:
(�
NOTICE Recently, we have had se.eral usai� �eport bro�°.ie� compatibillty �swes when trying to access ow GIS �vebsrtr lyp�cally Ihe problem stems fion� use�s who hav
recently upgraded to the Windo�v� 8 operating system or a new version of lntemet Explorer. We were able to resolve this issue by directing users to the Internet Explore
Compatibility View tooL This link is to MicrosofYs "How f o" for the tool: http.//windows microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility-vie�
f this does not solve the problem feel free to contact us at the number listed on our main page Welcome to the Person County GIS Website. ConnectGlS has bee
prepared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats and other public records Users of GIS system ar
notified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311. ConnectGl
assume no leqal responsibility for the informatlon in this system Grid is based on the NC state plane coordinate system 1983 NAD.
http://gis.personcounty.net/ConnectGIS_��6/DownloadFile.ashx?i=_ags_map7577af45f557... 6/17/20l (>
����,�� �1!_e�dJ�J�
`v "'— �: � ����
I� aa.a nsao-�-� � maa+��.71 IE-"��.m:]L�]Ea.
SITE PLAN
Name .\Ci���_ C��r Tax Map #_� Parcel #�
�bdivision Seaion/Lot#
�.A� io � 1� ���ll'-1
Authorized St1te Ageat Date
System rnmponeats tepmseat appmaimam conmurs aaly. Thr coamcmrmusttlzg t6e system pdot m beglnniag thelnsra�oa tu
lnsrur t6arpmpergrade is maintained
�..�, - -- ----�-----� � �r.�:,,,-��� a�� �4ixzcks
� �- �a`'�� � '�►,s-� �6�em �r-� c�►�s�y,,�r-
� '�� no�- \n�-�1\ �S�ear ln �ve�% C�r�i•i�iQnS
= '� ��ues-1i�s C�-�.CE Env- ���
� -
' '_ �' � �i-7- t-1R�
-�>- ' �. �ra�;� c���, cr;,c� h� QChe�vecl
��,��` � , c��f'�-'�►-,� �, -�ac�- �-,�„��e lcxo_._-�;or�
�
�\\� .
�
. i�� �
�;. �:� ��o
�t
� i .-
�
.° �, �f-� � �
K�Po.�s • •°° _ � ➢ s
� Q.
_ /°'`4 �
,�. , �
, ���
J / �� � �
��v
`� ��.
T r� i �-i 2Q �90
3 � Us �,
��g�a °�
�a�5 � ►�
3� �'-� �k' Acr� d t�,�
�'Y e55t�.��e MG2r�i -�01 �
s�
�� .
5C�.9 -
I "_ � �
�5,
. �r�
��� 5
0 �\�
�
�wnP -b
►�c��
�/o Cecl�cFia�
,EZ F(ow o� CJ�tmhe.r�
�
���� �� �� �..�� � ' .��
�^��� � � ���� �
�[— "�d"Z�`�O-r"� -r"Tr'� �Z.Z��1.� ��.2t.��rt�
�� �� 32 ���� � � ��
�i. � '�ao�
����s�o�L��� �
�� ° �ai ao �j 3
Ar�plicani:
L�ca�ion:
a
F� a� �� !� ��• _ t � �. -
. ' ' ' ��
. Syst�m Tyge (Zn Accnrdanc� Wi'rh Table Va):
THIS �YS"1'�� F��+� �Ei� �N�T�LEi3 i�! C�[§�F��I�A�C� �lT�-i �P�F�1C�.PLE .I�QRTH
�'Ai�OLiNA GE�E�L ST�4�i1T��, ��U�.�B FaR Sc�il�G� TR�A�1ViE�IT ��ID DISPOSAL,
� �,i�D •��i COIV�3tTlt)PdS �� � TH� 4t�9FR01/�:�I��T ���iL i A�6�D GOf�STRUCTIOf�
�l�i�lO�iZ.�iTi�iV. .
� /— ZGe - o�j .
' A thorized State Agerrt Daie
lnstalle�l. B� ' . Date: � /'Zl� ` D9 . .
. ��� � � • . . . .
