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A40 424$, �, t 3 Application Date: l� Jn/'Zj f j2 p4 �� S� �� Tax Map: Amount Paid: �,CQ'�n� ��. .�,.; �� Parcel#i Receipt #: i 7 I 389 �� Z3 (� 3'�i �� id U� IE:�rn� an-ananmra�zav:�en.� IC�[�e.s.114,�n. e,�� S{�1 "J Application for Services Services �mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition �i5G.00 �if site visit requiredj O '�Vell Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of system permitted) 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Chazge/ CA $150.00 or $300.00 1) Applicant Informa ' Name: �D� t Address: ,� �� /�a �u�D 2) Name and address of current ow er (if different than applicant): Name: __ Address: �� Phone (home): �6� ��— ��`{ (work/cell): phor.e: �,�p �Z��/ ��+ -��-1�t 3) Property Description: Lot Size: �_ Subdiv►sion: Lot #: _,___ Address and/or directions to Property: �-t i . ❑ yes �Lfio Does the site contain any jurisdictional wetlands7 � ❑ yes G,Lfio Does the site contain any existing wzstewater systems? ❑ yes �)o Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes L�I"n,� 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: G}I�esidential � '�New Single Family Residence Maximum number of bedrooms: 0 Expznsion of Existing System If expansion: Cu►rant r,•amber of bedrooms: 0 Repair t� A?stfunct:oning System Will there be a basement? C] yes �-rfo JVith plumbing fixtures? ❑ yes � . � ❑Non-Residential �� Type of business: Total Square footage of Building: Mzximu:n �umber of employees: N�cimum numbe; o: scats: 5) Water Sup�ly: Q`New well ❑ Existing Well ❑ Community Weli ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Aut6orization to Construct', please indicate preferred system type(s): t�onventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid Signature (Owner/ Legal�Represei * Supporting documentation required. � ive*) / '' Z� � % 7i 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. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��, sf ��.� �� 7E�s��u-��.� ��.Il IL��.Il�I�. Appl icant: Permit Valid for: Five Yea s Type of Facility: Z�l� Number of Bedrooms Z / � Proposed Wastewat r System: Proposed Repair: ' � r r �rl Improvement Permit Non-expiring New � Addition �Emulovees / Seats: Tax Map: � Parcel:� Subdivision Phase/Section/Lot # Water Supply: �. �� rrojected Daily Flow: � C gallons/day Type: � Type:�0. Permit Conditions: �� (Acvl � Authorized State Agent: �(✓�/�'►� Date: ll `� (X) Owner or Legal Repr entative: / Date: -- The issuance of this permit hy the Health Uepartment does not guarantee the issuance of other required permits. !t is the responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with the Qrovisions of the PTorth Carolina `Laws �rnd Rules %r SewaQe Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �yqp . -�,(J1�k�C' �<• � New � Repair _ Expansion Type of Facility: �� S• (*)Type �� Design Flow 2 �0 gal./day Soil LTAR: � Z� gal./day/ftz Basement: _ Yes � No (*) System Types IIIb, Illbg, Iv, and V, reguire pe�iodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tar�k � t� (iC�i gaI. " Pump Tank �!� V' O gal. Grease Trap "-"' gal. Drainfield: Total Area qd C7 sq. ft. Total Length � � � ft. Max. Trench Depth �z in. Trench Width 3 ft. Min.Soil Cover � in. Min.Trench Separation � ft. Distribution: Distribution Box / Serial Di Specifications: Authorized State Agen�: / Pressure Manifold i( � 5 3n �� ` /� � f Issue Date: �/ ll / Permit Expiratior� Date: The system permitted is: Conventional ccepted __�__/ Alternative / Innovative . I accept the conditions and specifications of th+s permit. ' (X) Owner or Legal Representative: � Date: �' � l Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) _ - — �.