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A40 282} `' 0 0 :r : a Amount paid ��d•� '" R$ceipC � ' 1 � � " , .. �o�°S aas' Q� �1�1as � � O � , w � � a v2-��2-� cl Da ce . .. �J',. Improvemencs Pecmic (Establishcd/Reeorded Lot) _ Reiaspeeeion oi Exiscing Syscem (Loan Closin Im[uovemencs Permit (Unrcccrded Lot) ,.,�, Reozir/�2eplace exiSting Se�ti� Systcm Impro�emcacs Permit (Iviobile Home Repiace) .,..,. Pctmit foc New Woll Impravemcnts Pcrmic (Addition) � _ Reptace Existing Well '�; •+'ri �li: ?^�"` s' n.i� �N' .•�� y71n .�et Y . •. � w�.y�.. 7 v: �M�.+ti;�`•ti k ,Vr � ;�,.� �,sc �d'� � ��'�� .�,�� ,� ��5;, ��'{� aEer le'��i�e�Goll��ted��;,;,�.�f,' b ,�,"`��,`'�;.. �,� - ,�, u..� ..�. �.r�.»3�:��`•��''�-.�-z.�ar�,� .P ,�1".:c� r�► .,.:: � � _ �acteria _ Chamical _ Petrolee�m Pcsticidc ._,._ Lcad 1. it ceques;ed by: . wn�r pcospeccive owne:: cess: . � � � �" fi�� ;omc Phone #: o��/ �/- � �-� � usiness Photte :: , 7. Dimensions or Fra�oscd Suuccurc: � Wicth: Dc�tEt: --- 8. What typc (if any, additions, cxpansions, or -�- replacetnent is antieiaated to thc stnlctur� or facility — tt�at this sewa;e dis�dsal systecn is inteadcd co serve' Namc and addre s oE,c::rrent owncr. 9: Water sugoly typc: ,.' , c�n privatc�public❑ communiry[� spring�) ��-�/� �� !�d r�(lP rl'1; /l s/c�, _ Are any wells on adjoining property?Yes � No �' �n �,b�ro , iY C ,� � b� 03 Lf so. idenufy locacian: . Property Descc�ption: Lat s . Tax Map#: d� . � 0 Pa�rcal�: �' , r .' Dircctians co pcaperty: Stzt� Road #& Road �11I�CS..�tC- . , , i n � /J / 0 14. Type of structurelfa�iliry: Proposed: QExisting: ( Type aF dwellSng: Hause: ��Mobile Home: Q Busincss: CI Typc of busincss: Number of Emplcyees: Numher af bcdrooms: _.�___ C�bagc Disposal? Yes C7 No �1 Hasement? Yes ❑ NoQ If so, # of basement fixtur� 6. Number 4f occupants or peoQic to bo scrvcd: CLEARLY STAKE ALL COI�NERS OF TI� FROPERTY AND THE CO�tI`IERS ��' A�L PROFOSED STRUC'�'URES• I hcreby make application to the Persoil COUIIty' ��lth Depat'tm�nt foc a sitG evaluation for chc on•s sewag� disposat syscem far the gbove descritxd gmQccty. I agrea that the �on!cots of chis application �te ttua and ceprescnt the maximum facilitics co be plaecd on the property. I undecstand if the site is� altered or the intended usc changes. thc permit shall bccome invalid. I undec�tattd that beforo an Improvcmcnts Pecmit can issued, I must present a sucvcy piat aE t�e property �o tha Healch Depc. I unders�and that in thc avcnt I have n delivccod a survcy plat of the property to the Health Dept. within 60 DAYS aftcr thc datc oE thc evalu�tioa ol the site by thc Hcalth Depc., this application shall become void and a11 fccs paid forfcitcd. � ;t.. z • � S�gnc� qwn�r or Authoriud Agcn� 7 -, . '[0 3�Gd JfJINI]Z QN�1 �NINNt��d 66LiL65 6b �EZ 666ti/80/Z0 .- ; � a w � a B 2969 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # �-�}(� Parcel # o�� Zoning Township �/� �`vc� Owner/Contractor F�� nc Date 7 2J- PQ Location/Address/S7 S. �u,1'��%�� lc ed ��1�. � S.R.# Subdivision Name Dc /�' .- �S Lot# 7 SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area %/G c. Size of Tank I0� SFD Mobile Home '� Size of Pump Tank Business # of Bedrooms 3 Nitrification Line �/f3U'X 3' Max Depth Trenches ?'�" Permits may be voided if s� e �s altered or intended use changed. Well and Septic Layout by �. • Comme�ts: .Sec �o' ��' %o� o,l� CA, 1'7ee• Ei�/S o� ��s,�.auf obo� f� 1,� a� �.., i� /� �., . ate 9-Z- 99 Installed by �j . L�wiS Approved by� Well Permit Paid WELL S`YSTEM SPECIFICATIONS � Site Approved_� Well Head Approved Grouting Approved Comments: r (LiN _Semi-Public Required Slab �/ Replacement Air Vent Required Well Log , ,� -' � Well Tag �/ � r �.�1�� , l � �/ � Date X �-( - 9q Installed Approved by This report is based in par"t on information provided the hdfneowner or his/her representative in the application submitted for this permit. The 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 report that may have resulted from false or misleading statements provided to him in the application. 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. c:\amipro\permit.sam O1/95 rev.l.l _ „Z� ; �0 "9�- 3 \� ,� a SI . � Q� �� N , e � � ao '� � r . N � ,o� S1�"M o� �9l'0� � '" 6 SN , � ' ' . ��S 0� ��. . �Z �j �� ,� 6 �� S r srv . � y SN � 0 �-." � �° . SN SN 5 SN 9 SN L l.:t f {�y, � � `� t L f � . t' ��t • 5: t ... � . .. �.l..t . . � _. "r , � ` .r ;.j :� { Date: � - !