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A33 15Y M The District Health Depar ent Orange, Person, Caswell, Chatham, Lee Counti Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No � Date �– � Owner: '� �• � Location: � �� .�� Contractor: � �, ^,s,� �--� Water Supply: Private .—.� Public � i� M1.�,.�� Sewage Disposal Facilifies: No: �edr washing machine.�other automatic appliances �� • . �llJ Size of tank: ��ti ��.�� Nitrification ��\..�JC-�-{ f Other disposal facility: Dishwasher, Disposal, , _.� _ Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and 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 ANI} AP- PROVEI} BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. a \ � �+ ^t, Date approved: Signe ; �r, �� 9J.,U,,�� Sanitarian Well: Sewage Disposal: By Counter- sign� (Owner or his representative) Certificale of Completion � r� �' � . i �, �, ; �\'- � �� .. � � �� Date Approved: � � � By: ' �'��`''`' �' i `� - ��M Sanitarian (OVER) 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 applies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located t later date. Note location of water supplies on adjacent lots. � ��) � 1� � >�J �2� .� � �� .T i n � �.,,'—�.�,� I r, y��- �� -�oy �� -�,�son County Health Department Well Permit Date: '�-5- 9-3This Permit Void After 3 Years r �: s� l'� ��•�� S1t# /3z 3 Owner• /— �L, �, , < <3ae LocadonNirecdons: . - - . _ , „ . . . . _ WELL CONSTRUGTION / Distance from Nearest Pmperty Line 3o Distance from Source of Pollution �/ `� o -_ Total Depth: oSFG Yield: �_GPM Static Water Level ___{�Z_Ft. Water Bearing Zones: Depth Z �,to Ft�oS Ft. FG Ft. Casing: Depth: From �..r to 3�L FG Diameter. �_ Inches TYPE: Steel � Galvanized Sssel No If Steel, does o approve: Yes •� Weight: Thiclrness� �� v Height Above Crround: �� Inches Drive Shce: Yes vj No Were Problems Encountered in Setting the Casingl Yes No_� If "yes" give reason: Grout: Type: Neat Sand/Cement �� Conczete Annular Space Width � Inches Water in Armular Space: Yes No t/ Method: P�mped Pressure Poured � Depth: From �n to �_ Ft Materials Used: No. Bags Portland Cement �_ Weight of 1 bag �Q_ lbs. If mixture (sand gtavel, cuttings) - Ratio: to ID Plates: Yes � No 4 x 4 slab Yes t� No � � � � �e 'o � '� c� I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECf AND THAT � THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATTONS SET r; FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. � p �� ft Sign of Contractor Date ��.,-:,D ��-- 9- �s-�3 Sanitarian's Si ature Date Issued Sanitarian's Signacure Date Completed Sketch well location on reverse side. .�� `��rson County Health Department � Well Permit � Date: -� 's Permit Void After 3 Years r Owner: � _ .o� ��;�,�,`�-�- C i1 v1�!`. �1SR# �� Name: # Drilling Contracwr. � WELL CONSTRUCTION Distance from Nearest Praperty Line //_'� Distence from Source of Pollution,�r%l� Tatal Depth:��FG Yield: �_GPM Stadc Water L.evel L�. �FG Water Bearing Zones: Depth s b Ft Ft. Ft. Ft. Casing: Depth: From � to 3 � FG Diameter: ,9_(7, '�_ Inches TYPE: Steel / �' �Z' Galvanized Steel �� If Steel, dces owner approve; Yes No Weighr. � Vv Thiclrness: •� HeighrAbove Groimd: Inches Drive Shce: Yes No � Were Problems Encoimteced in Setting the Casingl Yes No If "yes" give reason: Grour. Type: Neat � Sand/Cement Concrete Annular Space Width 't Inches w� �► a,�� s��: Y� xo � a Method: Pumpod Pressure Poured �� ' Depth From � to 3 o FG Materials Used: No. Bags Portland Cement �'',__ Weight of 1 bag ro CT O lbs. � If mixture (sand, gravel, cuttings) - Ratio: 2 to 1 ID Plates: Yes � No 4 x 4 slab Yes Z No De th From To Formation Descri tion a 0 b c� . I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � 'THIS WELL WAS CONSTRUCfED IN ACCORDANCE WITH REGULATIONS SET ,.,; FORTH BY THE PERSON COUNTY HEALTH DEPAR'TMENT. , � R.,� 62.,.,,,� t� ��,� /�� ,[�a��r�� - 3 �'%a�'� j�A Sign of Contractor Date 80�J- s72- 7osG � � ,� _ n � Issued ' Sanitarian's Signature Date Completed Sketch well locarion on reverse side. 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. Note location of water supplies on adjacent lots. � ? (1) �2� .. ■��e��■�■ ■��.��e■ ■��■��■ ■��■ ■��■ ■��s��■ ■��s�■ ■��■ ■��e■�� ■ ■�� ■ ■��■��■�■ ■��■�■ ■��■�e��e�e■ ■��■��■��■ Appiir.ation Date: l 0 oZ �-'Q 2— Amount �aid• �� Rec�i t�#�. � 2 � 3 � �� -��- �� C � �T1��`�Y" ��-a.a-�-�-�- -�-�-� .o�.�� .�.a��. Tax iVIaQ #: .�� Parc2! �: � � APPl.ICA71�N Ft3R SEiiVlC�S � IF �HE INFORMATION IN THE APP�1CATtOf�l F�R AN IMPRO�IEAAENT PE�MIT IS INCORRE�'i', F�4LSI�iE�J. Ca-lANGED OR THE SITE 15 AL'TERED THE3M iHE 1MPROVEMENT PERflATt' A1�ID AUTHORIZA'i101d TO CONSTRUCT SHALL BECOME INVALID. � p b 6J a,l � aCs� - 3`�3 -� Z Z-- � 1) Pertnii requested by: (�wnerlagentlprospeclive cwne�j: � 2S� S� i� "` `, Home Phone; �• Address: 1 10 - e Su- S� Business Phone: � 9 5- I � 4 Se ntio Y-a N C � 73 4 3- q� � S 2) Name and �ddress of currer�t ov+mer 3) � Property Description: Lot size: 1� °2� Township: �-u^� �' N ubdivision: Di�tions to the property (lnduding raad names�and numbers): �• � _ � Lot # 4) Propcsed Use and Structure Desaription: answer eacii af the fpllowing questions: a) Proposed _, Existin9 �! TYPe of Structure: �'�►urCJ�.