A40 6Ap�licati�n Date: � � �-d % � � Tax Map:
Amount Paid: � 0, O Parcel #:
Receipt#: j p 3� 2
�-� _�.`'_'�.� ���� ���
1 � �" � �- �C � ?�1,r�.�-`��C°�:�T
.�w:t71�N']LSL: .CDSC]l_ICDC11_.['"._-..lLT:1L.LD..LL 7f--3i'.�.t,..11.-a::7LT.
� �PPlic�tion for �ervi�es , � :
(Septic Svstems and Wellsl
G Tmprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
���Mobile I�ome Repiacement or �uilding Addition
$150.00 (if site visit required) �
� Well Permit (New/Repiace�ent)
$225.00/$125.00
Seavic�s l�e uested
G Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
.'_ ❑ 1Repair of Egisting Septic System
No Charee
Tmportant: If tfte iriformatian in tfie applicatia�: for an Improvement Permit is incnrrecs, faisifted, or• tfie site is altered, tl:e�:1/Ye
Impropement Permit and theAuthnrization to Cn�istruci shall becnme invalid �
1) Sea-vices Requested b�: � .
Name: (./ �R.�.►a�J R � vSc �-o �' b* LN � Phone #(home):
Address: �o �h�• 1Jv �w (worlJcell): 33� - S ��' �Z3 �f
-���lo�>Z� /L'�C• 2�573 . �
. � - �ie
Z)ledame �nd acldress of cnrre�t ow�ner (if different tban �pplicant): �� ��GIY%-�
Name: C D� � w► t l:� �; t-�'► �� c� . � e ti� 1J
Address: s��� ss ��,� m. �.�- �� .
12� � o �2.t> fv • t. • - �
3) 1'�operty Description: Lot Size: Subdivision:
Address and/or directions.to Property:
Lot #:
4) �'rop�sed �7se �nd Type of �tructure: �
Residential � Business/Type: � Other � Z- X Z,$� � o o��
Number of bedrooms / Number of people served (seats/employees): ,
Basemen� �es No (with plumbing: Yes No _� � .
Garbage disposal: Yes No � . �
5) Water Supply: • • .
Private Well t/ (Proposed Existing _)
Community Well: Public Water System:
Are there on flie adjoining properties? No Yes
(please show location on site plan)
l�o�e: A cnm,�leted applicatiort treust also include: �
9 A plat/site plan nf Phe property tltat shows property dirraensio�tts and tlae size. and docaation of �11
proposed structures.
➢ A signed copy o, f'the `Lot �'reparation' form ver�ing that the property rs ready io be evaluated.
���e s�b�itting tl�is applicataon to a�eque�t sey-v�ces %offi t�e �epson County �ealth IDepa�ent. The
� nnforBnation praviaied is aceurate. X uaaclers#and ilaat ii amy site is afltered or tlae imtended use changes, all
per�its �hall lbeeaffie inv�lad. �
�igna�uare (Owner/Legal Representative): ,�/ ���� ; � � —,�-�
06/07 Person County Environmental Health, 325 S. Morgan St., 5uite C, Roxboro, NC 27573 (336-�97-1790)
2�
�2 �� -
a��
�
DATE,TIME
FAX NO.INAME
DURATION
PAGE{S}
RESULT
M�DE
TRANSMISSION VERIFICATION REPORT
11102 15:48
99194719750
00: 02: 09
06
OK
STANDARD
ECM
TIME : 11/021200i 15:5�
NAME : PERSON COUNTV ENVIRO
FAX : 3365977808
TEL : 3365971790
SER.# : BROG5J3�1308
��
�
� },� �
��.� �_-' � � �.A. � � .1l.
�"! r�.�:n.�'crnn�.]r�rn.a��Cn.��n.� ���m.�tE�.
