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A23 202t� Application Date: � �" C�'� � � 3 Amount Paid:,2' G}C� �L�C.� � � �� , � � Receipt#: .� 3.��'� G� ..5 ,��-�5 �?� � I � ; :� �'��'��.� � �:k� � _� � �' `--,�-.� S � �I��:� �� I ��4 . ��-� � �' -- <C � �7��C� � aia.-�n.a-.m.na.�n.�cam�ca�.ra�L ��L.c�.�m..Il.��.a (� � �-`'t�'� Application for Services (Sentic Svstems and Wells) Services Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile.Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement) $225.00/$125.00 Tax Map: Parcel #: Construction Authorization (Fee is dependent on the type of sys Permit Revision $75.00 Repair of Ezisting Septic System No Char�e Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, tlien the Imnrovement Permit and the Authorization to Construct shall become invalid 1) Services ues ed b� Name: Ci O�'� �� • r Address: ` : P � ' � �-- v� t .S-e � �,d � � -• ,,,1 . / L'�� ` `-�� J� �i �� Phone # (home). �o c/cell): 3� - � ....' v `��`� �� 7� � �� `y� 2)Name a address of current wner (if different than applicant): Name: �i��'�� 55 �i� ' S"�3 �C Address: . �� 3) Property Description: Lot Size: � �` S divis} �n: Address an or directions to Property: r'c� �,�1 g�o 'n 1'L �-' "='•� �'' _ �"''�' .�.'t t-� G •s- � I,T_T r� �. rt � �,r-�� 4) Proposed Use and Type of Structure: Residential �� Bu�iness/Type: . Other Number of bedrooms � / Number of people served (seats/employees): _ Basement: Yes No (with plumbing: Yes No � Gazbage disposal: Yes No PJ 5� Water Supply:/ Private Well �/ (Proposed E�usting _) Community Well: Public Water Syste�} Are there on the adjoining properties? No '�/ . Yes (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property tlzat shows property dimensions and the size and location of all . proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. . � �,� \ �_,�:_ , . Signature (Owner/Legal Representative): ��C�:� �`"�`-��' '� Date : _'' � � � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) i �� i ��.LL.1' �� ' >j1� _�'I �L� � �� a�."S^3S �O -�� -rn-n � 723'�.ffi. ' i? J.L �.Sl.�'�� A�niiC��: I.oca#ion: Cu�;�n itit / ! �t�c �p � z3 ��,� � 2oz �:,o, ��a�� c��t4:1P ��l1� � � � �prmwe�esa�.��ri� �� '��l'a� �a�r %� �'��e � 1�� Sas��son Type of FaciIity: 3 . New � Acidition � �� Sa��gady 1�✓2( ( � of Oc�antsM�X � f Be�rooms—� Proje �te3 Daiiy Flow 3� g.�.d. Proposeci �Vastej,vatez Sys •�,� ` f�� e�--�heA Type: Praposed Repair: " ` – �^- Typ�: �9 . . Uwne= �r Lega1 Represe A,�'�orize3 State Agex� 'I�e issuaaca of �iris per�it lry ;.�e Heal� Depazttneut ia does nat gnaza�i� the issuancs of other per.�niis. It is the �esponsibilry of tliie ��IoP�Y owner m� siue that aIl i'ersun. Cou�t.y Plaa�ag and Zonmg and Bw']�mg Ivsp�tions requ�emeuts axe me� �S �pro��t �'�at i� saafl�j�t tm re��e�ad�an if time sa�e ��; �pl��'�� tt� iaate�de� use e3�aag�s. i�a� �n�+uve�ae�t �erffiat �s �� as�e� isq � c�e in o�er"siang� o� t�ae }n��gser#�►, 'i� p�s�it v�as is�uaesi a� cu�lianca w�i�a #Ine ��i�s� �f th� l�oriH� �C�limm�, .� `��s �d l�ules f�r 3`ewar�e �'rs�drsaeas� a� �as�osal �'vstesras' (].SA NCA� ��A .19��). I�eeitheu� ��rs�n ��a�.fy:�oa�';t.�r�.''� �atv��nt� �eeaiith Spers�ias# �r�rr.