�— Width: � Qe�th: b) Number of Bedrooms: Number of occupants or peopie to be served: ��q,�. � - c) Basemer�t Yes . No _ Will there be plumbing in the•baseme�t? d) 6arbage Disposal: Yes . No _ . 7Q �1 eo P�� 5) Water Supply Type: Private �ew _ or existing�. Pubiic . Cammunity� , Spring . Are any wells on adjoining praperty? Yes fdo _ lf yes, piease indicate apptvximate locatiari on the .site pi�n. � � 6� Daes your property c�ntain_previousfy ideM3fied �wisdic�iona! wetlands? Yes_ No Pt.�ASE NO'TE TFiE FaLLO1NlNG: ➢ A PfAT OF THE PROPE�2TY OR SiT+E Pl:4iN MUST SE SUBM1TfE� WtfH THIS APQ�lCAT10N. ➢ PROP�ti LINES AaVD CORNERS MUST BE CLEARLY MARi�. -, 9 THE PROPOSED LflCAT10N OF ALl,. STRUCTURES MUST HE STAKED OR FLAGGEH3, 9 THE SITE MUST BE RE�►DILY ACCESSIBL� E�R Ai1t EVALUA7]ON BY THE HEALTH DEi�ARTNiEiVT STAFF. I herel�y make appiic�tion to the Person County Health Deparlment for a site evaivation for the an-siie sewage disposal system for the above-described property. i agree that the cantents af this application are true and re�resent the maximum facili�es to be plac�d on the property. I understand ifi the site is altered or the irrtended use ct�anges, the permii shali becom� irnalid. Cwner o� Lega! Repces�tative �_� � Date PCiiD, cev. U6127/02 ��, ; ,�f �� . � � � �� . . I��aa-��.� ��.71 1E-3I��:71�]Ila Applicant: Location: 0 T��x M•�,E� � Parc�l # S�uhc1'ivi�sion � Fh�a•se Sect�ion Lo�t + . � � �� 2- � Improvement Permit -- - ` Permit Valid for Five Years No Ezpiration + Ex � 5�� ^-� Type of Facility: �' i,� , i n� C� u rc �► New Addition Water Supply (,J c. I I # of Occupants ]�_ # f Bedrooms �1 !R Projected Daily Flow �s� g.p.d. � � Proposed Wastewater Sy}�tem: � Type: ProposedRepair: (�a�cLvi iv �nnvu�`�� CaS%o 2zdu.c-�r'on) Type: Z�I� Pernut Conditions: �n �-Ea l( Sy�Stc rn i�� a rca- 6�o �.a n. =n,� izi 1 I S v�S-Ec r� O n _ /tnn�f'!)c.�r . nrn�,�.f� �r,-f-l�f f'n,�i�c nVU' c�raincL9c. ditC(� erLdS. � � Owner or Legal Represe ta e i ture: G�-- . Date: �� o�:-�D� Authorized State Agent: Date: / � —O� The issuance of this permit by e Health Deparkment in does not guarantee the issuance of other permits. It is the respons{bility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met Tlus Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. � Authorization to Construct Wastewater System �Required for Building Permit) � * See site plan and additional attachments (�. 4 Proposed Wastewater Sy em: l� �aU i{y �/t r► � �tt-Ei v L Type ��_ Wastewater Flow c�� g.p.d. New Repair �Expansion Soil LTAR: • O g.p.d./ ft 2 Type of Facility: ,�1U, rc.� W/ /�i �G�.c�'1 ,_%(�, Sc�a.: r�, Basement _ Yes _No Wastewater System Requirements Tank Size: Septic Tank: �Q(� gal Pump Tank: N � R gal Grease Trap: N/ �t gal Drainfield: Total Area: qo� sq ft Total Length�� ft Mazimum Trench Depth � in Trench Width Minimum Soil Covert l.0 in Minimum Trench Sepazation: �_ ft Distribution: Dishibution Box : Serial Distribution Pressure Manifold Specifications: ( p" �f cDOr'� cd eoU cr js f2�u.i�Z.d all�p" 5 yS�C2r+� �L�'cc�-� �r15�. � � l t i r�.l�i i n n/"� i`n C Ot, .� 4�a c.J n r -- Autharized State Agent: __�� Pernut Expirati Date: Date: � o�s O a The type of system pernutted is Conven 'onal V Innovative Alternative. I accept the specifications of the pennit. Owner/Legal Representative: � � Date: �� o�� a Z— PCHD7/30/2002 . �� ;; )`� �� m��e�� ' SIZ'E �B�TCI�i N e �%t.�3t,�.� gc�.Pfl�S� C'.�.c��2�► S � �1 Au�orized State Agent ,�,�� -iZ Ta� lvtap # 1�33 Paz�� iS � � Section/Lot#� � 1( a� oa - Date � • sy� ��o� �� apro�� y. The comractor must, flag the system prior be�tsn,� tha rnstallai�ion to insure thatpropergrade is masnt��red � s .� � �i IUOT� ZF Trcnt.h 9 ra� � d- d c p{�► Cu.r� nat bc /haint�i�cd � P�►vp Writ b� rc�uircd. Scale: n� �r� E c.,1�.- ��Rs � . �aa _ - _ � �- � l.�.Y'►CoUc � Pump � cR.uS �+ D� 5� T � �,urtai n �ra,jn '�'�dtQ� �, � I.�G �.Jowld 2c.comw��d _ . CICti.nou.� ;n �p� �� s'. S�oPt '_-� � ,�' ► i• i • � �� i ..�� OKGtP C�,i,r�a��n � d ra i n oi�' Frarn, Ed�cS oF 5c,�-�ic: Fi�cd. Kcc� ou.-e OF 2� p, W, 0 l,a.�d p�P�.: aw-�rt-�s, K«� �. �« a bo,�t �yrc�.d c Co�cr o�c.� ends. I'G�3D, =ev. 09/12/01 � � A��lication Date: �l �13`�li Amount Paid: �� Recei�t#: �1� Taz MaQ #• �33 Parcel #: � � ��`�� - - _ --_ � � �,TZ�� Y 1E�a�x��a.a-oaa,-�• maa�mll ��L�.m.IL�1l.a /1PPLICATION FOR SEiiVICES IF THE INFORMATI�N IN THE APPLICAi'ION FOR AN IMPROVEMEiVT PERMIT IS INCORRECT, F�►LSIFIED, CHAIVGED OR THE SITE IS ALTERED THEM THE IMPROVEiVIENT PERMIT AiVD AUTHORIZ�►T10N TO COIVSTRUCT SHALL BECOME INVALID. � 1) Permit requested by: (Owne �agent/ rospective owner): �� 0'1 0�O oal� �� Home Phone: - 3.3 �- S5 i�- � � 7 � Address: Business Phone: �.� G� s g3 -�3 % 3 � : _ B�P�:�F� 2) • N a m e a n d a d d r e s s o f c u r r e n t o w n e r. �� c. S C� u�c ti O S Ll� ic-1�� rn o �'� � 7 � �l � 3) Property Description: Lot size: 11 � S T.ownship: Subdivision: Lot # Directions to the property (Including road names and numbers): 4) P'roposed Use and Structure Description: answer each f the following questions: a) Proposed ✓. Existing = Type of Structure: ��on � -�o _�e//a.ds�l.�Gdth: .