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A25 135The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and �ewage Disposal IMPROVEMENTS PERMIT No. , Date (,�Z-$� ''" � � Owner: �5,,,) C� �1 �.�' 4 '?3ii � Location: �1 � �.�uaaacwa. � • / 1 � Water Supplp: Private � Public � \`^ � i � 1 C��c� Sewage Disposal Facilities: No. bedroom,�� Dishwasher, Disposal, washing machine, othe}� �utom�tic appliances _ _ _ Size of tank: —; NitriRcation line: � Other disposal facility: • � �v }— �j t � 4� �,,.-� a r Water supply and sewage isposal facilities location, installatioy an protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years an3 shail be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY • PORTION OF THE I TION IS COV- ERED AND PUT INTO USE. Date approved: Sig d anitari We1L• Sewage DisposaL• By: �, Counter-� aigned (Owner or his repres tative) CerYi�cate of Completion Date Approved: By. � Sanitarian (OVER) Location of well and sewage disposal facilities sketched on back. r e NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located Apalication Date: � ��� �� 3 Tax Map #: •��'� Amount Paid: l . Receipt #: 7 7 Parcel #: � 3� � 2� ����5� ���� �� � � - _ --� � � �1��� f�%� l� �aavn.a-oaa��-TM-�� �aa��-71 g��ac En.7L�Iia ❑ Improvements Permit Improvements Pertnit- $150.00 (Mobile Home ReplacemenUAddition) RepaidReplace Existing System Pem APPLICATION FOR SERVICES Well Pertnit $150.00!$200.00 nent) �$2�i�6�' for Septic Systems- V1� IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1�rmit requested by: (Owner/agent/prospective owner): S U�— l� �� '�-- Home Phone: 59 9-7 �h9 ?� Address: /yl eC- ecti � d, Business Phone: ���mo y�U-. � �Z't � �'3 2) Name and address of current owner: 3) Property Description: Lot size: �'�c...��Fownship: r,�u -�+..�v�- Subdivision: Directions to the property (Including road names and numbers): 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed _, Existing _, Type of Structure: Width: b) Number of Bedrooms: Number of occupants or people to be served: c) Basement: Yes_, No Will there be plumbing in the basement? d) Garbage Disposal: Yes _, No _ Lot # Depth: 5) Water Supply Type: Private �(new _ or existing�, Public_, Community_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. �� Owner or Legal � /�=1�3 Date PCHD, rev. 06/27/02 < � � ,' NOTE - Qll physico/ fea�ures are proposea SUE H. F�FE Cunninghom Twp• , Person Co• , N. Ca . �nn��a�v /984, Hol� ��H°3D tt � Assc SCO/8 a 30 =-- __�- _ = �-�.�_.�____— -- C. Homlett RLS 2465 . r�,. �_�� � �'^� :,, � . .� .�....,.; �-- c� � ����'� ���������n�.n�z����.� ����������� Date: � /�/� Name: �c�GQ —i � Address: '�.5�'� �/`tc, fJ?i � �^'lcrw .Ve ?3 Y � Re: Bacteriological Test Results Dear Well Owner: Tax Map: 27 Parcel: � 3 r7 Your well water was sampled on �/ Z/�, and tested for both tota.l and fecal coliform bacteria. Your water sarr�ple test results are noted belo�v: No coliform bacteria were detected in the sample. Your w�l! water is safe to use far drinking, cooking, washing dishes, bathing and showering, based on t}ie vacterialogical re�ults only. � Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliforrn bacteria �re naturatly found in the soil. ��'ecal coliform bacteria are associated w:th animnal and/or human waste. The presence of either total or fecai coliform bacteria in well wat�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 present in your water sample, the water �.ia� not be srrfe for use. Young children, the elderly, a;zd the individuals with compr�mised immune systems are especially vulnerable and their physicians should be not�ed of the test results. A well that tests positive for total or fecal coliform bacteria should be properly disinfected and retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the 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, . ���� EnvironmEntal Health Specialist Person County Health Department (rev. 4/20/16) Person Coun'ry Environmental Health, 325 S. btorgan St., Suite C, Roxboro, NC 275'3, Phone: 33b-579-1790, Fax 336-597-7808 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BA�T�RIOLIOG�CAl. WATER SAMPLE ANAI.YSIS Narne of Owner or Tenani V� -� � Address 35 �°j ��,� /f.�r�(� �� County ✓�e �?3 Coilec�ed B� Date Collected �+Z'-� �D Time Collected e=� 5 Source: Q�Wep o Spring ❑ Other Location: ❑ House Tap ❑ Well Tap �Other ��r�Q �e� ❑ No Charge �Charge 25� �35 ■��sa�r��rr�����s����r���r��=�aR�eoeiaaa�a����i�rri�er�aesae�������r������r�s�� +f***dr*aF#�tit�lr�r*�F�friF�kirir�YYrir*i4*9t#�k�t*Yr�t�FAr*�Ar�lrir*irdrir*�r#*�Ir*ir*#*ie**�1r�t+t*�tdrwiFBr�fret�k*�kYr**�t�yie.