�l Owner. � Location/Di - -- PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG Subdivision Nam�: _Q Drilling Contzactor: � Distance from Nearest Property Line �(c'� � Distance from Source of Pollution �� ` Total D.ep.th:� rao Ft. Yield: a�C� GPM Static Water Level d�^ Ft. Water $earing Zones: Depth ��Ft. 7S � Fc.�_F� cl.�^ �t, Casing: Depth: From � to�_Ft. Diameter: Inches TYPE: Steel - Galvanized Steel / If Steel, does owner approve: Y�s No " Weight�: - Thickness: /� ,Height� Above Ground: < ti Inches Drive Shoe: Yes ✓ No ? : Were Problems Encountered in Setting the Casing? Yes No ✓ � If "yes" give reason: Grout: Type: Neat SandJCement_ ✓ Concrete • Annular. Space Width Inches Water in �lnnular Space: Yes � No _ .. Method: Pumped . . - � �Pressure � • Poured �/ -�- �. � - • •. - : . - Depth: From O to_ �� Ft. � � - Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixture (sand, gravel; cuttings) - Ratio: to :ID Plates: Yes ✓ No � � •� " . �� 4 x 4 slab Yes�—No � J I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERS0�1 C�Li�ITY HEALTH DEPARTMENT. ....� �- �!-��_ Signature of Contractor Datc � 9 NS N05'S5 � 8 �� NS 6 � NS 30.16' 248 ; NS `a � NS S ____,_,_.. -- - - - 4 �0 • �3 , �° w��s � NS � . �o� �� . ; . �' NS j S � ^' i 1 ,,� � � • NS �S � o • � N `�� N , ` � � � �� Op �, cp � .�, 'S _ — . : �' p�'� ' ° �c.r �� . � —+ . % � j S � � � �' � . - ��,� . . : w .� �� r : �� .J � -r , ,,, �� % ' 3� �,� � �d . j��C _ � 4 a � ,_ p .� � A C �.�� . _ RE� , a� a p 185 • 22 �� I S S05' �,,,� � 16e0�,�2 E �r � S v �. cn I S � N ./'� � �o SAMJ�Y � � s � � � , _ �• o `� 2� � � � S � 0 � � � , 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 Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 MICHEAL SLAUGHTER 606 HUFF RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES080814-0021001 Date Collected: 08/07/14 Time Collected: 1:35 PM Date Received: 08/08/14 Collected By: ACS Sample Type: Treated Sample Source: Well Sample Description: Comment: Sampling Point: Kitchen faucet Well Permit #: Temp. at Receipt: GPS #: Lead (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Lead < 0.005 0.015 mg/L Report Date: 08/19/2014 Page 1 of 1 Reported By: Arnold Holl 0 , North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: JUSTIN SMITH PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://sloh. nc�ublichealth. com Phone: 919-733-7308 Fax: 919-715-8611 MICHEAL SLAUGHTER 606 HUFF RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES071014-0034001 Date Collected: 07/09/14 Time Collected: 1:35 PM Date Received: 07/10/14 Collected By: ACS Sample Type: Raw Sample Source: Well Sample Description: 1st draw Comment: Sampling Point: Kitchen sink Well Permit #: Temp. at Receipt: GPS #: Lead (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Lead 0.029 0.015 mg/L Report Date: 07/16/2014 0 Page 1 of 1 Reported By: Arnold Hvll 0 c � North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis Report To: JUSTIN SMITH PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta:!/sloh.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 MICHEAL SLAUGHTER 606 HUFF RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES071014-0035001 Date Collected: 07/09/14 Time Collected: 1:50 PM Date Received: 07/10/14 Collected By: ACS Sample Type: Raw Sample Source: Well Sample Description: 15 min draw Comment: Sampling Point: Kitchen sink Well Permit #: Temp. at Receipt: GPS #: Lead (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Lead 0.033 0.015 mg/L Report Date: 07/16/2014 Page 1 of 1 Reported By: Arnold Hall 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: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto:!/si�h. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 MICHAEL SLAUGHTER 606 HUFF RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES062414-0007001 Date Collected: 06/23/14 Date Received: 06/24/14 Sample Type: Raw Sampling Point: Kitchen sink Sample Source: Well Temp. at Receipt: Sample Description: Comment: Time Collected: 10:20 AM 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 12 mg/L Chloride 9.90 250 mg/L Chromium < 0.01 0.10 mg/L Copper 0.28 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 0.18 0.30 mg/L Lead 0.046 0.015 mg/L Magnesium < 1.0 mg/L Manganese < 0.03 0.05 mg/L pH 6.8 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 11.00 mg/L Sulfate 7.50 250 mg/L Total Alkalinity 32 mg/L Total Hardness 35 mg/L Zinc 1.80 5.00 mg/L Report Date: 07/02/2014 � s.�c��v�� JUL 0 7 2014 �Y: —R Page 1 of 1 Reported By: Arno/d Holl