�d Depth: .3� b) Number �f Bedrooms: Number of occupants or people to be served: c) Basement: Yes , No �/ Will there be plumbing in the basement? d) �arbage Disposal: Yes No _ 5) Water Supply Type: Private �(new _ or existing�✓ , Public_, Community� , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the 'site-plan. 6) Does your properly cantain previously identified jurisdictional wetlands? Yes_ No ✓ PLEASE NOTE THE FOLLOWING: 9 A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARI�D. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTME�IT STAFF. I hereby make application to the Person County Health Department fo� a siie evaluation for the on-siie 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. Owner or Legal Representative I)-� 3-�� - Date PCHD, rev. 06127l02 �f �� J 1 � ��„r � � � �� .7rn.�n�rcmna.�rnn.��rn.��.� ��,�,�.t��n. Building Additions/ Mobile Home Replacements Tax Map #:�� Approval Requested for: Parcel#: �J` Mobile Home Replacement l�.J Building Addition ApplicantName: ��,,� �c�i�-� CI�I�YC�h Address: ' 1901 � �� hiam�, 2c� r �� Phone #'s: 599 - 1�i c� - �r�oia ��I-e,� Permit Located: �. Yes No Installation Date: �-� -�710 Design flow: (gpd) Current Contract with Certified Operator on file (if required): N �A Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: I 1 � I 3l (date) (Applicant's signature if site visit is not required) G� c '� 3-�� • - � f r � .l " �l �► � �f )� � �t :�i. t ♦ � �. l• : � � � � _ Addition/Replacem�nt Approved �� f� Environmental Health Specialist 11/15/OS 1 � �i310� Date � � � l � ` a � ��.� � � � � �.J � � � . ��n.�n��nnn�nrnc�n�.��.� �c��.��n Building Additions/ Mobile Home Replacements T� Map #:�� Parcel#:�_ Address: Approval Requested for: Mobile Home Replacement —� Building Addition Applicant Name: D d re Address: � h Se ►,n n ra NC 27 �f3 Phone #'s: Permit Located: '✓ Yes Installation Date: � - 2�f ' 7(0 No Design flow: (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: 3- 2R -(�- (date) (Applicant's signature if site visii is not required) �� Addition/Replacement Approved Enviro ental Hea Specialist Date � r / Z Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www_personcounty.net Application Date: �� 3 �� Tag Map: q 3 3 Amount Paid: 7� r,. .-• �r �� Parcel#: I_� Receipt #: � C� ]��ravna-an�+m*o�an.d�.Il IHIaomIl�,�:Ln. Application for Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 endl ❑ 1�Iobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ WeU Permit (New/Re c t/Repair,) $3oo.00i$Zoo.o i$�s.00 �� N e l� Services Re uested � Construction Authorization Fee is de endent on the e of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: n, Name: �%1�S'�t S � �" i� vhu r� Address: 1 D L E a�e�u 5 C{ �, .� � 2) Name and address of curren owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone (home): (worWcell): _ Phone: Lot #: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? G� yes ❑ no Is any rvastewater going to be generated on the site other than domestic sewage? O 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) 4) Proposed Use and Type of Structure: ❑Residentiat ❑ New Single Family Residence Maximum number of bedrooms: � Expansion of Existing System If expansion: Current munber of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ E:cisting Well ❑ Cominunity Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? a yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I cert� that the information pravided above is complete and correct. I also understand that if the information provided is inaccurat�, or if the site is s�rbsec�e�� altered, or the intended arse changes, all permits and appf•ovals shall be invalid. Sign'�fture (Owner/ Legat'Represer * Supporting documentation required. ��-l� Date Permits are valid for eiiher 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. (10/1 I) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) 7/ `' - � . i r.►v � ��rson County. Health Department � � VU�ell Permit� � � -/:s- 93Thia Pamit votd At'Gtr Years � �� _ - - -. R,,:, �: s � �'� ��—._ _ �R� �'� Subdi'visiot� N��e: , Drilling Ccntc�csor: #� i .� � D�atsmce.fmnt Naasett Pmpeilji 1Lye "3�--' I)istsnce &om Sotttcc af Lyn PoIludon �:�5 O -- 'roial Depilie ..��Ft Y'�ola: ,_�...dPM' . Sta�o Water Lcvei �[+� F� Wecar 8earing Zones:. 3.$LP�� F� Ft. r G Casing: Depth: i�eom to • 3��• Diemeta: lnches T�E: �teCi . � Cia1V�lli7sd'S � If Steel, does ' 'approve: Ya No Weight: Th�ob►e�t' � � Height Above�Grouad: �—inchcs Drivs Shoc: Ya _ �r No Waro Prob2ems Enooi�taed in' Sening tke Casing? Yes No_ ✓ j( "yas" give ie�aa�' � .�/ Concrete , C}rout: Zj+�: Neat SandlCanei�t psu�ttj� Space Width �� - Inches . a Wesee' iat Armultr Sp�oe: Yes ' No_� taed .� . �e .. Method: �PumF+ed� --- �� ' - � Depth: Fraan �._ � — �—�— F� � ��Materiala Usad: No. Bags Postlend Cement ./�..:._ W�P�c cf 1 bag ,� 5't Q- jba, � _ • � if mixt�un (aend� grai►.el. cuttinBs) - Radot �� .m �-- ID PL�ei: Yes 3� No ' .. .• ' 4 x� sla� Yes ._�=Ne � I. . I �IEREB.�CiCERTIIiY 1•iiIS� WBl:T. WAS•C� iMORTH�BY THE i� i• . . . . .. ._..i.._ : , . -.. , . .. . •7 � � ��F.oanatiCn.Deecx's �acn ' . . � • ' t , , . . . � .. . . ... . ;: . � c �ts ABQ��o�'rtoN is�coRi�rr �n�tpiT � RUCTB,D�II+�;ACCOItDAI�C'B,}1V1TH RBC3ULATIONS;SET' � G�OUN'1'Y HBAi�TH.I�B��RTk�I�I�'• • ' : ;: • k 3 :��Q.R. I . � ' t._.• '._!. - � , �. .:. .. ' . • • -•t•. . , � �� Si�it� l of'Contraciar ` , : Date . . . - -;..y �,:� . �, � _ " 9_ is.