��ds� I�J��.�� . . . - � ��-��- � . ]Eaa�aso� � m��.11 ' IF��O�.A�]!a � STTE PLAN ��i Name •P'� y+� r SM �,`�� Tas Map #,� Parcel #� ; $IIl7 � � II $CC[LOII�LCIL# � �, Authorized State Ageut Da . . i.Systtmcompaaeuisxplrseatappmvmaternntomsaoly.73eeoaLraemrmuat9sgt6e:ryauempdortobegieaingeLeinsta!la�oam � i :..o,,...thatpmpergiadeiamsm�ed , . _ _ _� -------� � �,�-� � —I _ . _ J� M � �s� � �� -�-- . S s ��,. ��se.�.�-� -F p� �Mu S� � /ttar�� r, o,r �� i �^ S V�c ( (4'��j't - �� /�in��zre Sdr�� SV�c,�r�(kv.C^'2 WLt"Qn C.'�`Z9�ri J -�a � yha� (�Y Q � ,'1 � e. � Q i'-241 • / ya ��6 �� 7� �O vta.� ��,n S�l ( S�Sd�i�, (,utr�� W'e=�/Cp�..c�� eu S. .��''�rN u�t4 � Sor ( CRP c�V'er �vR%�•�; ��C cA:i �( � vik��'�IX, .. ' p� �o` �, . •�, �� g6�'�1 '�- ��,s � _ a ` � �'� �e �s y�k . � ' e - �r`s � '`�. �\ �Zf�9� „N,, �p` _, QLQ �0 .Nl� \ � H � M`8i `� � ° _ pr 1 � `� � ,= �e: nt `�`�� :9�; �'epq IY � N I _ � 0 �.``6�� 6,�1 ,7u� ``\� � ! �/�,QYi� `"" • � \ 3'S �r 8 � °�at g `� � �'�Fti �` Z�31� � � z�(� Spo� _ i �� o� 50� (- S-r � p7- � 300' accp� �,�;I; �.e � � s� �� (��e5 i - s� Y� ` ��' �� ps � � Z£.1�� r �ot; � � �" �� - � � � sa �p � ' \ �,�� . �fi �� : G�� . :...�'•w _... �..._ . _ �'..t� . . . ,. -� � � ., > I�eir d --.. . c ° iT �r J t � .sc"Pc�>>�+a�s'e'�,.''+n�fl=L..�' �.�. � „ . � • ��`�. � I�I��.� �� = � � �� 5�,, f � lE;�-s��a��eaa��.11 1HL�„m.n�ehn. Owner: Tax Map: � Parcel #: 2 Date: t! 1 I.ene �'ap Tap (Sc�) Tap �'lo� Line Length �'ilodv / foot # I)iameier(iin) ( m) � : • (ft) 1 � z . 5 n' . d 4 2 �. 3 4 5 6 7 2 �- � 8 9 10 � �� ft of line x 65 gal per 100 ft =� q 5�� '—"'� ; 100 =�- 9� gal 75 %a x� ga1= 1(n gal per dose �o gal per minute (gpm) = k'low I�ate �riction �e d � Loss: 7� 7� ft per 100 ft of supply line x N 3$d ft of supply.line � 100 =�_ft �_ ft x 1.2 = ��t ft of friction head Manifold Size: �" �'orce Main Size: Z" PVC �otal Dynaznic �ead =�i _ft of Elevation head + 2 ft of Pressure head +� 5 ft of Friction Head = 26•r TDH ��,,, � QP��x. Pump Requirement: �7� GPM @ 2� • ft of Head Drawdown: �� eal per dose � 21 gal per inch =�_ inch drawdown per dose .�� a:.,�,:� ;, � �� ,.�� ' �� — =�i��t0 . , �. j . . , , : .... v �=� .. .�t.»_omoo _�_o_o_�_� o_�_o_�_�_o_o_�_o_�_o_o_�_�-�_�_�_._e_�_�_o_o_� ._. 1�1 �I Q) 1�1 ��**��.��.�a,�� .. .. :. .. .. ... ��+�*��N�r��:��:�� '. ' :.� .,._ e a � : : : � Y: T�l'IIeoe6q, Lwt/m��oQ 53Z` � r'� �i� Na Taps v �/s ior ta �» � �� ta s r.•- ia �cbe�uie �i0 •,.,.,-,...,-ti.,-,w ............. � 2�. d Z � ! 3» � ' •ti.1.hAKK�Y'Y• K�Y1•1�Y�•4 � ..,...,.f.,...r.,,.-...r....�.s.... , �p 16 9 9mora �_ s-- ' i 5n 40.{. 2i . . . . - . " Flow er TaP Si�e iilcuerial FTotiv GPy! ?z'• Sclied 80 �.� ;, " Sched 10 i•= ;, •' Scl:ed 80 101 =5 " Sclied s0 I=•= x�z �na t�o�zzz��c, pQ .. . •. • � . t . . : ,. . . _ . ; - . .�. � i X'O[H • �r-� a��o� „b � '''' eazz �E� . •, , ajqeec„xa�- ; t s}Ya� 1 • '� ; � saxt� }eaq,; ed?d �AdOtiH�S ��Z ua�}nqu}nQ oy }aj}np }noz�}uauta�puet}:od ' �' � tC1ddnS �i?�A PaIIL3 2utuadp � , _ • n}cryY . }nnuJ a}azazo� puz�}zod-r'^"'' .t;�lJ"�; � ' • � uot}ezrdes ��4 sasr� a}aanxo� ada� ua�.SH s�y o� dt� atIYA a}YJ F�ani.L .. .. ;— uaaunnI^I��bZ --- i?�°� a'i.L30'Pu3 �}ogjeas }� # �o�,uoi�aaS as��ild iroi5in��ui� # la�.i�d � / ci�� x�l ' - • •• ; • • ''�• ,. . [ OOSE{ �i3�az�S t�a}ry�) �:•' xue.L a}a�uo� �sY�axd . . :� � � �, 1--- .