]B�aalding Acdditions/ 1VTobile �ome Replacements
Tax Map #: A��
Approval Requested for:
Parcel#: lo
Mobile Home Replacement
X' Building Addition
Applicant Name: �' ,,�-��c� rnn ►-� 1.`li��i ��i r� l cl
Address: " ,�955 Nurr� lP M� 11� 2d
��c�a� r�c, ��757�/
Phone #'s: ��98- aa3a ( l-lcrma.n R�x.�:��
Permit Located:
Installation Date:
i /
'Yes ✓ No '
Design flow:
Current Contract with Certified Operator on file (if required): N�/�-
Water Supply: ,� Well Public or Community
Wastewater system shows no visual evidence of failure on: t��`� ��7 (date)
�(Applicant's signature if site visit is not required)
• � ' 1 � Ir �r r ..t �. — i.r, �c" _t1
.�ddition/Iteplacem�nt Approved
�� /�
Environmental Health Specialist
11/15/OS
��17�0�
Date
����, �� ���� ��
� "'— � � ����
1Eaa�na-o�--�.Baa�.]L IE-3L.a.�.]l�l�n.
STTE PLAN
Name ��P t�s`[�t� l�r'�� h�e �C� Tax Map # 1,T � Pazcel #�_
�b � �sion Section/Lor#
� �\'�J�-� i n �\ 1, �
Authorized State Ageut Date
System cnmpoaeats representappmximate conmurs oaly. 73e contractormustllag t6e system pdor m beginniug theinsrrllatioa to
insure tGat pmpergrade is mainrsined
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a
Ro�M
A�d����
SI�
s��: ?.� F
lk ,.�,o.•-�
� �,,-i, �, �.S-�
l�e�� a-�- IeQS-� lo-�'�-
�� �,�-i � s�s-lea�
rcxn, r�., o�l�z/oi
North Carolina Sta�e 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: Whitfield, Coleman
Address: 5955 Hurdle Mills Rd
Roxboro, NC Zip: 27574
County: PERSON
Report To: Person Co. Health Dept.
325 South Morgan Str.eet
Roxboro, NC 27523
Courier: 02-33-15
Collected By: BONNIE HOLT Date:
Location of sampling point: outside spigot
Remarks:
Parameters
Alkalinity as CaCO3
Arsenic
Calcium
Chloride IC
Copper
Fluoride
Iron
Hardness as CaCO3 (Ca,Mg
Magnesium
Manganese
Lead
pH ,_
Zinc
ATTN: Bonnie Holt
(336) 597-2371
14/2005
/ k
Its Units
� k �
Source of Water: Ground
Source of Sample:
Type of Sample: Raw
Type of Treatment: None
Type of Analysis Private
Time: 12;59:00 PM
0
�142 � �,�- ' . mg/I _ � � � (� '12/15/2005 � �
<0.001 ` � � mgll��� �_ � � 12/15�2005
, ,
<0.5�� :� � F � �mg/I"�""� � 12/1512005
� _ _ � _� i_
38� : mg/I ,, 12/15/2005
<0.05 mg/I 12/15/2005
<0.20 mg/I 12/15/2005
0.08 mg/I 12/15/2005 /
) <2 mgll 12/15/2005
0.1 < , mg/I 12/15/2005
� ����
-. w _ _
'{° � <Q Q3 .„,�. ;._�: _ � mgll �� _ _ _ _ 12�15/2005
�� `��� <0.005 �� , �� ;mg/I , � �� �� k � � 12/15/2005
°k� fi,�, tF ,d; r�• � �: ��i j f►; ��=, _
� t , , °
� � � �� 6.8 �� � ' � ��_ Std.�unit ' � � 12;15/2005
M...��..� ..� . ��.� __.�� __ �u
<0.05 m /I 12/15/2005
- -- � g �
,�,�, � °� � � n.�, � �� ��� � �* �
. '� �
' '_m` `' ��,� � �.� � �-...$��.� ���,��$ ii'�� ��W ������ � ai� �.���� ., `,;
.
,
� ;" �
-.._ i. � ,� � .� '' �
"„"`�� � � ' � �. — i a ;� � � � � , m� ry � � t� , �
1 I , � f �� I p �i! �: � "i �
�".„�.,..,,=,..,., +-...,� t..:.,�' w �...f �a' .__s ,rr,. 1�7..s� �.- �� � . vu � �s �yr'f �� ` e.. .. �w;a.a ... ' ta n ..,,.+ �� +..�' �'4,...- aa 1..x � ,... a.. _ i.�.�
_1/� (.� �a � �
� 1�� �� � � �Gu�
I"
� j 3) i�10
Date Received: 12/15/2005 Report Date: 12/29/2005 Reported By: �����
Today's Date: 12/29/2005 Ref: 17696 Login Batch Q51200, ���..:; Sample Number: A636107
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 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
Hazdness
,
No establislied 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