� 9� �n::-.� c�� - _ _ . .. ---S�taii�i's;:S' iuie; ' Date tasucd . y. , �c r; _ � • . � `y, l' .. .. . . � • � �..�siiimn�'m.�3;rgaenue ' Date�Complet�ed Sket�-.h well'locetic� on revetst side. ..: •� .,_:�e � '� � �" � d�' _ .n �> >, a. � � o :� � � .. � � •y « 0yR1 .G N � � � o � � o � � � � � � �C � V1 �+ .-Qi '� ,r.+' � c � � o, � � ^ � � r � ~ O � O + � "'a o « a A �M N � °' w o � � � d � � � Q � �+ C LL R � e � o •� � � �' � , C 'a'' O N o �xz d � a � � N y � "�" � a r? a � � a 't�erson County Health Depar�ment Weli P�ermii .��Permit Void AfDer 3 Y�s r_ t� C �,�� `G'�' t1t/i�C:GISR# ,��_ z w � Subdivision Name:.,�►t�l�V Y•ot #� L�Y�[. " Drilling Contractor. w�t _i . CON�UCi10ri Distance from Neacest PropertY Lin$-�� s�� &am So�ax of Polludon Tota! Depth:��F� reld: _��GPM Static Water Level �_Ft Water Beating Zones: Dep:h 2 F� Ft FG � Ft Casing: Depth From �- �.3 d FG Di�meter. � Inches TYPE: Steel � Gaiv�d Steal 1f Steel, does ownes approva Yes_ No Weighr. �'�clnmess: - Haght Above Ground: Inches Dtiva Shce: Yes No . � Were Problems Erxrountered in Scuitig the C�ing? Yes No lf "yes" give reasm�, Gmu� Type: Neat ±� . SandlCement Concrete Atmular Spaca Width . Z— Inc,ities � Water in Armulra Space: Yes N0 �Poured �� Methad: Pumped Depth From �� —�� Mataials Used: No. Bags Portland Cement !�^ WeiBhc of 1 bag ,� �_ lbs. � If mixture (sand. gravel. cuttings) - Ratio: � w ! ID Plates: Yes �� No_ ` d . d �tAt, Yas � No � ` � � � I HEREBY CERTIFY THAT THE ABOVE WFORMA'i'ION IS CORRECT AN� THAT = THIS WELL WAS CONSTRUCTED IN ACCORDANCE ti'VTtH REGUL�►TIONS SEi � FORTH BY THE PER50N COUNTY HEAL'TH DEPARTMEIv"i'. �_ � f� L`7 l3�•,�,u �. Na/.�x� 1A 8py- s�z- yosc ' Contracto� j - Due : � `� Sasu�'s Si�su� Date Comgieted Sketch we111ocation on reve:se side. f Appli�;;ation Date: /�/� �; Tax Map: �/ �_ Amount Paid: .� �1,o Parcel #: fS _ Receipt#: � �yZ�� w� ��,� �� rf�/` `_., = _ — c� � T�.�� ,�x �� a ZL. � ��n-.v �i �u �ca :u_a �x�n. <c# �rv zf .,zn �1 ).r 3_L a-+.,=a �i �1��a �i��/s Application for Services (Septic Systems and Wells) Services Re uested � Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 g d) (Fee is de endent on the ty e of system ermitted) O Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 ell Permit ( placement/Repair) ❑ Repair of Existing Septic System $300.00 $200.00 $75.00 No CharQe n 1) Services Requested by: Q / � Name: L' f, e 4S !JG r i S i C�u�c Address: /�6 L" �heSyS L��u�cti �d a �3ys Phone # (home): .3-3� � S�S ' l° S" (work/cell): � .3�0 — �1.�" ��"�3 X 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: �� Subdivision: Lot #: Address andlor directions to Property: /�3 c� �� C�j�1',1� . 4) Proposed Use and Type of Structure: Residential Business/Type: � Other � h �i�-�^ Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � ` �G��`tX'/ Garbage disposal: Yes No ,, ��G � ��y� /l��i� � lf/� 5) Water Supply: ' 9� G�i�f�i�1 ��O�Sf..� u� Private Well (Proposed Existing _) : ��,�U�1. ��'.Pltl�%� �j�n�'� Community Well: Public Water System: ,��f a��/ 0��j . Are there wells on the adjoining properties? No Yes (please show location on site plan) ,� Note: A comvleted application must also include: ➢ A pladsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' fo�•m verifying tltat 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): ��-r�T�u D G✓►i"`1 Date : � ��' �� 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��.sf ��.�� —= � � � �� 7��.�a�-� ��.��.Il IHL � �►.11 �1� WELL PERMIT (New �/ Repair� Tax Map: �?�� Parcel• l s Subdivision: Lot: Applicant's Name: C - Mailing Address: b,+.. Phone Numbers: r��- ID,�rD �45��,,�T_ Location of Property: �� p,.�� `,� [',�� t�. �-T Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. Other Conditions/Comments: - Permit issued by: � Date: � �� CERTIFICATE OF COMPLETION New Well Inspection: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: EHS/Date � p .�/ y. �r �� Well Driller: �'i/iy,�/y Pump Installer: Well Approved by: Date Sample Collected: // O Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: �v Q n 5 Depth: !d0 Grout: �- (�- � � Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date: i! Date Results Mailed: �'"Uf 2c, o Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 Nov 13 09 09:27a ��'Sf `�' `.�"""'��" 4�;'�`'�. � ' ..:;� -:`��':��"�`:�.�' ''�a`�"''r�'m�'ra.�cxaea.ara�.sr.]f • �3�r� .��: • � �"' ��.. ' - -* � .,� . . �, .i t / , ,. „ .. �,e�l�'i',�'s��; �.� . . ! • ry • p.1 �� o , � ��-� „1 r�,�� (� O�J� �l.�.f2}, . . - ut L,og _ T� MaP ,�3,.,3 ParceI # 15 Distancc F:mm �tarest Pro '�'�!1 Co�L�atdioa nisrancz $�Om �Y Line (Miaimum• 1 o fe�c? �ln Sq�tic Systam {Miai�um b0 f g e t) __ � sZ """""" Total ]7epth: ^�� ft Yie1d: � C� E' s PM � Static QVatar Lev�L• tiVa#er Be�tiug Zones: Dop� i� �^'�} �r� � fo o ft L�� @�— � �+I4 i �� l � Cswing: � , • . Depth' Fr'°Rn-__�__�. � ft. Diamdacr; L.� in �'YPe� �nized Si�I � - � �1'Velg� S�, L Thic3ctte�s: �p�,� �ght abuvc C�round:. � Drive. Sho� Yes �No AttY Pzoblems. cncotm�e'.t�d vvhtie eep�n c' 2 "yes�� give reas�uu: g �b Ycs .✓�u Gra�t:' • � � . Nca� �,� SandlC�inen# ��Co�nc�rotd Asu►ular Space Wicim / t� `' C�avelfCement. ivt,�tthc,d of Cncx� -�---"_ �r� 3Na �e Aamular S��Ca �- No Msiet�inir U9ed: �� . �"�. " ' °� �� ,.