�o a,�,a- i�,ez �z . t�x dn) � e�=a ' u^w! � _ �oH ;'' x�oZ zodr�,� � � "`�� u0 dumd ' ia"a'I �H , _ �ua�}YzedaS .9� ' ianaZ usxejy xa}Y� �cH _ �'TEA . �� iiI?H uAhO� �rnrcJ �uauza� puej}xod aloHu°'idiSs}uV K}z.hAPaIi�.33unxed0 '' � ed�d �Ad Otr H�S ��tr �xed. n}dag uza:g 3aI'$ , ;' ., . ,�,•_� - ; ,,�� ,�• 1 K : , , , . ' •iaao� ssa��y � , �. zeao� w9 . ` .., ' � �?SI�LTV� jCJci}�3[,� � ' uoi}ertdaS . ZI � . � za}elY� P�iS �.L Pad�iS � }sod pa}Eazy amssazd ��tr X ��b i L� x i�d i°11uo� xa�diazTS Xb VI^I3td -��.�-a�� .v�c�,r.-�a�-v�ca�sc��v�� i ,•-,^� �� ~� ��. ss ��.� �� ' �``�- C� � �T�T�� I-�+ sn.waa-��n�n��n��.Il �3L�.m.Il�I�n. Applicant: �.--r�-�%•�',�u �.r,� Location: 3z.� ,��- �_ � � Operation Perrnit Tax Map � Parcel # � Subdivision Phase/Section/Lot # # of Bedrooms System Type (From Table Va): i Product (IIIg): �� c.v Type V& �/I Expiration Date: 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 of the Improvement Permit and Construction Authorization. (Authorized A t) l�lG4�A.El� 1..�'W �� (Licensed Contractor) Scale �r-S PCiiD, rev. 12/14/12 /o / (Date o %�f (Da e) ��.lt �aLD �� NDTG :�lG 6�-�!L Gi.d.�,( CON :''y.iT l OJ �' �Wc'S� ^i�L''�.1F-`i' �I ia' 7'!� 3/.� ~ I Z�' T2 i:."'niC� �o�4s" � ` �'`�s 5��3�,�,. .SL. Cof�2 �►.�c.�t� \ S�3/� , t � �'�T�.V(, �A "j�wo t� � t t�S'1'l�cL-Q•t. �so ►.1 �u �Q� l..t �1c E='��M,E�.1'i' Line Lengt � �� z 3 Tota1 I 300 ' Tax Map: � Parcel #: �� Septic Tank System Checklist (Type II-I� System Type: _�� Se tic Tank InitiaUDate State ID & Date: ,� q �✓t!3 3z G��r �� Capacity: j� 5 !oo 0 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: 7 i� i Ca acity: o 0 0 Riser (6" min.) NEMA 4X Box i Model: Piggy back plug Hard wired Alarm functioning Mounted on ost Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: %2'' Tank Com onents InitiaVDate Pum model: �0 9 Block (4") Nylon retrieva.l rope 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 S� 1 Line Size and material: � in. sch, o Length: -�-3 �o ft. Contracted Certified Operator (Type IV Systems): i� Ac � � � � i ,.. . , .` � .. .., � �- ��, ; � �� V .�-..� " �{ � � � � � J!. ��n�n�^am�na�xnc��rn.�a�..� �a�.a�,�.��n. Tax Map: `�� Subdivision• WELL PERMIT (New�Repair� Parcel• � z Lot: Applicant's Name: r S�f �%'� Ll Mailing Address: R � � Phone Numbers: Location of Properly: ��'� �C.+�f�- }�• Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicabde State and County regulations governing construction and setbacks apply. � 3) Permits expire S years from the date of issue. Other Conditions/Comments: l Permit issued by: �, �i r� �� Date: CERTIFICATE OF COMPLETION New Well Inspection: Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller• Pump Installer: Well Approved Date Sample Collected: 2'2 �� S �,�. �/V`-� Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 �Liner Inspection: EHS/Date Installer: � Depth: Grout: Well Abandonment: EHS/Date Completed: Mettiod/Material(s): _ License #: Lic�nse#: Date: 2- I 1- l Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 WELL CONSTRUCTION RECORD This form can bc uud for singlc a multipie wclls l. Wdl Contractor f.nForma6on: �o �� E E. �R � fi� Well ContraUor Name 3� 7 G -,� NC Well Conhacttor Ccrtification Mumba Barnette Well Drilling, Inc. Co�any Name Z Well Constrnctioo Permit t!: �'7 '� Lisr afl applicablt we(( cons[rvction permiu �.t Crumry. Smte, Varia�e, eu.) 3. R'dl Use (check wd! use): Water Sappty Well: ❑Agricultural ❑MunicipaUPublic- ❑Geothamal (Heating/Cooling Supply) �� idential Water Supply (single} �IndustriaUCommercial ❑Residential Water Supply (shared) Non-Water Supply Well: lujectioa �Vdl: �Aquifer RCcharge ❑Groundwattr Remediatian ❑Aquifer Storage and Rxovery OSaliniry Barrier OAquifcrTest �Stonnwater Drainage �Fa�erimentai Technology OSubsidence Control �Geothermal (Closed L.00p) �T�acer �Geothamal (HeatinglCoo(ing Retum) ❑Other (explain under #2I Remarl�sj 4. Date R'ell(s) Complctedz LD —ZQ /y9Ve11 ID# /! 