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A40 375Application Date: `► �7 � Amount Paid: •ol% Receipt #: (07�✓ ? A Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 1VTobile Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 `� l, ) � �� Tax Map: �� .,_. �^ �'��,�,,� Parcel#: ��$ 1�".ffn.�v�i n'acn nn mrn �.- �rn ;(:,ci Il II=3I Q- cn.11 ;[,1E1 tion for Services Services Re uested Construction Authorization (Fee is deoendent on the tvpe of system permi Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Informati� �� Name: ��. � „�,,,,,_ (�,�E � Address: - t� In �-� 1 �! �% 4- 2) Name and address of current owner (if different than applicant): Name: , a, -�_z,,,.ckins Address: '� �-� T[� 7-7�`►� 3) Property Description: Lot Size: �_ Subdivision: Address and/or directions to Propertv: ✓,i� ! n.�i Phone (home): 3?�i 5�i i-553� (work/cell): Phone: Lot #: L�S ❑ yes �.no Does the site contain any juris�tional wetlands? ' ' ' � ❑ yes �no Does the site contain any existing wastewater systems? ❑ yes f�.n" o (s any wastewater going to be generated on the site other than domestic sewage? ❑ yes o ls 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: esidential New Single Family Residence Maximum number of bedrooms: ��/ Occupants: _� Expansion of Existing System If expansion: Cunent number of bedrooms: ❑ Repair to.Malfunctioning System Will there be a basement? ❑ yes l�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 ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, 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 preferred system type(s): �Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any � 1 cert� that the information provided above is complete and correct. I also zinderstand that if the information provided is inacctrrate, the site� is szrbseqzrently altered, or the intended arse changes, all pernzits and approvals shall be invalid. Signature ( wner/ al epresentative*) * Supportin� documentation required. �-27- ?�t(� Date Permits are valid for either 60 months or are non-expiring when accompanied by an a�proved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27�73 (336-597-1790) ��, sf ��.� �� ., �� J.C�eara�a�r��taTMTM�+ ��rntE�s.�. �-��.�.��a Applicant: ja4 Address/Location: QvQ , �--� z cc Tax Map: y0 Parcel: 375 Subdivision � c Phase/Section/Lot # $S Improvement Permit Permit Valid for: Five Years � Non-expiring �"� Type of Facility: ' New �Addition _ Water Supply: Yv Number of: Bedroo �/ Occu ants� Employees / Seats: Projected Daily Flow: (ap gallons/day Proposed Wastewater System: ��„�,�_l Type: Proposed Repair:�n-- Type: � 1 � Permit Conditions: _�.�i��,�v�Y urndr�sl�a� Pr�nP�l,a Authorized Sta.te Agent: Date: �-2� - � (� (X) Owner or Legal Represe ative: � Date: c'� - Z7- �r�� The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are me� This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeat is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina �Laws a�:rl Rules for SewaQe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County aor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply yviU remain potabie. Authorization to Coostruct Wastewater System See site plan and additional attachments (�. Proposed stewater System: ��h,,P,,-}-,�n�� (*)Type� Design Flow ,�b_ gal./day New �Repair � Expansion _ Soil LTAR: . 