�t� tta�t t�ae s��tic :� sy��a � c�n�n�� tm fn�s�taon s�ia�u�iflly in tflne faai�ae'oe�i��. #fla�-wa�+er supgciy �v�II r��aiaa �aot�ie. . . . � :��ai9noa��ion t� �r��strmct �T��atea� S�s� (.$�.a.��s� ��r �a�1a% ��i) � *. Ses site plan cmd additianal attac3iments (_ j. �. � . -� Frop�os �it7astewater System: �� ✓Y► 4,-t�� t/ ��ir�2"�Ty-pe �q �rVas�tewates �la�w -�� 0 g.p.d. � t ' . New R.e�air FxQapsio � � - 5��i ��. , a� g.}�.�.! ft Z Type ofFac�ii.y: 3��.5. • � Baseffient�Yes_No - -� ��,,�,✓e�° ,�°oGe � - �'6� ��a�� Sp�$��n �33��e�� .. _ �.+°�' . 1(o�,�a(, r�';Yc.. -i�tiK . . . '�� : Se�c '�� 'T� / `ta� g� � g� � . �2a��a�: 'T�-� �'�: � � O sa� i� �� Ls�agth QO D � ' ' � �_ �a�a �ep� � n� . . . '��ac3a �d�a � #� �o� �nve�: �o � � ��n�a ��a�o� a � ��baa�ion: �i�baa#non �o� Se� ��n�non � �res�e �o��.��( O��ui�C ��h' f �p�c,�ti��a -vr S� ��( �–/k a, vr�q; �. a 5 G�6PS�� aK a� Q��• . . . -. . � � a� �� .� ��. Perrnii Exp � �on Date: Date: .'I� tyae oi system p�ii�e3 �s Co en�onai A Cb�r tea Altsrna�ve. I a��s�t the �erificacions of the P�- r � �• �e:'/��g�� 2i9�?��.�3'T8: ='^ C►� �ai�: 0 �� / �e 4 _s �l i �i.� Te�i. I j %� Q��J- . 0�—i ��Z a � � �) � �� , , � �� t � '� . . S ��.; � �� 1 � I�;��. ��.,��-�� :�I I--1��:�1� (� CLEARWATER S/D PERMIT CONDITIONS Information for the Installer: nsuring a healthy environment 1. System shall be installed per approved engineered plans. 2. Contractor must be certifi�d by the drip and pretreatment manufacturer in order to install system. 3. Contractor shall have a set of approved engineer's plans on the job site througl7ot�t installation. 4. Pre-installation meeting mandatory (Design engineer and drip/pretreatment manufacturer rep. must be present). 5. Contractor must re-flag drip lines on contour after clearing and have ]ayout approved by health dept. 6. When clearing drainfield area disturb soil as little as possible. 7. No site work should be done under wet conditions. 8. Contractor, design engineer, drip and pretreatment manufacturer rep., and certified operator must be present at system start-up. 9. Before operation permit can be released a registered professional engiueer or certified designer and drip/pretreatment manufacturer rep. must certify in writiug that the systein was installed in accordance with the approved plans and specifications. 10. All tanks must be accessible from grade. phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 � �� ;ii n � . J .� � a aw��, •� �� . � ..... � � �11. V �� wa��n�an'n.��n.��.� �c��,�tL� CLEARWATER S/D PERMIT CONDITIONS Information for the owner: nsuring a healthy environment 1. Before the operation permit can be released a copy of the signed certified operatar (ORC)contract must be given to the health dept. (a contract for operation �iuc� maintenance with an American Certified ORC shall remain in effect for as long as the system is to remain in use.) The URC must be both a Grade II licensed wastewater treatment facility operator and a licensed subsurface operator. 2. Grass must be established over the drainfield area and cut when needecl. 