� Total Coliform Fecal/E. Coli Results Present � ❑ Reported By Date Reported __ `3 ` / (O Report Gadlest �(ES ❑ NO 1 ' Called To %�'l��N� v/�� S 3��Ir � Absent ■ �� � North Carolina State Laboratory of Public Health 3�12 Di tnct�Drve Environmental Sciences Raleigh, NC 27611-8047 htta://slph. 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 SUE FIFE 325 S MORGAN STREET 3599 MCGHEES MILL RD ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES050316-0034001 Date Collected: 05/02/16 Time Collected: 10:15 AM Date Received: 05/03/16 Collected By: A Sarver Sample Type: Raw Sampling Point: Outside spigot Well Permit #: Sample Source: Well Temp. at Receipt: GPS #: Sample Description: Comment: CA Well Monitoring (Profile) Analyte Result CAMA Screening Unit Qualifier(s) Level Aluminum < 0.05 3.5 mg/L Antimony < 0.002 0.001 mg/L Arsenic < 0.005 0.01 mg/L Barium < 0.1 0.7 mg/L Beryllium < 0.002 0.004 mg/L Boron < 0.1 0.7 mg/L Cadmium < 0.001 0.002 mg/L Chloride 7.90 250 Chromium 0.002 0.01 Cobalt < 0.001 0.001 1.0 0.30 � < 0.005 o.U15 m nesium 4 m ese m Nickel < 0.01 0.05 < 0.010 < 0.01 0.1 Potassium 1.11 Selenium < 0.01 0.02 Sulfate Thallium Total Alk Solids 20.0 < 0.5 Z.1 m < 5.00 250 m < 0.0001 0.0002 m 500 m Total Hardness 37 mgi� Total Sus ended Solids < 5 m/L Vanadium 0.0052 0.0003 mg/L < 0.10 1.0 Page 1 of 2 Report Date:05/19/2016 North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis CAMA = Coal Ash Management Ad Page 2 of 2 P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 Reported By: Deddie .�ivnco! = 1 r � .` � � ( ti' f s•Z �.� t �` l �_..� %" /-1 / � / �!2 E C yS : �� nM �� S� � ' '/`i � ,t g f- {t i i j � i L ` � F � 1 P rI ' �� � P 1 Q S � � � i i•S ` � f ' {I} e � �,P ( f e �k a LJ �J ✓ i f � L�'1 ,. � `s � [y �---� . f r� / �- �ti l.�} /:^l.'^1 � � -- = �' �~�I r,� t ; ie, f_��4 "`.i ��. f �� !' f ^ F 1�� (r-�.� if I�"� i•-' l--.i ��..� t—: - - ��<j i t �_ a ...,.r� `... '�,t �`Z �J �`�./� \/ E � e Z � � �l P � �,; ;.�F f.. E \,? E i � � For Inorganic Chemical Con�aminan#s County: .QrS� ✓t Name: l� � Sample ID #: Reviewer: � TEST RESULTS AND U3E REC�MME,'VDATIONS 1. � Your well water meets federal drinking water standards fo� inorganic cdemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inar��nic chemi�al resul!� or.lv. You may have other water sampling results that are not taken into account in this report. 2. 0 The following substance(s) exceeded federal drinking water standaxds or the Nort.h Carolina 2L calculatzd health lev�ls. The North Carolina Division of Puhlic Hsal±h recommends that your �•�ell w�ter na: �e used fcr drir►ki��g �nd cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inoreunic chemical results onlv. Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead Iron Manganese � Mercury � Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH 3. � a. Sodium levels exceed the U.S. Environmental Protection Agency's-(USEPA) Hea[th 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 uss this w�ter for drinking or cooking. It ma� be used for washing, cleaning, bathing, and showering based on the inorPa.nic chemical results onit�. ❑ 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. 0 Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferab(y the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the we(I 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 sho;�ering bas�d on the inoreanic che�;ticat results onlv, but aesthetic problems such as bad taste, odor, staining of porceIain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. � Barium Cadmium Chromium � Fluoride * Man�anese Selenium Silver pH Zinc For_more_information regarding your wel! water results, please call the North Carolina Division ojPublic Health at 919-707-5900. ; North Carolina State Laboratar�� of Public Health P�o. Box28047 ' 7 4312 District Drive Environmenta! Sciences Rafeigh, NC 27619-8047 htto://sloh.nceublichealth com inorganic Chemisfry Phone: 919-733-7308 Certificate of Analysis F�� 919-715-8611 Report To: ADAM C. SARVER PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: SUE FIFE 3599 MCGHEES MILL RD ROXBORO, NC 27573 Courter # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES050316-0036007 Date Collect��: 06/02/96 Date Received: 05/03/16 Sample Type: Raw Sampling Point: Outside spigot Sam�ls Source: Well Temp. at Receipt Time Coliected: 10:15 AM Collected By: A Sarver Well Permit #: A25-135 GPS #: Sample Description: �ommer�t Hexavalent Chromium (Profile) Analyte Result CAMA Screening Unit Qualifter(s) Level �l.exavalent,Chromium 1:92� 0.07 ug/L Report Date:05/09/2016 CAMA = Coal Ash Management Act � V �l� �iM r $ a ��m (�� �t(�' 'Zd�— r� �o� Reporte� By: Ci�2d'y ?�'i ic2 "U �`�( . �.� - �' �^�Lo� Page 1 of 1 r � ��-�,�'� .