3 gal./day/ft2 Type of �acility: �•�,,,�p_ ,,1,,; �,� Qu,,o�/,�,�n — 3$� Basement: _ Yes _ o IV. and [! the Person County Health Wastewater System Requirements Tank Size: Septic Tank Do0 gal. Pump Tank � gat. irease Trap-------- gaL 57ow�+s� Drainfield: Total Area � sq. ft. Total Length �/OU ft. Max. Trench Depth � in. s�� Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft. °` �` Distribution: Distribution Box / Serial Distribution �Pressure Manifold Specifications: Authoriz�d State Agent: Issue Date: �/- Z7- /(� Permit Expiration Date: �/- 27- 21 The system permitte� is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: - / Date: - a� �, Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) -�.��,.)� ��L��l V � ��L' IE�..zu•m...,",,.��Y ]E��.�fl� SITE S�ETCH � Name S oE �,•,,,� �." w k: � S Taz Map #� 4-Psxcel #�� 'S Su division O4 kr�, �� Section/Lot# Lo t�S � — `f' �—=-,- Z�/� Authoxized State Ageut � ate sy.�„ �o„�o�� Yep,��„r app%�,��w,�ou,� op y: The contracter mrut, fTag she ry�e»: prior to begimung the inrtallation to insure tha�t propergrade ir nra:��arired �O i L�'�ll�I =�90' u � �° / �Rb��s ED'w Etc� 1,� !V E�= J ao � �'� � f}0.�� / l r ` ��/� E 3 = ►°O, LTN� �t = 110 r 7'oTf�C � � �.on�� ' ' �� . , . t� - �1 7 �' , � 300� �-c�� 3 gR 5F1� � C? — —� �io' , � � � . Scale: � � � � b C� 4b, � D��vP �� d ,'sr�P � � N � � :v .�, 0 ' �0 �:� ��p� , • _". : � � ! ��. � �F.do��'✓p . � H�N�I��Y �W�N�1� 5�' r� rw � �.� n��s�- � a f' �P�Or'r/� 4�pa . 1 �- 5 � � Must install septic system on contour. Must not install septic system during wet conditions. Septic system must maintain all proper setbacks. Any questions call Environmental Health Dept. 336-597-17�0 ��. sf ��.� �� I��n�aa-��a.�aa.��n��,Il IE� ��.Il�I�n. Applicant: �'/�1 � — G'� Location: �/ lC � Operation Pern�it System Type (From Table Va): .l1� Type V& VI Expiration Date: Taz Map 1'� `�� Parcel # 75 Subdivision �r' v� Phase/Section/Lot # S # of Bedrooms 3 Product (IIIg): � t�� Type V& VI Renewal Date: �_ This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions af the Improvement Permit and Construction Authorization. Authorized Agent � � ��e4 (Licensed Contractor) Scale � PCFID, rev. 12/14/12 ,(�� J 5- zS-�� (Date) l�� S � Il7�s�,. 5r�7�� (Date) S�" w( Line 2 Total �� Tax Map: Parcel #• Septic Tank System Checklist (Type II-I� System Type: l(/ ��Z �d�J � Septic Tank InitiaUDate State ID & Date: . —( S z Capacity: �d�rv Tee and filter Baffle Vent Riser � Outlet boot Perm. Marker Distribution D-box levels set) Serial Pressure Manifold � LPP Notes• Pump System Checklist Pum Tank InitiaUDate State ID & Date: Ca acity: Riser (6" min. NEMA 4X Box Model: Piggy back lug � Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of ta s: Size and sch: Contracted Certified Operator (Type IV Systems): Notes• Tank Com onents InitiallDate Pump model: Block (4") Nylon retrieval ro e Float tree and attachments On/Off float swing: in. Alarm float (6" se aration) Anti-si hon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed A proved and secured riser Su 1 Line Size and material: in. sch. Length: ft. `��f �/ l J1 J�..