3. Caution must be used concerning volume of water entering system and what is put down the drain(ex. Grease, personal hygiene products, cigarette butts) phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 - _ �ii `,E I_ 1 CJl_S A, i �'r I`:; C;t. ; l:. . (:ARpL.INA I='Citi'�r;'R ta L 1 GH�� C:��P.ard�� h�l'CO L,�F�:E ,,.. ��.1�;;L ( t -� j,., ) f _,�_' 1A _ 1' _ __ ._ � ��.�.. t�� . _ ^�"�.. "�\J1,.'.� g�..`(,.. � � . �—'—'—__�_ C..,_, i `' '^ . /'� i L 1 � �7� � 1 19 ,�J� t, '��.'/�q�x�7�,�,9q1�-� f1't3'�r.l �'` _,_-- __'_--�.�., � � [.i; r r 1.. � 1 ' � ' �--_ _ � /� ��+�-� �..b�� i�,;� I cai�` ��_ ►�, C�_ �� ,p,,,�i `�� .�-7 �; r�;;?c� , �a.; {'p p r` P � 4�n ',' � fA 1'.�.�_��- ""� � I7 "' � O I � . . � � � � � � . 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" � . � ,. , :' , , : ,, :� � . , . , �� : � ,, �� ,;. � � � � �, , , �, �� . � ,; , , , ��/ ; �� , , /� � �� , , � �� /flj.�.�tltr-� t,fli'1 7t t,.� �Yl � �,� :'i� � / �': � , �% �� i� - �,k1'�i�- . � ' , E ��, � � ' f'liy ,��' " :- �' , � � ' m ��---,�• . � J �� "• � � � � • : , �'f� �' � '/,�' ,;,� �,�-,� .- : ,=<<:,� ,- ; � �W�, , ; ,;, �. , ,,, , � � l � . • /' �' �� ' �, , ,-� .'� '� �'� � �£fW'� �� (� ,/ / / ,'/ -\ �.._: ., , .- � - � �- �,. / / , , _� , , . - ";I ' • � <'''�.., ��1 , , ��. � � .� o \ '\ �. �:� �1�,;,�� %� � � �� II� �.�a��.��11 IH..C��.11�1�. W��L P�RMIT (New j�Repair� Taz 1VIap: � � � Parcel• � 2- Subdivision: � Lot: � Applicant's Name: � �O�_ 1l�Iailing Address: Phone Numbers: Location oi � , n ✓1 • Permit Conddtaons: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire � years fi•om the date of issue. Other Conditions/Comments: Permit i�sued lb�: ��., l�C �'tvv-2..� IDate: � C�12'I'IF'ICA'I'E OF COlVI�L�TI�11eT New Well inspection: EHS/Date Location: �� la� I � o Grouting: � ��a� /i � Well Log: � � �a�1� Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: ✓�_ Concrete Slab: Well Driller: ��Y�� Pump Installer: � �Vel1 Approved by: /`� ''�� Date Sample Collected: �( - ?2 _�U Person County Environmental Health 325 S. Moraan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: I9ate: � � — 0 Date Results Mailed: " � "�' Phone: 3�6-�97-1790 Fax: 336-597-7808 giiios : ''r. STATf �, •.. �'P�%, � ''! ,�i . :�, ��'~�,;��i..'"•,�`: i Io'O'. •�� • 1 _-�C. ri.� i/,��: 4�:... RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Deparhnent of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERT1FICATION # J-I�G ( l� 1. WELL CONTRACT ! : /) /�� ' rtT n Well ConVactor (I di dual) Na e Bamette Well Drillina Inc. Well Contractor Company Name 611 Barnette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2. WELI INFORMATION: � � WELL CONSTRUCTION PERMIT# ^ � OTHER ASSOCIATED PERMIT#(if app�icab�e) 2°i SITE WELL ID #(rf applicable) g. WATER ZONES (depth): ' Top � t� Bottom ! l2 Top Bottom � Top l 6 S Bottom (� O Top Bottom : Top Bottom Top Bottom Thickness! : 7. CAS/I�NG: Depth Diameter Weight Material � Top Y Bottom 6 3 Ft. �9 S�¢-$( P�C Top Bottom Ft. Top Bottom Ft. : 8. GROUT: Depth Material � Top� Bottom�� Ft. Sand/Cemenl Top Bottom Ft. : Top Bottom Ft. � 9. SCREEN: Depth Diameter Slot Size Method Poured 3. WELL USE (Check Applicable Box): Residential Water Supply ❑ Top Bottom Ft. in. in. DATE DRILLED �- a 6 �� V Top Bottom Ft. in. in. TIME COMPLETED �.t� AM p PM Lf Top Bottom Ft. in. in. 4. WELL LOCATION: � 10. SAND/GRAVEL PACK: /� / �� Depth Size Material CIN: /7/A�t��ICL,e.