� _„ to � ��, Y�aer: NQ. Hags PottIattd cr.meat„___ �n _� �PVeight oi 18ag 95� �ou�tds Xf miztvre (cm�d, gr�v�, cutbngs} - Ratia�_ to ! . ID platcs: �Ycs ,� No 4 x 4 alab?Yes _ N� �� , . � Ilate lnatalted: ��^ Crrou� ilrilting Log �st�led by: 7.�►catiuu D.r�wittg �C� «..c,rt. � x cht+R � -._" ' �.,J'.. F N n \ . w � i hefCbY ��Y t� tb0 abave iniD�y8i2071 t8 co[nCCt � 1�13t �115 wC[j WBB CQOg�C� Ld BOCo[ . . � � P�on Caunty Ha�#� neper�nt. �acc with regula�ioua set f�t s � t SLgaatuEre o�'Contr�cto�r� • ' . , . � � �=�- 9 DAt� //' i� - �i � - - Pru�np rnat�llmeat . �mp Installation Canu�sctor, � � PutnpDepih; $ staticWaterie�vel• State�.�atratic>n1Yu;nber; �F �ks �& Mod�I: Pump �ize attd Ra,ting; � . i herehY xrtify �si this _ ""—�� - ou thfs date aud thet a capY� �$ �.ca�rd. h�as�bes�n� Q il heed �ompteted accor�ng to tha �Feraoa Coum.j► We� Rules in affect 3�' �cd to thc well owaer. Put� �ast�tler �� . . �� Jt►d Qz1IIsN3 1.1Nfi1� Nr'�1� D:dC: � PG�ib rev 0 i127lR4 nnn..�..��_ ' ..I' , i '`Y� t , �' �.�,' .`�'tihL�^' C ( s .� .r, ":, t 1 � "x L -.+ � 4 .r x � ,��, .- � ,"^j+- � i 7 � K f' • $. > •'Y 7 �ti;. -0" 'H' ' � - t y Y �* �. f:. , x. f arn' i? . �'i y `i Y � n"-♦ t II`�' .i��• a, i'� x �- �,,� �. r . .�` ._. .. i�T'.:'i f '7� ,...� . �c, .__h . e. 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Y -� � �',;r t( p �i. r .� r '� �� H cl CD � -� q � �; �� , � = X �y., � ; � ., �, s r, `� e �. t x �t�• �ay. �' H fr � ;��/�., a `�+1� . iJ � � ' } 9 f �a,� � �-I S x � r e� � . ir `i O -G� k� ��'� �C s � x .(Q �'t ' � rY C � .°, a. ;-,th t1 ' �:g � �•„ t (�' p , � �'"'� � � � y� F �\� •, � t � � ` ,� a 1 n n', -_ w� ' t � � z �. y .� \� � � � "�_ . . �� 1u _� sk' � L�i1k r s,� : , •�r'�' � �� ^ � t"' '+ � � � Q � � s { , � t ,:. d t_ �� ( r� � C7� " r� C! � `I-1, ^y; �` � .� � �- � .��Ye`V� { vYV' \ �. $ r lr� ..M � ` yt �h ef 'ti- � , R. `' . . , . , ,, . , , ` �, u ; p .. . � .,." r ' '> . �- . � ♦ A , �, y : _,, . ; t � � � � � � � E ' "' � � f-F - � � � �' j�� ♦ �� ?;x�.,� �A', r .�1� � � iT� d 1 y ��y n.. ..t.� .a� �� !1v+. �� `�� ._.:ir�. .-Y�� F �� .�'� . � J :� X � � :�� ` � ^ L �.,,� +r� /� N. � '�� ,^ , �/'� a.'� � 1 • � .-$.:� ,�f"' � s , ;' � -�`j � � �, �, � ' « ,. �, r .,. i : ,.. , . :-�: ,� z , :R �:: �. � .` �.�. �� ,w t ♦ �^ Vl w�- (� � ' (�` � •;,.' `\ + � � �rr� .: , I`1„/" � � � � � L..3 `� ny`�' �V� `c � � _ a • �.��+ Y� ! � ,i �I� � A�� r ' } ,... � fi"+' ^ �� 11+ � � � � �� +��/� ``+ � � u �� ,:� � `SRw� . . � ♦ ti �:� . 4 } . ,0� i . v-V^ cn -Jy,11' � � x \ � � � � ' ` " � f-- 1 1�\\ � IT . ` ,��.A VI �� !� 1 M 1 � , �� 1 �µ .id 2 �.: � '�.9 � I � ,� � � -`' . �� 'M / A 4.-� \ . . 7 �l�3 � � I � � t � J w � � � ��' �. �`�� "� �� .� " �� "� i , ^ °� '1 '� � t - `.�.�. '� �µ � y� , ; ��' t �k,.v.. �° ` �V v . l" ' _ t � t � fi � � 4 _ r �' � rn t �, `. � -. . . , ; 4 , . ,ry � t ez �r c.-.` ,C { �*.':. � • . _ . . .. � U6} `� {1i 1 a t � .- .. . . , � . - .. �"� 1, a y� A�-. i� � �: r ; > ,' � l � .'v 1� k ' �^xf � . ,. '��J � 4 �l ::y�iA� �,N � i t � � ''�• .� 3'�� v� tn .�r `5 i d�.:. '.. . , . . . .. . ;Q..\�S� . - . �., 07`� . F+ ^� �'. .Y�� . ,, t ... . .;'21�. A �• Applicatiou Date: Amount Paid: Receipt #: ` � -�a "�-� �� sf �IEI�.��T �oo .Od �--= "�" ��TI�T�� 171.26j IE!.rra�a>n.n-cn4nv.xaees:�rn.G:�.� �jao.e�..�.�.;ia. 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> E(1Q gpd�_^__ ❑ Mobile Hame Repiacement or Building Addition $15U.U0 if site visit rec�u_iredl � Well Permit ' placement/Repair) $300. /$200.0 /$75.00 for Services Tax Map: /�3 3 Parcel#: � F� }0 � , � ; \ � �anti � c�-�-- Services Re uested ❑ Construction Authorization __� (Fee is de ep ndent on the type of system permitted) ❑ Permit Revis�on _ $75.00 � Kcpair of E�isting Septic System Application: No Chargei CA $150.00 or $300.00 ) Applicant Information: D Name: � /�l� e5� S p ��o� ;S-� G %i �-ciC � Addres�l�6 � 2) Name and address of current owner (if different than applicani): Name: Address: 3) Property Description: Lot Size: _ Subdivision: Address and/or directions to Property: /Q °1 � _F Phone (home): 3 3 G- I-/O �I o (work/cell): �jC �!/ P'��4G��/' �8" �12- 3; �� ,�y cG�,� Phone: ❑ yes L�fio Does the site contain any jurisdictional wetlands? �s ❑ no Does the site contair. any existing wastewater systems? ❑ yes i�o Is any wastewater going to be �ener�ted on the site �iher tl:an 3crrestic sewage^ ❑ yes L�nu Is the site subject t,� appraval by any other pubiic agency? ❑ yes Ca n rlre there any easements or right of ways on this property? (if `yes' is checked, plcase provide supporting documentation) 4) Proposed Use an�l Tvpe of Structure: ❑Reci�entia� � ❑ Ivew Siii;le Family Residence Maximum number ofbedrooms: ❑ Expansioi� of Existing System If expansion: Current number of �edroums: _� ❑ Rapair t� ivialfunctioning System Will there be a basement? ❑ yes .LR�o With plumbing fixtures? ❑ yes ❑ no ❑Nun-Residential / Ty�pe of business: L`i �r�� Total Square foota�e uf Building: . Maximum tiumber of employees: ! ` _ Nlaximum number of seats: /> �) Water Supply: ❑ New well ❑ Existing Well ❑ Community Vvell ❑ Public Vvater ❑ Spring Are th�re any existing wells, springs, or existing wzterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization io Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Iru:ovative ❑ Alternative ❑ Other ❑ Any I certify t;zat the information provided above is corzplete and correct. I also u;u�'er•stancl tlzat if the inforrnation provided is ir.accurate, or if the site is subsequently altered, or the intended use changes, all pef•,mits and approvals sdtall be invalicl. /r � � -/o - �� /.3 Signature (Owner/ Legal presentative*) Date '� Supporti,7g documentation required. • Permits are valid far either 60 months or are non-expiring wheu accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site e��aluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��, ; � �� V�1, � � �� c�-.