� � �1.� V � \_•..- � �1J `iJ � �. V � � I�.a.-��a��.a�.��.�.11 IF -3C � �]l�.l� W�I.,I1 ]PE}�M3'T (New��2epair� Tag Map: ! 1 �� Parcel: � �S Subdivision: C�t}t��a� �-c.rPS Lat: g5 Applicant's Name: �Q M M Y �o �,�, f� i^ S Mailing Address: S� S��F��IP M i I/,� �, ��a�a � NG a- 75 �4 Phone Numbers: ��} - �-s � a- SQg—�i �I Lo�a � r.. _ _ .�-. ,.� 1�P�G G� Permit Conditions: 1) See attached site plan for proposed well location. 2) All a�p[icable State and Counry regulations governing construction and setbacks apply.� 3) Permiis expire S yeat-s from the date of issue. / / fitherC�nditions/Cosnments: S2e 5i � 5%ZeYz-�r. ��I ^"�5�= �e �d �% ��'M a'� Y � e/� �j�- s�fs7�Ptir, a5 7�ft'}F' .�/�^'� q"� �f ��a� i�n� . �b -�Qo � f�o ^-, a^ y . c��per�hj !t� c / - Pe�-mit issued by: ��CS�' �lz� I)ate: � S�IS��% C�R��F�CATE OF C011�LETIOI�T New Weli lnspection: HS/Date Location: 'Z�-�� Grouting: ?�-(.�e Well Log: Well Tag: Pump Tag: i l Air Vent: Hose Bib: " � Gasing Height: `/ Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: . Method/Material(s): _ Well llriller: ��-K,P d'� Liceuse #: Pump Installer: ' a"�, „�« License#: Well Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date: ��Q'`��P Date Results Mailed: ' � Phone: 336-597-1790 Fax: 33b-597-7808 3/1/08 ��.�� .�� _.� � � � �� I� a-n.� a � � �. A-�. � � � �, ll. IHI � .�.11 -�.I� W��,�, PERII�IIT (New��Repair� Tas Map: r'�� Parcel: ��S gs- Subdivision: at}t�;d�p �/'PS Lot: Applicant's Name: �a .�.. ,� � � � �i ^ S Nlailing Address: ,Sy,Ss fFc,�d(� �� I/� �d, �t�a �a ��G 2- 75 7� Phone Numbers: �to4 - �-5 � � SQg-�-� a-9 Lacatio of Property: %{� ��(p l`t ��5 �� -� � �'%�� `� �� i'Pn SjP Y �- JP, � �!'� Ca�' v� �. - Q �4 ��-P�G �� Permit �onditions: 1) See attached site plan for proposed well location. 2) All applicable State and Counry Yegulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. OtherConditions/Comments: S2e S� � ��'teY'c..�, �Q�� ^^"s�= l,be �O �r}'� F�"� "„ y Sep�tC. StiS7�e�, �S �� -��^� �� y ��as�i�� , /b -�Po `I— 7��0^-, a^ y. �r��e ��"7 <<"� � ��t� 2/L� � S/lS�� y' Permit issued by: � `, � Date: C�ER'�'��i�ATE aF COlVIPZ.E'I'ION New Well Inspection: HS/Date Location: 'Z�� Grouting: �LC�-C�e Well Log: Well Tag: Pump Tag: �/ Air Vent: Hose Bib: � Gasing Height: - Concrete Slab: Well Driller: �Y �.� �'� Pump Installer: p"„ � ,. Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: MethodlMaterial(s): _ Liceuse #: License#: Well Approved by: Date Sample Collected: '�l-<<P Date Results Mailed: ' Person County Environmental Health 325 S. Morgan St., Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 sit�os WELL CONSTRUCTION RECORD This form can bc usod for sic�lc «mulaple wcfls l. Wdl Contractor Iniorma600: }- �J e � ��i/��1% �` C' F� ' /�, C,l. L � . w�u co�� t+,� .