�✓� COUNTY l"'(J'SP� ; Top Bottom Ft. C�l � W/� �1G/ ��,t, ��D T'� 'J� Top Bottom Ft. (Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code) _ Top BOttOnt Ft. TOP GRAPHIC / LAND SETTING: (check appropriate box) lope ❑Valley ❑Flat pRidge ❑Other LATITUDE 36 °_' " DMS OR 3X.XXXXXXXXX DD LONGITUDE 75 °,' " DMS OR 7X.XXXXXXXxX DD Latitude/longitude source: �PS QTopographic map ' (location o/.we!! must be shown on a USGS topo map andattached to this form if not using GPS) 5. WELL OWN �6 flosc � Owner Name i;l�e,�wt�4t�✓ La�'l StreetRd'dress �.��.�� tM/,�x�.� r�, �. a�� y City or Town State Zip Code 36 J i 7- �2 O� Area code Phone number 6. WELL DETAILS: a. TOTAL DEPTH:�,� �� b. DOES WELL REPLACE EXISTING WELL? YES O NO l� c. WATER LEVEL Below Top of Casing: �.� FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS � FT. Above Land Surface' '7op of casing terminated aUor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): �,.t7 METHOD OF TEST BIOWII ZOfll r. DISINFECTION: Type HTH anount 1/2 CUp 11. DRILLING LOG Top Bottom _�/� 2 �_� J' �—�� / / � � / / / / / 12. REMARKS: Material Formation Description �'t,psb�� "J � / �4 C�A.rv�r1-t� I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. � �!� SIG U E OF IFIED WELL CONTRACTOR DATE �b �,.� �r� � Ci c 6 � --• PRINTED AME OF PER ON CONSTRUC ING THE WELL Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/09 ��.sf ��.�� ` � � �� IE��aa-�� .11 IF��.IL�I� Tax Map�� Parcel # o�a Subdivision (',�.�arwa•�e� Phase/Section/Lot # S # of Bedrooms � Applicant: �� d� Location: F„ Operation Permit System Type (From Table Va): _ � Product (IIIg): P r 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. f'� � �'Vv�.� uthorized Agent � � - Scale: o�' at�� 5,23 �° i 5 ��'-; —� [ ; � �� Z� (o (Date) � �7 �o (Da e) � ,e � l'f�li iT � � � N/1 �1� 1 7e�� 0� s� � � � �-►�-�° �'�--' P -�1� } `l�fA 1 d� 5 ��;' 31:3 � c 5 ��%�J��, LA I� �..� Line Length � Total Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� System Type: �� Notes: Pump System Checklist Tankl Pump model: Block (4"1 Nylon retrieval rope Float tree and attachments On/Off float swing: Alarm float (6" separation Anti-siphon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed and secured riser in. Supply Line Size and material: in. sch. Length: ft. Contracted Certified Operator (Type IV +Systems): _ �Vo �i�,.�Q ,��r'Z �y ��., S Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP �e-mail Date: lO �,� �� Thursday, September 02, 2010 Mr. Harold Kelly Person County Environmental Health 325 S. Morgan Street Roxboro, NC 27573 Caro�ina �ero�ic 5ystems, I��. Re: Certification of Installation Mr. Kelly, PO Box 1413, 163 Highway 64 W, Ste 9, Hayesvilie, North Carolina 28904 Randall: (828) 332-7221 Michael: (828) 33Z-1818 Facs3mile: (828) 707-9463 Pretreaimant Systems • Drip Systems • Direct Discharge • Effluent Pumps - Grinder Pumps • Control Pane�s Recircutating Sand Fillers • Low Pressure Pipe Sewage Systems • Lift Stations Single Family • Muiti-Famlly • STEP Systems • Community Systems up to 1,000,000 