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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
o a�n L- �H a E1�S
ater�upply and Sewage�isposal
IMPROVEMENTS PERMIT No.
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ner:
� Locati ri:. -
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Contractor: � L � S
Water Supplp: Private ��- -• " Public
I
Sewage Disposal Faciliiies: No. bedrooms � Dishwasher, Disposal,
washing machine,
Size of tank: �
Other disposal facility:
� appliances
NitriBcation line: _LL[1C1'_
�
Water supply and sewage disposal facilitj��'lpe�i'�n; installation and
protection must meet state and local regulatiori"s. �
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to crea'te 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 INSTALLATION IS COV-
ERED AND PUT INTO USE.
! i , f.
Date approved: 5ign � �� `` � `�
� . itari� � v �
Well: �
Sewage Disposal: Counter-� "�'
By: signed�,'-�t1- -
(Owner or his repre tive)
Ceriif'icate of Compleiion
Date Approved: '' y:
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
Aoalication• Date. �— � �'-G . . . T�c Matx� � °�J
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. � ��UcknoN Fot�s�rc�s - .
sHa�a. B�oe�e wvaun, �
1) Remiit requested by: edagent/pros�ective owne�: �
Home Phane: � �d�
Business Phane: .
2' Name and addness �f c�urent ownec
l
3) Property �'es '�ion: Lct size: �� Tcwnship� � ubdivision: Lot#
Diredions to the P�P�Y (indud'ing road. names and numbers � r �. �� ' A,e �
. �. 2 �� .
4) Proposed Use and S�ructure Descpiption: answer eac� af the foltawing questions:
a) Propased _, Existing Type af Strudure: iZ�-(�f�,. ,�� /Yl Width:. j� Depth: �
6} Number af Hedroom� _��, _ Number of occupants or peopie fic be served: �_ � ,
c) Basement Yes _, No �iMll they� be plumbing in the basement?
d) Garbage Dt�asak Yes _, Nc ✓ �
W r new or e�dsfin PubUc!/ COmmunity .,� SP�9 _ -
5� aba Suppty Type: Prnate _( 9�i. �
Ar+e� any wells on adjanir�9 P��"hl? Y�s _ No _ ff yes. Plea�e in�iCabe aPPrcximate location cn the siie plan.
6j Does the pro{�rty �ntain preeiously iderrtiRed jurts�nal w�lands? Yes _ No _
PLEASE NOTE THE FOLLOWING:
➢ A P4�T OF TI� PROPERTY OR SITE PLdN NUST HE SIDBBAITT� WITH THiS !�'P!.lCA77ON:
9 PROPEiZTY LINES AND CaRNEiiS AiUST 8E CLEARLY NAR1�D. .
➢ THE PROPOS� LOCAT7ON OF ALi. STRUCTURES flp]ST BE STAI�'D OR �AGGEU. � .
➢ THE SiTE 1MUST BE RF�►DILY ACC�SSSiBLE FOR APl EYALUATtON BY THE HE�LTH DEi��►�2TSIE�IT STAF�.
1� here� maice application to the Persan County H�ith Oepar�nent for a s�e evaivation �or the op-siie sewage dtsposal
systern far the above-descn'bed propeaiy. 1 agree that the co�er�ts of this applic�tion are true ac�d repre��t the rrra�amum
faa7ities ta be placed on the property. 1 understand i� #he sifie is alte�ed er the inbended use changes, the pem�ii shall
becarrte in�al�. n� � n..
Owner or f�ga!
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c) Baeemen� Yee _, No ✓IA1W the�s he pb�nbing In 1t�a b+�sameM? � ' ._
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� tNa� suppty Zypa: Priv�e �new ,_ ar �PueBc_, Cartmm��j► _. � _ .
Ars-eay �Is an ad�ni�g �? Yea�No _!f yas. pie�e i�e ap�aoa�s ioc�#ia�t an �e s� �an.
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� ooe� m. pe�prly r.� p�iou�y 1�.a jurL�iooai �ef�nds4 Yea _ tro ,/ .
PLF�19E NOTE T#1! FOLL�IYYNC� . . . , . �' . .
� � A PLAT OR'ML' PROP�T� OR SI� Pt.�1N W9T HE � W�l�I Tti� APPLf�CATION:
� i�OPEit?Y L1NE9 AND CORI�iS f�18T � q�ARLY 11ARf�.
'� .17�1E L�P09� LACA7�N OF AU. 9'iRUCitAiE3 �1�I' 8E �TA1tE� OR F�iAG[�. • .
D Ti� 9irE �NJBT HE RgAD�.Y A�iBLE FOR AN EYALUJR"TION 8Y THE HEALTH DH�!►i�ii@IT �'TAFfr.