�� d -� NC VYeil Couvactor Cuc;ficadon (dumbar 8arnette Weil Drilling, inc. Compaay Name z. wa� consc,v�doo e«,n�ia: � �O Gsr dl appltcabk xr!! corwrnuan permrrr (t.a Camry. Stvte, {�o+iome,�etcJ 3: Wdl Use (check wdt use): QF�I1QI�hItfl� �iV�U[11Cip'd�/PU(J(IC- dcrtocn«mal(Eieacing/CooliogSupplrj C9R�d«�4atwatcsupp�r(sinsk) a�a�� oz��c«�u� w�r s„pplr (st,�) Wdl: Q�Yqui�'cr Recharge �Fimia�dwatatie�icdiation �Aquifer Stotage and Rxovay �Salidity Bartia DAquifaTesE OStwrq.watrrDrainage �E�q>uimentat Technology O3ubsidenCe Contml �Ciehtt�n21 iGlosed Lodp) Qitaca QGwthamal (Heahng/Cool"mg Rofum) ❑Other (eScplaiu md� tF2t R.�marfcs) X. bate Wdl(s) Completed: S�G/'��9Vdl:�DlF� � Sa. We0 Lotation: ��r.n.d� � /��ll�lki %� 'C� f �3� Facitity/� ame FacSliCyID#(ifsppliea6ic) S�ihS�" as��c�� /1c. e!� 5 t�� nea�. ��. �tia �e�so,� 3 7� c�b e�► ra�as�No. �n� Sb. Lafitudc and Lougi[nde in degrfes/miaptes/satoodxor deamal d� (�FweD �eld. o� lar/long :s satGcicat) . . 36'" �, � r?CJ�r N � � �' % � � � � �P �'Is(are)&esv,d((s): �xnent or �1'naPo�Y 7: ia ihi3 arepair to au ezis6ag:wdl: OXes oc [�Ytd� �drls ts n repatr,f `r�! ombraron �ret1 c�ouxswaiai frrfosawuan mrd rrp161e t1rc nmars ojihe +rpair+ederCll n+�ar4cs«6on oron du boc4ofdd3fona. S.�lYamb�r of wdls consiructcd: � For muttipie taJecUon or noa-aatersrq�,ly xeflt ONLPxilh !lre same eo�rn�e6aa: y� aot subuttroaejorat 9. Tatai wc41 d�ptG bclow land sattau: �� D (ft} �Foraadriple weIla lirt of! depdis +idffer�erit (�le-3(�IGO ��d1�100'I Fa � uu ox[.Y: 14: �Vd'i'ER ZONES;: FROM TO 7PI70N ��o �- �� - r 2.S' �c %� D f° `O � ' iS. difTElb�A$Q'TG for mulutated ihelk :OR°tAYER �f a' ici6t� OM 1'O DLIMEYHt THICfaViSS MATPRL�L �� o � � % �- sa�c � , v' c 1�:nats��,+�wc_n�.-runwc . . _: .- �►�t :. ; _,, , _ FBOM � TO DL4NE748 7FIC1INES3 MAIFRIAL� . - fc. R. � � � � . `; 37;5(:1tEEHI . r.. ,_ . .::- ,. , . , ., _. .,. RROM .TO DIAMEIER. SLOTS6E tH1GS�1kS5 #tAtiRL�L �. . � � � Q fL �- > i� �rti3ir�' FROM TQ MAFFRfAL � FJHPLACFTtFNI'PtE{BODQ�M[OUKC�:: '� 1i' 7r �� fl�0 OU - [c fc R 2 � =:L4SAI�[DllittA'(rE�PA I�..�.,::t e•.i.i a :. . _..;, :'� r- •� FROM TO MAtER1AL iTiPtACq1[q�i7'MCfHOD �L �L. tt 2 rr. 2O. rc � (t �S ft .r t� ti.e� It. � tt I 1i�� ct s� � ?.Z C�ie�lioa: � � �— c�.�.,b,�:�� .. : /� Si�manuf,C�sed wdt C,00�x �: 8J! �+�*I�+. � �+�++�bY ��Y � +� �(SI � i+�l �bardal In acnoid�ae, ,.� r3,t t�ceazc.oiao.o. tst xc.cc aic.azoo ��a r,�r;uar�sr� m;ar�ra copyafdds,eco�aA�nrbe.�,�rov�ea rl,e �trlt or�ur. x3.5"itb dirgitn� aCadditioua[wdt dEtu'is: You may usb flie liack of this pagC to prbvidt: additibnal wdl. sitc dda�ls or will �a� dcfar'Is. Yon niay slso.attaeh sdditional pages:if aea,csaty. Si7�tifi�fAL IIVSTUCI70NS 24a. For Ait WtJts Submit fhis�fwm witliia 3D days of cdnpldibn of well o�iStinetion [Ott��fo((cswiitg: IQ Sta6e w�ater tevel bdox top of e�sing: 4� ([i� Divisioa of R'stcrQaalit}, Infurmztion Processieg Uouf, /fKater /ei�el.ir abovt msi,c� nse '+" f61.7 &tu'1 St[v.iae Ceater, Rxttigh, l`�C �769�-1G17 11. Borefwte diam�ter_ {'in.) 24b. For Ibiectioe- WeUs: Tn addition to satding �he f�n to du additss in 24a �/ above, also subruit a cs�ry of this fond withirt 30 days of sompletiai of' woll 1Z Well construction.metLad: �-!�1? �'=[�1} �� ialtbthefollotvi�i� C�� .