�."11�7L7P am r-n rmm �a.��.�.11 IE--3I� �.11 �.1� � W�I.,L PERNIIT (New Repair� Taz Map: 33 Parcel: Subdivision• Lot: � . Applicant's Name: ' Q Mailing Address: " � 2 � Phone Numbers: Locaiion of Property: l ' � I�y"C , PePri1l� G'OltllliY0i1S: 1) Seg attached site plan for proposed well location. 2) Add applicable State and County regulations governing construction and setbacks apply.� 3) Permits expire S years, f-om the date o issue. Othe Conditions/Comments: A � u ' � . _ � � �� - � /�-� � --L._. t ��1 ��L -� •-� �' - - ..._ � • ,_ .�_' ; U ' P�rsnit issued by: ,�, � I)ate: Z-�-/ 3 CERTIFICAT� O� C01dIPLE'�Ol�i New Well Inspection: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Well Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: E ��ate Installer: f�►�arlsrrE Depth: � � o' D�A s Grout: P��o -Z� s� �3 �� Well Abandonment: EHS/Date Completed: Method/Material(s}: License #: License#: Date: Date Results Mailed: '' Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 �� i ) � � )t A�� .. .. . �� Jl � T�f;a-n.�a�� .�.�.��..Il. ].HI � �.]l �Ih�. WELL PERMIT (New ✓ Repair� Tax Map: �'�� Parcel: �,t Subdivision: Lot: Applicant's Name: — / Mailing Address: � Phone Numbers: � ��i Location of Property: � �7i,�rL'Z�� / �/ Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. Other Conditions/Comments: � �('� Permit issued by: _ Date: !o� �� CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: i�qs zi r3 Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: ' Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller• �'r�v� License #: Pump Installer: License#: Well Approved by: Date Sample Collected: �� 3 Person County Environmental Health 325 S. Morgan St., Suite C� Roxboro, NC 27573 Date: /,3 Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 ConnectGIS Feature Report �j��V$ ��''/""" /�l� �^�'�� /J Page 1 of 1 ' /�q� E��cr�� V�� K.(/' ��I /� 1/�'tZG 1��% � NOTICE: Recently, we have had several users report browser compatibility issues when trying to access ou users who have recently upgraded to the Windows 8 operating system or a new version of Internet Explorer to the Internet Explorer Compatibility View tool. This link is to Microsoft's "How To" for the tool: http://windo�n 9/features/compatibility-view If this does not solve the problem feel free to contact us at the number listed on our r Website. ConnectGlS has been prepared for the inventory of real property found within Person County, and is cor records. Users of GIS system are notified that the aforementioned public information sources should be consulteo Person County, Mobile 311, ConnectGlS assume no legal responsibility for the information in this system. Grid is NAD. £PHc�tSS �Y�3�� c �('. 1� f: 3� " � ��a ,;.� tt�� -J iTS1 � ��,f� ; r �t'f ---,---_,_.".�`_,_--� �y,a ri .f !��tti?'� , ;� 3: � `� � �,�..,.� `� � � r � .,. � .. �- - .. '' =e,^�,�.. . ,�`-� tiJ�h,✓��rn/ 9u S��G� �„/�/ 4►��o•✓S Ca�/�'�� ,��" ��' �sg�-��o .. -�.7.. ." F: � ��n c ��t-�,� :�. �^'s . .... � . �� + L�� :. M~ . ti ,. � Perss�;£;ounty Ernironmental Health 325 S. Morgan Street ` sas Slll�B Ci Roxboro, NC 27573 � i��3 � i535 G-}��c��' � .�:,�.;; ., '`i�.cs . i�..x:`"s r �Qy.:N ' �it. � n� � i= '" 7A91 �� : �oo �e�t ' ,.��t,µ ��., http://gis.personcounty.net/connectgis_v6/DownloadFile.ashx?i=_ags_mapd983ec37245a4... 6/11 /2013 l�,sjD,EjV�j'IAL WELL CONSTRIICTION RECORD North Carolina llepartmem of Enviro�nent and Nativai Resouic� Division of Watea Qualih' WELt CONTRACTOR CERTIFICATION # �� ? 1. WEL1yCON7RACT0� I � . ./r� ..� wp�t,cont c�nrnndnridua!)Name Contrador Company .`� ...�.� �1�. �7�7� Cihl or'I�wn " �� -�7d� Phor�e number Z WELL INFORNIATION: WELL CONSTRl3CTION PERM(T� 07HER ASSOCIA7ED PERMtT� aPP�) srrewEu.. �n��'(o•x !`'r�,,� /1 �3 r�-•� �:� � 5 3. WF1.L USE (Check Appiicable Bmc): Residemial Water SupP�Y t� DATE DRILI.ED�� "�`J � ( S . 71ME COMPLETED `i � O C� AM ❑ PM I� 4. WELL LOCATION: cmr. cour�rv p��Sv n 1 � �'i �P� • sk,� C�,�,..ic�. r�� (Str� Name,�t umberS. Cortu�autY. Subdiv�sion. Lot No.. Parcet. T.iP Code) TOPOGRAPHIC / LAND SETl7NG: {d�edc appropriate bmc) ❑ 5bpe O V�Y ❑ Flat p Rid9e OOther LATiTUDE � �' ` " DMS 3X.�OOOC)OOC7C DD LONGfTUDE 75 �`� • ' ' DMS 7X.)o000000�c DD Latihxie/longitude source: p�PS pTopographic map pocafion of we/1 must be shown on a USGS topo map anda�lac!►ed fn this fionn ifnot using GPS) 5. YYELL OWNER �e�.cs� c �rn i t.