�5 �
�
p
�
�
U
�
L-�
- ?CHC�, r�i. G7(2�iC�,�
� ol-�� R�. � —
W
�
�
�
��� ;�� �'�cc^�� �NS����'a�R� �'�E�a�.�� a � 9��� �9 � 18�
Ta.: IVi�p ��32 �arcz! � 7(� S�s�e� Type (Tabde V2) z
O��¢�erfA�p{icant � .-lason PaCIC¢Y - Si1�]�N1Si097
AddresslL�cafion Se��Pf�as� Lot # �
State �(D/da�e 5?6- �IZ " G -
Ca aci S- o0o al.
Tee and Fiifer �
� Baf�ie
Sealant �
� Ris�r ifi applicable
� Tan� Outiet Sead
Perman�trt Ii�arker
. P�m� ��n�s
- ��r�a���
� Wate� roof /Sealant
Rise�
Water Ti ht � .
� � ��am�
Checic ValvelG2te 1laive
and autiible
�onents
' i�ate qpm) . .
A rove� Pump fViode!
Blac� Under Pum �
Pum� Removal �RopelC
. �•�as�ibaa�ora.: ���
� Se�ial Disini�ution
�ressure i�an�rad
�ow Press�re Pi e
A r. F'i � Ntateria� and
,.-� -- -
.�d��� � �o�r�c���ca ���
- o� re�cf� VVidih . 3 f�.
� T.renci� De�ti� in.
T.renc� Len o �.
� ire�cti Ga�ade �
Tre�cf� S ac�n �
� Roc:�c De th and C�ual"
' Darns/St� davvr�s �#c.
/ Pressure Laier�als �
Hole Spacing �
o e :.�z�
Pi��. Slesve �
f�qui�d� Set��°�
Frorn� Wells � '
From Properiy iines �
Ini___L'___T___�•�__� ..
Sur�ac9 Waters
Public V�laier �uppi
�l.erticai Cuis (�2 i�.
1lt�ater Lines
Ve�ic�� �Traffic �
�
I
�a�mme�a�
�/Righf of V�
O��e'
s Recaa�d�si
��ra— to- r �i
i
0
�
y.�
�c:�c r��. 3t1�/G �
North Carolina Division of Public Health
Occupational and Environmental Epidemiology Branch, Epidemiology Section
BIOLOGICAL ANALYSIS REPORT
Private well water information and recommendations
Coun . �`� Name: (�i�/� Sam le IdNumber: 3��
tY' � P
Location: Reviewer ��1�
Your well water was tested for biological contaminants (total col'iform and fecal coliform bacteria). The
results were evaluated using the federal drinking water standazds.
Drinking water may contain substances that can occur naturally in water or can be introduced into water
from man-made sources. Tota1 colifbrm bacteria are found in soil and fecal coliform bacteria are found in
animal and human waste. Total coliform or fecal coliform bacteria in well water indicate that the well may
have structural problems or that the well was not pmperly disinfected.
BIOL GICAL ANALYSIS RESULTS AND RECOMII�NDATIONS FOR USES OF YOUR
PRIV TE WELL WATER (These recommendations are based on biological analysis onl .
No coliform bacteria were found in your�well water. Your water can be used for drinking, cooking,
washing dishes, bathing and showering.
Total coliform and/or fecal coliform bacteria were detected in the sample wluch indicates that
hannful bacteria from human or animal waste could enter the well. Do not use the water for
drinking, cooking, washing dishes, bathing or showering unless you boil it for at least one minute.
If you have been drinking the well water and are pregnant, nursing, have a child in the household
under 5 years of age, or immunocompromised (such as an individual with AIDS, cancer, hepatitis,
dialysis or surgical procedures) inform your physician of these results at your negt visi�
There may be a problem with the construction of the well, the groundwater source, or operation of the well.
The well needs to be inspected by the local health department or a local well contractor to determine the
problem with the well and to give guidance on how to correct the problem.
You should re-sample your water after proper well inspection and disinfection to make sure that the problem
does not continue. If the contamination continues, you should investigate the possibility of drilling a new
well or installing a point-of-entry disinfection unit which can use chlorine, ultraviolet light, or ozone.