+�r. «bk. a�i �s4 �a-) pi4isiod ef Water Qaalily, Uadugrnaud.Injection ConhnCPmgnm, FOB WATER SUPPLY WELES ONLY: 1636 i1fa�. Scrviee Ctnter, Rateigh, NC Z7699-1636 13a. �dd (gpm). %�� Mct�od oftuk Blown20 min 24C Fot'Si�Afu.SapW9 &.Iniettiou �Vdls iq 2dditiott to sCndinB the�Orfi to the addirss(es) slwvc,� aLto Submit onc copy of. this form within 30 days oi 136. Disinfeclion typG HTH Amoaut '��L CiUp compidion o€ wcll cons6ructioo to the auuniy hcaltti dc{�artioad of t#�e crounty where oo�istri►�ed_ Fam GW-1 Nad� Caroliaa DepadmmtafFavimnmmt aad Nand Ruovors— Divisim of WaierQ�firy � Revixdlaa. 20t3 � � � �. .� , � � �•, �+ �+ `�,✓ `�.�Y � � � � �L.f 3li'ARrll �' �CD]CIl1t7C�1 �D A':t t��ii.31 1�� '�� Pl � ll1L L�ate: l /�/� Name: �'►'�` s � S Address: S S C Re: Bacteriological Test Results Dear Well Owner: Tax Man:� Parcel: 3?S Your weil water ��as sampled on �i�i� and tested for both total and fecal coliform bacteria. Your water sample test results are noted beiow: No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriolo�ical results only. � Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Tota.l col form �ac+�ria are n�turall; found in :he soi?. Fecad col form ha�t�ria ar� associa±ed with animnal and,'or human waste. Th� p::.senc� �f eith�r total o: fecal coliforrr� bacte: ia in well vrat�r may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are preser�t in your water sample, the water snay not be safe for use. Young child; en, the elderly, and the individuals with con:promised immune systems are especially vulnerable and their physicians should be notifred of the test results. A:vell t,�iat te°iS�JO.itllb�e %r total cr ecal c��orm bacteria should be �rov�rly disinfected and ; etested �rior to resuming normal use. The well ma,y be disinfected using the enclosed disinfection procedure. A wetl contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the sysiem, please contact tne Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, , �W��/ Environmental Health Specialist Person County Health Department (rev. �/2G/i6) Fenon Cuunty Em�ironmental Hzaith, 325 S. Morgsn St., Suite C, Roxboro, NC 27573, Phone: 336-579-1'90, FaY 33G-597-730fi North Carolina State Laboratory Public Health Environmental Sciences Nlicrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES071216-0079001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: 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 OAKRIDGE ACRES LOT 85 75 HENSLEY AVE. ROXBORO, NC 27574 Collected: 07/11 /2016 10:50 Received: 07/12/2016 08:10 Sample Source: New Well Sampling Point: well head A. Sarver Angela Heybroek Well Permit Number: A40-375 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Susan Beasley 07/13/2016 E. coli, Colilert Absent Susan Beasley 07/13/2016 Report Date: 07/15/2016 Explanations of Coliform Analysis: Reported By: Susan Beaslev If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. �• ri ��I1� ne deparhnent Of EIQ8�tF1 8fld humen serviees ;.'� . ` ' j� l s � ! f• � 5'� � .., ! ;S f r._. S { � ��i 1 � f �1 � F � `� f � l �,'" j r5 �`3 �S i � � (; 'r"� ,�� a g_� , � � ` S 1 � � I � ° p � ! �� 5 L: �' }s L� � � ' F ! � �,' � i < < {Ia t.. � '.