0allons per day American Manufacturing Perc-Rite Drip System This letter is to certify that the waste water treatment systems installed for lots 4& 5 in the Ciearwater Subdivision, Semora, North Carolina, consisting of an aerobic drip was installed byin accordance with both the manufacturers and the designer's specifications by limmy Lewis & Sons. All system functions have been tested and are operating within the designed parameters. For lot 4, the dosing rate has been calculated at 4.5 gpm and each dose has been set for 720 seconds (12 minutes) for a total of 54 gallons per dose. The system, under normal usage, should dose approximately four times per day with a standard rest time of 360 minutes. Additionally, the flushing rate has been calculated at 11.8 gpm for a total flush volume of 142 gallons. For lot 5, the dosing rate has been calculated at 4.8 gpm and each dose has been set for 675 seconds (11 minutes 25 seconds) for a totai of 54 gallons per dose. The system, under normal usage, should dose approximately four times per day with a standard rest time of 360 minutes. Additionally, the flushing rate has been calculated at 14.4 gpm for a totai flush volume of 162 gailons. As requested, attached is a copy of the service contract between Carolina Aerobic Systems and the homeowners. Ms. Lynn Mann will submit a finai "as-built" drawing within the next 10 business days. If you do not receive the "as-built", or should you have any other questions, please feel free to call me at your convenience. We appreciate the opportunity to serve the cititens of Person County. Sincerely, d1o.-c.� � ��. Randail G. Nelson 0 Smoky Mountain Geology Lynn Mann, PG Certified American Perc-Rite Drip System Designer 131 Carriage Drive Fairview, NC 28730 828-273-4453 Person County Environmental Health Dept. Attn: H. Kelly and Adam Sarver 325 S. Morgan St. Suite C Roxboro, NC 27573 336-597-1790 Re: Lot 5 Clearwater As-Built Adam, The system was installed with 9731inear feet of drip tubing, which exceeds the minimum design requirements of 900 linear feet. Please see the attached as-built schematic for the actual run and lateral lengths. The pressures measured during the dose and flush are adequate for system performance according to American Manufacturing guidelines. The minimum flush rate required with 973 lf is (4 Lat x 1.59)+ 4.8 gpm dose = 11.16 gpm. The measured flush rate is 14.4 gpm, so it exceeds the minimum required to maintain 2' per second scouring of the lines during flushing. Overall the system appears to be installed and functioning as intended. I have enclosed one copy of the as-built drawing for your records. If you have any questions please don't hesitate to call. Q< Lynn A. Mann .... � _ �_ � . . _ � . . . � �YS'I'EM DLS1C:Iv: ._ i �mok3� Mt�n.' Geology Lynn Mann, PG Fairview, NC 828-273-4453 SYSTEM INSTALLATION � Jimmy Lewis & Sons i Retrac Lewis Roxboro, NC '336-598-1704 � SYSTEM SUPPLIER.: i Carolina Aerobic Sys. ' Randall Nelson I Hayesville, NC � £328-8�5-2332 DF /�' LOT 4� � 0 � 1, '�—_ / �, .� �� _, �� , ��_ PRIMARY SYSTEM DESIGN: 3 BDR: 360 GPD LTAR: 0.2 900 LF REQUIRED PRIMARY SYSTEM INSTALLATION: 973 LF INSTALLED PRIMARY ZONE 1— DRIP LATERAL RUN LENGTHS a ' ,.., i�'V �8� .