Contact your local health department for more information or go to
��� � :� ����
March 10,1009 ,�:�}�c,T ;
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
Report To: J Name of System:
PERSON CO ENVIRONMENTAL HEALT�� Jason Parker
�
325 S MORGAN STREET Wolfe Rd
ROXBORO, NC 27573
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
htta://slah. state. nc. u s
Phone: 919-733-7834
Fax: 919-733-8695
StarLiMS Sample ID: ESO40909-0040001 Collected: 04/08/2009 10:00 Jonathan Wiley
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ` Received: 04/09/2009 08:32 Angela Heybroek
,_� . } ,
ES Microbiology ID: 3652 Sample Source: New Well Well Permit Number:
GPS Number: , Sampling Point: Outside spigot A32-76
Sample Description:
Comment:
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert -
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Darneice Lyons 04/13/2009
E. COIi, Colilert Absent Darneice Lyons 04/13/2009
Report Date: 04/13/2009 °� Reported By: Susan Beasley
AP�
� a�
V U;�
.�_�.
Page 1 of 1
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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 rebarded as a complete report on the water supply.
�
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mgll
No established limits�
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
r
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mgll(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
North Carolina State Laboratory of Public Health
Department of Health and Human Services
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM
Name of System: Parker, Jason
Address: Wolfe Rd
Zip:
County: PERSON
Report To: Person Co. Health Dept. ATTN:
325 South Morgan Street Ste C (336) 597-2371
Roxboro, NC 27573
Courier: 02-33-15
Collected By• J WILEY Date: 4/8/2009
Source of Water:
Source of Sample:
Type of Sample:
Type of Treatment:
Type of Analysis Private
Time: 10:00:00 AM
Location of sampling point: Outside spigot
Remarks: Permit # A32-76
Parameters Results . Units Date Analyzed:
Silver <0.05 mg/I 4/9/2009
Alkalinity as CaCO3 118 mg/I 4/9/2009 �
Arsenic <0.005 mg/I 4/9/2009
Barium <0.1 mgll 4/9/2009 ��: "�
Calcium 26.5 mg/I 4/9/2009
Cadmium <0.001 mg/I 4/9/2009
Chloride IC 5 mg/I 4/9/2009
Chromium <0.01 mg/I 4/9/2009
Copper . <0.05 mg/I 4/9/2009
Fluoride <0.20 ` mg/I 4/9/2009
I ron 0.65 . mg/I . . 4/9/2009 .
Hardness as CaCO3 (Ca,Mg) 102 mg/I 4/9/2009
Mercury ` <0.0005 mg/I 4/9/2009
Magnesium 8.8 mg/I _4/9/2009
Manganese 0.28 mg/I 4/9/2009
Sodium 8 mg/I 4/9/2009
Nitrite as N <0.10 mg/I 4/9/2009
Nitrate as N <1.0 mg/I 4/9/2009
Lead <0.005 mg/I 4/9/2009
pH 7.5 Std. units 4/9/2009
Selenium <0.005 mg/I 4/9/2009
Sulfate 7 mg/I 4/9/2009
Zinc 0.22 mg/I 4/9/2009
•I�Date Received: 4/9/2009 Report Date: 4/27/2009 Reported By: �j1I�,Ul.�(.Q.,
Today's Date: 4/27/2009 Ref: 5026 Login Batch. `0�(}4002i '�� Sample Number: A687888
Explanations
Coliform Analysis:
If coliform bacteria aze Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
..'�. . .
�;����''.'�'''.. , ��(
.��
. :.
.
; . ...
;��;E.: .:��„r� t �,��
:.::::..�:::., �:!�`a:: ..... :��., �'. ....::.. ...'`'.�"��,J'�`�.. �. `:. .
b'� �` ::::. .... .....� . ... ... . .. ..::. .. .
�•�.+`�'ti..• ..... �. . ..
�� {'i�!.�,•� �•�
...........x•::.:vs�;•�..:•.v•:�.�v'.vryv� .....:...... . :. . .