� w,�c�. - er Name o ('�i� ��.eSuS C� rtvl Street Address C1y or Town State ZiP Code Are� a �eCod Ptwne m�mber 6. YYELL DETAIi.S: a TOTAL DEPTH: 3 Z� p, ppES YyELL REPLACE EXISTING WELL? YES ❑ NO p �. wA,� �. s�►T� �c�: 37 Fr. �•+ if Above Top of Casing) d. TOP OF CASMG iS � Ff. Above L.a�d Surfa°e� '�roP of c�i� tertn;�atea aua b�a�r lana s�,r�e mar �q��re a variance in accordance with 15A NCAC 2C .0118. e. YIELD (9Pm�: � METHOD OF TESi' � f. DiSWFECTION: Type ��'� Amour�t i�n�� g. WA7ER 7ANES (depth). �t,� Top,'�v5 �ot "'tcm_"`�'�op=�—B�tom�.�'�.- Top gottom - Top B�tam Top Bottom Top Bottom Thlckness/ T. CASING: Dept�t �� Diamet,er Weight Naberiat Tap •t 1 Bottom�Ft b I�� I Y3� .s �,° Top Bottom F�- Top Bottan Ft 8. GROtIT: Depth terial � Method Top 4 sottom o�OfFt rG � TOUQ Top Bottom Ft .�i4A� T'op Bot6om �- 9. scREEN: oeptn u;ameter stots�oa � Top Bottam Ft- m- �- 'Top got{pm Ft in. in. � T� g�m Ft, irt. in. 10. SAND/GRAVEL PACK: pep� Si�e Material Top Bottom �- Top gpttpm Ft Top Bottom ft 11. DRIWIJG LOG Top Bottom � / S o � so � g_/ i. �. • y;�_I 3 Z - / 1 / / / / / /�_. !�_ 12 RENAARKS: FoRnation DesaiPiion b� !�; �' /�P�,i'�tn C�t G� G-r�, � I' f�n �'J� I DO HEREBY CER7IFY 7'HAT i�i1S�lYELL WAS CONSTRUCTED IN ACCORDANCE Wf7N 15A NCAC 2C, WELL CONSTRUC710N STqNpARDS, AND THAT A COPY OF 7HIS RECORD HAS BEEN PROVIDED't�0 THE �! �I OWI�IIER �' -�'�.� ,.; �i � r�nrrRaCTOR DATE OF PERSOiV CONSTRUCIINC'iHE WEL�- Submit within 30 days of comptetion to: Division of Water Quality - infortnatien Pcncessing, Fortn GW 1a � ,,O ,..Q. . .., . . . . .. ..p . . • North Carolina Division of Pablic Heatth . Occupational and Bnvironment�l Epidemiology Branob, Epidemiology Section • INORGAI�IIC CB�NIICAL ANAL�SI3 REPORT . prh►ate weD water informaflon aad t�ecommendationa Coun . ,PrVf° Nama: '�*�"J � �� SampleIdNumber: �� l�f� . � tY' Location: Reviawer �"�h � ANALY8I8 YtEPORT Your well water was tested for 15 metals, Plus nihates, nitrites, aad pH. The results were evaluated using the feQeral drinldng water standards. The pH is a measure of the acidity of the water. Drinking water may contain substaaces that can occur natmally in water or can be iutroduced into the wat� from manmade sources. TE$T gESiTLTB AND USE RECONIlVIENDATiO1�S ' Your well water meets federal �n�ng water standards. Yonr water can Ue used for drinlang, cooking, washing, cleaning, bathing, aad showering. . . The following sabstance(s) exceeded federal drinking vvater standards. Your water can be used for dru�lsing, cooking, washin�, cleaning, bsthing, and showering, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may accur. You may want to install a household water treatment system to sddress aesthetic problems. The following substance(s) exceeded federal drinking water standards• We recomm�nd that yo�r well water aot be used for drinkiug and cooking, unless yau install a water tc+eatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing and showering. Re-sampling is recommended in months. :� f R�sample for lead aud /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 detern�ine the source of the lead and/or capper. OTSER CONBIDERATYONS Routine well water sampling for the above substances is recommended every two to three years. Sample your well water when there is a known pmblem or contamination in your area, after repairs or replacement of your well, or after a flooding event. Contact your local health department for sampling instructions. For fnrther information please contact yonr coanty health department or the OccupaHonal and Environmeatal Epidemiology Branch at 919 707-5900. ' Revised Jsaaary� 2011 North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES070913-0087001 Date Collected: 07/08/13 Date Received: 07/09/13 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 7.0 Sample Description: Comment: Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slph.nc�ublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 EPHESUS BAPTIST 1894 EPHESUS CH RD Time Collected: 10:35 AM Collected By: Adam C. Sarver Well Permit #: A33-15 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 Cadmium < 0.001 0.005 mg/L Calcium 36 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.39 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 4 mg/L Manganese 0.05 0.05 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 8.4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 41.00 mg/L Sulfate 5.20 250 mg/L Total Alkalinity 179 mg/L Total Hardness 110 mg/L Zinc < 0.05 5.00 mg/L RIECEIVL�D Report Date: 07/19/2013 ,1UL 2 5 2013 Reported By: Arnold Hol/ BY: Page 1 of 1 North C:�rolina Division of Pablic Health • ,, O�onal and Bnvironmental Bpiddniology Branch, Bpidemiology Ssction BIOLOaICAL ANALYSI3 RBFORT Privat�e well v�ter i,n,foffiation and recommeudations Cotm:ty: ' J'cL► Name: "� �J �� "�;� Sam�le ID .