7-0 Sa. VVell LocaHon: j�e.� e 2 .�cas t�e�e .�. ��i FaciGtylQtvr�r Namc Facility ID# (if applicabk� 3 z� �-�� R�� Phyuw Address, Ciry, and Zip ',��25os' � �Ztt� Couory Pa�cel Tdentificatioo No. (PTN) 56 I.afitudc and LonaiEude in d ees/ ' tes/ ds d' l d F« ►o�i uu orr�.v: f cYr�`� o « 2Qb « 28Src z A 15. OCITER CASIIYG for fnulu-n,ud �vdts' PROM iYl DCAMETER � ft �� f� 6 F��r � -'�; 3, f� � 2� I i�� 000l ` .: � � . ... � ft R ia ft fw ia .F.F.N�� .. . . . � . . � :. .. . . . ... ft (k :ou fG ft k NU/ ft it « ct ia ft �- � ft anai rwrea ment ft ft SGPACIC �ia tinble <` nzxre�. �eucenten ft f4 JG 9ttach'additiouat shetts iCneca58rY) ' - DF:SCWP7'ION coler Yard�a -ce7V�k � t° � v e Q b c� 2�1 o,J 5- rc �oQoruiv 1 ' i/` ao �o r� 6 R� L o � 2 ft ft f� „ egr rtuou saon or ecima egreu. ��rt�fcation: (if.veu setd, onc ladtong is sufi5c;ent) . .. � 36 -!� - z 9 N � `l -v � �_3z w �a��.r,c� � �.�c�C �a -'�`t'-� � � s�� oc�rus�a w�u coo� n� 6. Is (are) the wol!(sj: QPcrmanent or OTemporaiy By rign;ng t6is jorm. ! hereby cei-rijy rhm rhe weU(sj wns (were) co,utrrrc�ed in accordm+ee �� wiih !3A NG4C 02G .O100 or 15A NGG Q2G A200 Wetl Corulrvction Standards and dfwl a 7. Is tfiis a repair to au ezisting:wdl: OYes or �Qo nopyajthts reaonlhas beenpmvtded eo rhe well owner. IjtFir is n re�wt , frll out b+own wel! consuvc�ion iajorn�ria+ uird ezplvia tlu natarcofthc rrpairr�ader.4`?1 remarks section nr qr iye baek ofthltr fomf. 23. 5'Ite diag[$M ol' Ad�i6odai Wtll dtttil5: ; You may asc die badc of this paoc to provide,additional wep. site details or well &. Nambcr of wells constructed: � construcxion defails. Yoa may al5o attach addititln8l paaes if necessary. For muhrpte injectiort or non-woter supply wells ONLY wi!% the srtme tonsdttclioq; yort [mt svbm�ronejorm. 5UBMI'[7'AL INSTUCfI0A15 9.Totalwelldeptb belowlandsudaee: � T V (ft) 24a For All WcJlx Submit this.focm within 30 days of �ompl�iott of wdl FormxltipleweUsGsla!ldeptluifdijfererrr(eaon�e-3()a200•andz(a�1oo� c�nnsavaiontothcfo(lowing: I0. Sta6c water level6elow top of casing: Z' 7 (�� Divisioa of Watcr Quality, Information Processiu� Uai� IfH+a/er leve! is abwe aosing, use "+ � 1617 Mail Secyice Center, Rale'tgh, NC Z7699-1617 A 1. Borehote diameCer. D Cn.) 24� For Iniectioo Wells: In addition to sending the foim to the address in 24a n above, atso submit a copy of this form within 30 days of completion of �l( 12. Welt coostruetiou metLod: �j 1`/Q �Df� IC �i caostruChon to the fallowing: (ia au�ner. [ofaq': cabte, direct pustS dc.) . Division of Water Qualilp, Undergroaad [njectioa Control Program, FOA WATER SUPPLY WELLS ONL'Y• 163b Aiail Service Center, Rateigh, NC 27699-1636 13a Yicld (gpm) � 11�[cthod of tak B�own20 minYte 1Ac. For tYater Supo1V & Inieetion �Vdls: In addition to sending the form to HTH �e addiess(es) above; also submit pne wpy of this form within 30 days of 136. Disinfcction type: Amoan� 7�2 r+u p CO�P�� of wdl construction to the cauitiy hcalth dcpa�tment of thc counry whve constructed. Fam GW-I North Carolina DcpatWacat ofF�vitotiment ud Na4d Resources—Divisioo of WalaQtality Rcviscd Jau. 2013 � �hh ��S nc department af health end humao services �� :�� E � �� 1�.