.v. .,�i••.':.:.. .r:..in.,... : }.....:.. : . �.. �.....� .
�::. .
. . . . .. ' . . ., . :: .� .
..:v . . ..
. . (i��%.�}l:�a�%�•.. � �•
... �.�:���'��Q�i•1F'lY•1t'.1�..t�.; .... ' 1
.�••.1�•.I:..::i .. .,.,.��...r•.:-.:.::::'.t.�„'. . .: '.. 'v • �i'!�.�1{�1LY �.
1��} ��� �.-..�Y�� �
YL��� ��� �Y JI.�VY�. n"•� 3--.Y\ i'O� !1 '-•�J� �Y1:•-•.�JL�`i./�
Tax Map � parcel # �lSo Tovvnship:
Applicant• �,�,-�n �r r
Subdivision: Lot #
Location: ��.��W N,:��� Pr� -�-� .�„_ ('1-v,,-I: o r.n �_ �, � � . �. _
'�ype of �1�i�r 5ug�pfly: �, Individual _ Community Public
�e�t�aa�eme�is:
Site Approved By: �Qw� l Ol �" �/ d�
Grouting Approved By: '
Well Log: �
Pump Tag: ''s'(�,� c�"> .n; ay
Well Tag _ �'$ 1� 2 6- og
Air Vent: �' 13 �•J �"y � 3/ c� �
�IoseBib: S -2�-�
Casing Height: 5 � �
Concrete Slab: � J S �
Liner:
Tnstalled by: _
Depth set: ,
Grouted:
I�ate:
Watea� �ample:
Well Driller: � `' � S v �'1 �
Well A roved b: � C� ��j �
PP Y Date:, �
���*See Attaehed Si�e Sketc�*�** .
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems,
Wells must be at least 25 feet from any builcling founda o.
Other conditions:
PCFID rev Ol!27/0�4
�'�`�.S..f` I�I��.���
~ ~ � � �7�� 1L
IE.��..�.a-����.��Il IE�I��Il¢�.
��� ��a
�� � - /�1�so�t ���L" �
� o�_ /�'Zi t'1�i
______
,p��.. � Well Log
e �- Tax Map ���� p� # ��o
I.ocation: �r 1 ,__,_�
�
StYbdivigiur.: - - � _�.
I.Ot ii
Well Conitructioa
Distance Frvz� n+�rest Pruperty Linc (Minimw�u f 0 feet) ___ ! U��
I7istance fzam �e7pqc System (Minimum 60 fett) ,..._.i�_
Totai D�pz�h: I�_ ft Yield: _�� GPM Static Watcr I,�vel: ��^ g
Water Hearing Zar�es: Depth _17Q ft ft ft
C'aala�: !� 3
Deptb: From to `
.,..�,�,_. ft. Diametxr• � in
Type: Ga�lvanizCd Stecl
1�'eaght: � ) � �, 'Ibicla�ess: , �� . , Height �bave Cmnund: � r in
�ive Shn�: _,_ �,,.-�Yes NU Any pmblrnas enc:ounterCci whi]e settivg r,as�ng? �Yes �--i�'o
�f "y�s" give re�san•
Grout.
iVr�t: Saud/Cemcnt Canc�et� GraveUCenotat
Annular Spece Width ,�_ inc�es Water ia Attnular Space r Yes No
'.VlCthor! of Grout: Pwnpe� ..,�...,.. Pressure Poured Depth to �
'_'�ktrrials tT�ed: _
No. Bag.s Portland cement Wcight of 1 Beg _,__� Pounds�
If m.ixtcue (sand, grav�l, cuttings) — Ratio to
ID plaus: .____ Yes ____ No 4 x 4 slffib � Ycs � No
Drlll�n� Lc� L�tion Drawing
Fk
� hereby cerar'y th�.t �is� above informntioa ia correct and that this wall was canswcted in accorcfance v�rith regulations
s�t fart� by �he P�'rson County Heaith Degartrnent.
Si�auture nf (.'uatrxctor � . __1�� � IL � � �� Dste _,�," �� G�
' �y'�?�� PCHD rev t�1/16f02