� F :��..� ��N S 1�� TOTAL F? 5� l� . � � `� �/ r-''i ` '.�-. �� I �E\ � N , EME� , ` � �60 15' WASTEWATER `'�'/ I PUMP LINE . � ' 'SEMENT �' �' , � �. ,�5 � ,' ' ,, , ,� , �' , , �. _ � ,, , ,, . . , , . . , , � �� i i , , � , , , , � � . ,' (� � / , � /, , h // / � , � , �, , � � , . � � , , � � , . � , �` � / , � , , ;� . , � , , , � . ,' c� ' � S� • , � �' � D� v . L ____ / � ; , o _,, . ��. , . . , -� �� s� ,. .�, , . � �� , . . , .�� a SYSTEM START—UP PRESSURES ZONE 1 DOSE FLUSH Supply: 44 Supply: 30 Return: 42 Return: 7 4.8 GPM 14.4 GPM / <`� 't t'Vl. lrtCHdii 1 :�L` i�Wi,i� :rciWi�. 0 NORWECO SINGULAIR BIO—� ETIC 500 GPD WASTEWATER TREATMENT SYSTEM. ;,. ,�� eu O �'UMP TANK. NOR11EC0 & AMERICAN PERC—RITE CONTROL PANELS. 15 GPM 1PASHDOIPN UNIT American Man�ifacturing DRIP SYSTEM. 1.5" Sch 40 PVC � ,� �,�0 �� l M ' �, � for / PERC-1�ITE � . GRAVITY BACKWASH RETURN LINE. LAT 4 RUIV �3 � � �i � I�t T1�1 1� 1 i� /�2,1 � '�'.��`� L � �:� � TOTAL 4 LATERALS 973 , NoJ � AS-BUILT SCHEMATIC FOR 360 GPD AEROBIC / ,.� O SUBSURFACE DRIP SYSTEM `�,\0 �s LOT 5 �'" � � � � CLEARWATER SUBDIVISION ` � •�• �`��r. �CALE 1'=50' DRAWN BY: LM SHEET 1 OF 1 1 �` / i� ti. �c< � � � a� -'� 1 v / i /� / . � � �� , /. / �� H YCO � LAKE % �/ _ North Carolina State Labor tory Public Health Environmental Sciences Microbiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NG 27573 EIN:566000331 EH StarLiMS Sample ID: ES112310-0114001 � �� ES Microbiology ID: 22626 GPS Number: Sample Description: Comment: Name of System: BOB ROSE P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 httq://slph.ncqublichealth.com Phone: 919-733-7834 Fax: 919-733-8695 CLEARWATER, LOT 5 Collected: 11 /22/2010 14:30 Received: 11/23/2010 09:02 Sample Source: New Well Sampling Point: Well head J. Smith Angela Heybroek Well Permit Number: A23-202 Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Joy Hayes 11/24/2010 E. coli, Colilert Absent ,� `—' Joy Hayes 11/24/2010 Report Date: 11/24/2010 Explanations of Coliform Analysis: Reported By: Joy Hayes �;- .��,�� } � If coliform bacteria are Absent, the water is considered safe for drinking purpose. Ifi 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. Vorth Carolina State Laboratory of Public Healtr O6 N. W?mo gton St. Environmental Sciences Raleigh, NC 27611-8047 htta://slqh. ncaublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH BOB ROSE 325 S MORGAN STREET CLEARWATER, LOT 5 ROXBORO, NC 27573 Courier # 02-33-15 EIN: 566000331 EH StarLiMS ID: ES112310-0061001 Date Collected: 11/22/10 Date Received: 11/23/10 Sample Type: Sampling Point: Well head Sample Source: New Well Temp. at Receipt: 4.5 Sample Description: Comment: Time Collected: 2:30 PM Collected By: J. Smith Well Permit #: A23-202 GPS #: New Well 1(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 100 mg/L Chloride 40.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride < 0.20 2.