�� : ��i • �..�� ' a' �' �` � . �� 1 � � � � � I � �� For lnorganic Chemical Confaminants County: Name: S +'' � ` TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standazds for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorQanic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2.`�-The following substance(s) exceeded federal drinking water standards or the North Carolina 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 circled substance(s). However, it may be used for washing, cteaning, bathing and showering based on the inor�anic chemical results onlv. Arsenic Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron an��aries�l Mercurv I Nitrate%Nitrite I Selenium I Silver � Ivlagnesiurn � Ginc � pri 3. [] a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. 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 showering based on the inorQanic chemical resu[ts 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. ❑ 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 well head to determine the source of the lead and/or copper. 6. 0 The fo(lowing 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 aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. Barium Cadmium � Chromium � Fluoride Iron Ma esium Maneanese Selenium Silver pH Zinc For more information regarding your well water results, please cal! the North Carolina Division of Public Health at 919-707-5900. 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 http://slph.ncoublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 PETER FOSTER SMITH 319 HUFF RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES022415-0074001 Date Collected: 02/23/15 Date Received: 02/24/15 Sample Type: Raw Sampling Point: Kitchen sink Sample Source: New Well Temp. at Receipt: 3.0 Sample Description: Comment: Time Collected: 12:20 PM Collected By: Adam C Sarver Well Permit #: A40-424 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 55 mg/L Chloride 5.50 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron 0.13 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 7 mg/L Manganese 0.27 P-4 S 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 8.0 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 14.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 172 mg/L Total Hardness 160 mg/L Zinc < 0.05 5.00 mg/L Report Date: 03/04/2015 Page 1 of 1 Reported By: Arnold Holl North Carolina State Laboratory Public Heaith Environmental Sciences f�licrobiology 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: ES022415-0100001 � �� u u�� U �� u �� ES Microbiology ID: GPS Number: Sample Description: Comment: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htt�://sloh. ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Name of System: PETER FOSTER SMITH 319 HUFF RD ROXBORO, NC 27574 Col lected: 02/23/2015 12:20 Received: 02/24/2015 08:44 Sample Source: New Well Sampling Point: Kitchen sink Adam Sarver Angela Heybroek Well Permit Number: A40-424 Environmental Microbiology - Colisure Profile Method: SM 92236 Test Name: Water - Colisure Analyte Test Result Analyst Date Total Coliform, Colisure Present Denise Richardson o2/25/2015 E. coli, Colisure Absent Denise Richardson o2/25/2015 Report Date: 02/27/2015 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.