�� II �6G J Location . Revie�uar z �3 Initial Sample Conf nnation Sample '�r BIOLOOICAL ANALYSI3 RBSULTS ATID RBCOM1VIDd�1DATI0NS FOR U3&S OF YOUR PItiVATB WELL WATBR �'Thasa recommendations ere based on biological analysis only.). No coliform bacteria �were found 'm qour well wat�: Your wa'ter can be used for all P�Po es including dtinking, coaking, washing dishes, batluag and sbowering. ' � Total coliform bacteria w�e detected in tbe sample wbich iadicates that harmfal.bac�eria from human or animal waste could emer tha well. Do not nse tha water for dr�nking or cooldng unless it �as bailed for 3 minutes. Yon may use your water for all �eor pmposes including washing ' , bathing or showerit�. Your well water:needs to b8 re-tested fi� veafy ti�at the result is acWrate. Fecal colifarm bac�eeria were detectied in the sample. Do not use the water for drinkin�, cooking, washing dishes, bathing or aho�rering. If the ra-test shows contamination by bacte�ia co�ct pour loc�l health depmtment for assistaace. There may be a problem with tha constcaction of th8 well, the groundwater source, or oparation of tha well. The well aee�is ta he inspected by �e local heatth depa�tment or a local . well cont=actor to determine the problem wlth the well and to give gaidance on how to coaed � the problem. . . Your well water was tested for biological contaminants {total colifonn and fecal coliform bacteria). The results were evaluated using the federal ddnking water standards. Drinkin,� water may contain substances that can ocan nahuatlp in water or can he introduced into vvater from man-made sou�+c�s. Total coliform bact�ia are foimd in soil and fecal coliform bacteria ere found in animal and human waste. Total colif�m or fecal cofifoim bado�ia in well water indicate that the well may have stiiucharal problems or that the well was not properly 'disin,fected. If you have been drinldng the well water and are pregaant, nursing, have a child 'm the household under 5 years of age, or immunocompromised (such as an individual with AIDS, cancer, hepadtis, dialysis or surgical pmcedures) inform your physician of these results at your next visit. . If the contamination cantinues, 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. For further information please contact your county health department or the Occupational and Environmental Epidemiology Branch at 919-707-5900. North Carolina State Laboratory Public Health 3012 Distnct Drve Environmental Sciences Raleigh, Nc z�s„-aoa� htta://siph.nc�ublichealth.com � 1 C i0 b 1 O � O Phone: 919-733-7308 g y Fax: 919-715-8611 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ' EPHESUS BAPTIST 1894 EPHESUS CH RD ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02=33-15 StarLiMS Sample ID: ES070913-0113001 Collected: 07/08/2013 10:35 Adam C. Sarver IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Received: 07/09/2013 09:25 Angela Heybroek ES Microbiology ID: Sample Source: New Well Well Permit Number: GPS Number: Sampling Point: Well head ' A33-15 _ .,: Sample Description: Comment: Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert - Analyte Test Result Analyst � Date Total Coliform, Colilert - --Present HLBRASWELL 07/10/2013 E. coli, Colilert Absent HLBRASWELL 07/10/2013 Report Date: 07/11/2013 , _. Reported By: Susan Beasley �� RECEI'VED JUL 18 2013 BY: Explanations of Coliform Analysis: 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. 7� 7- � i i Pe.V 7. ��~ ��r.son �.County: Health Depaetrnent z . �; . � el : Permit� � �-�S- 93�� Peimit Vo�d Aftes� Yeats '~� �s�z�� B�o �ts� l'�_�� SR# /3z3 wner, OC8[10I1/li1iCCC10I1S': � '. `�—'-- --,.//: //v� � 11,�_ � C:../.! . C.�1__ �._�•'1__ .]J�1.�.. __' . .. .//1 ' . .. .' _ : __ � _ ..,. � � ` j�►ELL C�NSTRUCiTON . . � . Dastanca:�f:om Nearest Prop�ty'Lu�e 30 . ~._. Diatanca from. Source of .� �P011tl�'/ �S � : Totel D'epth. o`'�Ft Yeld: S G1PM ; Static Water Level t�. �F�. . Wata�� Beering Zflnes:. _ Depth .. 2 o F� 7o S F� F� _ � Ceaiag: Depth: From to 3� i�t. Diameter: .�.s Inches �� StCCI - .. ._ " _ QS1Yffi11Z8�d�.`$ ei . • If Steal, does o ;approve: Yes �'.' No � . . � Wagh� : : Thi� � � � Height Above-Grotmd: � I�ches _ Driv.e Shoe: 'Yea No . :- 1�Vere Problems Encoimtered in� Setta►g the Casing? Yes No_� � "j�CS" $1VC IEtS0l12 " ' ; (3rou� . Type:. Neat Sand/Ceirieat �/ Concrete� : Annuler Space Width.. � Inches . . Wata ia Annular Space: Yes ` No� H . : Metitiod:;: �AunpecL Pressu�e ; Potaed ._ � , �' . �m�: �. .. o ��. . � ...;Materlals U�yscd �No. Baga.�Portlac� Cenrent -/ b_..: Weight oE 1 bag ,� � +�� If mixtiue (sei�d, grav.el, cuttiaga) - Ratio� _ to ' iid ID Pletea. Yea � No � ._. _ . , � 4 x 4 slab Yes +�—' No.. _. .. + ' . . .. , �L . Yl . . , . _ . .... _. _. . _. __ ..... , . , . , , . ; : . �. . �� . �: • . Fmm To.. �.. _... �,�F.o:rnation.Descri ' on:?..:.. ..- . '- � � { � r. ; . , ,. - , ::._ .,._ _.. ,: _ . ... _.. . .. .... .--....._ ...,;,. . . _;.__,..,- ; ,-. ., , .. - r �--- . . . . _ . . _ . .. _ .. . ... � �. . � I HEREBY�CER'I�Y.THAT THS ABO�VE INFORMATION IS CORRECf AND.THAT � �s'wEta.wAs:coNs.�euci�nnv:ACCO1tDA1�CB:WITH IiEQULATIONS;sEr�,� FORTH�BY THE PERSON`COUNT�C.HEALTH:DEP.t�iRT11�NT... , : . � , ,... f� ; , . " .. . . � i : . �.�� {.. . , .. .. L '. ;, � r . 1 j . _ �: _ _,. . , `.. I ' _ : , Signa of `Contracfor ' Date _ ...._� - _... _ _. � ' � �,,,=.,11 ��.. .; 9- �s 93 � . . _. , .Sainta�i'a:'Si -':Date Isa�ed. • _ ; ., ; �. . ;� . . - � Saaitatian'a-Signebue � Date Completed skeccii weu location on reverse aiae: .'_ ..,,:;s:k � n d '� �„ �� 3 0 N - d d A , . •� � ��+ A a � _ .. x G 0 � � u '" _ « =° o. y a, .� H w A �� ° �o o ° � o � . :� a � � w Ql N A d y � o � b .�..' v ci � � »� d. d � � �3 � „N '' tl 0 � � ^'rt � C � o � oG a « a � � a y � W `. 6� 1+ O � � o��o a+ 3 yO O � a e.. . o .. ;� � o � c�� uvai "'0" ae °�' o N 0 dz�� N � ' ' V � � " ,+ �+' a'`� . . zy� : . . .. . � i1 , . .