� E f i' t M .,..'_"4 . �'� F ^'j ( � � � :,^ <�� ;•' ��.. � � �';'� ,'�y'�1 ,�, � , j ^��; �'- ' ^ i �p �^- = �I<j i { �,a �,..,.<` �rr ��.+ � �'Z �1 �`�.J� �• E ( e Q F i '�•�� l � ��,� =Jt �_ ` �l,? � i ti For Inorganic Chemica/ Confaminants • �'�. , . - [�1��:�.',.L�'.T��...�. .�� . ,- �.�=��•��- - - -�!�, _ � TEST RESULTS AND USE RECOMMENDATIONS 1. Your �vell water meets federa! drinking water s:andards f oP ijtorg�:ic c{se�nica[s. Yc,ur water c�n be used for drinkin , cooking, washing, cleaning, bathing, and showering based on the inorFanic chemical results onlv. You may nave other water sampiing results that are not taken into account in this report. 2. [] The rollowing substance(s) exceeded federal drinking water standards or the North Cazolina 2L calculated health levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to remove the ci:cled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inorganic chemica[ results onlv. Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride Lead Iron Manganese Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH 3. ❑ a. Sod:um levels exceed the U.S. Enviranme��af Protection Agency's�(USEPA) Health Advisory level for sodium of 20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showerng based oa the inorFanic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc. 4. � Re-sampling is recommended in months. 5. Q Re-sample for lead and /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 we(1 head to determine the source of the lead and/or copper. 6. [� The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv, but aes±hetic problerns such as bad taste, odor, staining of percelain, etc. may occur. You may want to install a hoasehald water treatment system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride � Iron Maneanese Selenium Silver pH Zinc For more information regarding your we!! water results, please cal! the �Vorth Carolma Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health 43012 Distnct�Drve Environmental Sciences Raleigh, NC 27611-8047 htta://siqh.ncpublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER Name of System: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET OAKRIDGE ACRES 75 HENSLEY AVE, LOT 85 ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES071216-0028001 Date Collected: 07/11/16 Time Collected: 10:50 AM Date Received: 07/12/16 Collected By: A Sarver Sample Type: Raw Sampling Point: Well head Well Permit #: A40-375 Sample Source: New Well Temp. at Receipt: 8.5 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Barium Cadmium Calcium Chloride Chromium Copper < O.UUS < 0.1 < 0.001 7 < 5.00 < 0.01 < 0.05 ).010 m 2.00 m ).005 m m 250 m 0.10 m 1.3 m Fluoride < 0.20 4.00 Iron < 0.10 C��I� Lead < 0.005 0.015 mg/L Magnesium 2 mg/L Manaanese < 0.03 0.05 mg/L Mercu < � � �� Nitrate < 1.00 10.00 mg/L Nitrite < 0.1 1.00 mg/L pH 7.0 N/A Selenium Silver Sodium Sulfate < 0.005 < 0.05 6.00 0.05 250 Total Alkalinity 24 mg/L Total Hardness 24 mg/L Zinc < 0.05 5.00 mg/L Report Date:07/20/2016 Reported By: Deddie .�toncol' Page 1 of 1