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 28 mg/L Manganese 0.22 O.Q5 mg/L Mercury < 0.0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L pH 7.4 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 24.00 mg/L Sulfate 56.00 250 mg/L Total Alkalinity 286 mg/L Total Hardness 370 mg/L Zinc 0.89 5.00 mg/L Report Date: 12/02/2010 Page 1 of 1 Reported By: � �i�s3 PERSON COUNTY HEALTH DEPARTMENT SUBSURFA�E WASTEWATER SYSTEM MONITORING REPORT t- �- � �- �'�- lo �c a3 �o� Date of Inspection System Installation Date Type ax Map Parcel # 5zo e(..�,,,�,�.d-� L.-,• Property Address Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for al( systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: YES / NO ��5 Evidence of leaks ? ❑ � Tank risers accessible, free of � C�.�� infiltration and surface water diverted ?�/� Septic tank needs pum�ing ? ❑ � r Inches of solids: % Septic tank filter cleaned ? � � ❑ EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alann operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids 7 r� Inches of solids(pump/dose tank):� Elapsed time readings ? Counter readings ? Drawdown rate: t: ■ : :' ■ ti ►': ■ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? � Diversions/swales properly maintained ? Vegetative cover maintained ? � Protected from traffic/unauthorized uses ? � Distribution devices in good condition ?� Field free of settled or low areas ? � / / / / / / / / i: i� ■ ■ ■ �umP C.�r ; (v r o �-�r �n7 � � � �l�► � �l � s�� s �,5 � C�r � 1 T ��k C�r: 2 Q �OtiJ �(2�-Qr : 5 Z.'��` s�a!P ��P�"-� �.-, PRESSURE DISTRIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessible ? � � ❑ / � . Pressure head properly adjusted ? ❑ � �� q °'� COMPLIANCE: Compliant �- Non-compliant ❑ Needs Maintenance ❑ 0�3� �-� �- DAVID BRANTLEY 8� SONS WASTEWATER TREATMENT INSPECTION REPORT SYSTEM OPERATOR: Y N REMARKS FACILITY: Type, size and sewage flow in accordance with permit '"` �� _.� �;;,s�;.- -- ,,, TANKAGE: Risers accessible, surface water diverted? ' ` �F' � ` " ` � 4 k;n� "+i'r�: ..Y. Risers structurall sound, waterti ht? ' ' " � , : •':� S_ _�a-, ` a�. � Sanita tee in ood condition? Effluent filters cleaned? �_ .�t.� �: r`. Slud e de th/a earance , level acce table? - k�:, � 4}�= .� ,� _�. Grease Tra : :*� � , � � �, `� � ,�� 4�,� =n.� EFFLUENT DOSING SYSTEM: Sludae depth/apoearance . effluent apoears clear? �"' "=� ..�-,�e� �,.�,: 3 s, . �z �� Required pumps present, operating, and cycling properly? High-water alarm present and operating properly? Vent/floats/pipe/valves/disconnects in good working condition? Control panel/electrical components in good condition? GROUND ABSORPTION FIELDS: No evidence of effluent surfacing/reaching surface waters? Minimal ponding in subsurface trenches? Surface water diverted around fields, no depressions? Line cover/vegetation adequate/maintained as needed? Protected from traffic, destructive uses? Distribution devices accessible? Distribution devices in good condition, working properly? Repair area properly reserved, maintained? Turn-ups/cleanouts/valves intact and accessible? No effluent standing in lower laterals? Laterals free of excess solids, flushed as needed? Diversion Ditch/Berm in aood condition? COMMENTS: MALFUNCTIONING NEEDS MAINTENANCE STRUCTURELY NON COMPLIANT COMPLIANT x�: � , - °'�.' i�� 5 �mp t� 9. � � ��1c� n� /��-�► ��s5.�-e,.-J � �� -� ,��.- �.� _�� s� �� L.�; 5 �� s� �