1• Izere� rr�aice �aa #c tha P�rsott Caw�y t�h De�nt i�Ct a s�a evsiu�ion i�c �he oty-eii�a �+e �i
gY�n fuc' the abave�ed prcperiy. 1 agree tfiat the cantents af ttt�a �pQca�on � true attd t�pr� the nmocrtcwm
� tin �e an th� prnperiy. 1 under�nd ii the s� is ait�red or the bnb�ed use c�artges, i�e gem� shai!
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Tax Map # a� Parcel # I So�
Existing Sewage System Report For: Mobile Home Replacement
� Addition Type• �Z-��i roa�rt
Requester: ,I�ona 1aI C�,ar►� bcr.s
4�� m��h��.� m� ri ,�o��
�crnora, NG �.? 73 43
Location•
Original Permit Located: eS
Septic System Designed For: V Residential
Home Phone# �99 c�9✓��l
Business #
Water Supply: r�"� VA`�C � e- ��
Business Other
# Bedrooms� # Employees Other
System Type: �n � ��'��O n� � Tank Size: �� �� � �� Nitrification Line: 1��X 3�
Date Installed: �� � V�s Certified Operator Required: � O
On-site wastewater disposal system shows no visual signs of malfunction on 3'`1 '�� .
Permission is granted to: �� �d 0.�o�'x la ����r'ppM•
Comments: �0 ��D (.J � i �:�- � kt �C � •
Environmental Health Specialist I , Date: ✓-S �o�
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Tax Map # 6-1a� Parcel # 15a
Existing Sewage System Report For. Mobile Home Replacement
- f Addition Type: i'ar�v f- �
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Home Phone#
�1'�� �� �� 1!� � ��.- Business # 3310 - S 49 '��3
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Location• �
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Original Permit Located: �t QT_ Water Supply: _/ n v�-h-
Septic System Designed For: `��Residential Business Other
# Bedrooms��_ # Employees Other
System Type: I^v^� Tank Size: `�� Nitrificatiott I.ine: �W ��
Date Installed: 3- lo -�'S Certified Operator Required: Y10
On-site wastewater disposal system shows no visual si.gns of malfunction on 5- a-�a
Pernussion is granted to: �u+ �a- ��-�� �-�'�r �
Comments:
S� � S
Environmental Health Specialist
Date: � � a � a�•
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SITE SBETCH�
Name �o�Z � �
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Auth �iz Sta.te Agent
Ta.g Map #� as Parcel # � s a
Section/Lot#
,� s-a^�a
Date
System components representupproximate�contours only. The contractor must, flab'the system prior to
be�inning the installution to insure thatprope�.g�.ude ��i��d
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Scale: � o� +� ��„
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PGHD, rev. 09/12/01
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nc department
of health and
human services
county: z
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�w.a �'.� �zaST �usc:� n� ty � s � : � � > .� � ik 3a:� J i. �GG %� ���` � � �� s � �vs'
Sample ID #: — Z
For lnorganic Chemical Contaminants
Name: �—
Reviewer:
TEST RESULTS AND USE RECOMMENDATIONS
1. ❑ Your well water meets federal drinking water standards for inorganic cl�emicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic che`nical 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, cleaning, bathing and showering based on the inorQanic chemical results onlv.
Arsenic � Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Manganese Mercurv Nitrate/Nitrite Selenium Siiver Ma�nesium Zinc nH
3. [�a. Sodium levels exceed the U.S. Environmental 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 showering based on
tlie ii:nr�anic c/:emica! results onlv.
[�b. Levels over 30 mg/I 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. ❑ 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 inorQanic chemica! 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 nesium
Manganese Selenium Silver H Zinc
For nrore information regarding your wel! water results, please call tlie Nort/: Caro[ina Division of Public Henith at 919-707-5900.
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: H. KELLY
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://sioh.ncaublichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
DONALD CHAMBERS
4300 MGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES110116-0008001 Date Collected: 10/31/16
Date Received: 11/01/16
Sample Type: Raw Sampling Point: Outside tap
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 3:30 PM
Collected By: H Kelly
Well Permit #: A25-152
GPS #:
CA Well Monitoring (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
minum <
Antimony < 0.002 0.001 mg/L
Arsenic < 0.005 0.01 mg/L
Barium < 0.1 0.7 mg/L
ium
< 0.002
0.004 m
Boron < 0.1 0.7 mg/L
Cadmium < 0.001 0.002 mg/L
Calcium 5 mg/L
Chloride 63.00 250 mg/L
Chromium < 0.001 0.01 mg/L
Cobalt < 0.001 0.001 mg/L
Copper 0.05 1.0 mg/L
Iron < 0.10 0.30 mg/L
Lead < 0.005 0.015 mg/L
nesium
<
Mercury < 0 0005 0.001 mg/L
Molybdenum < 0 010 0.018 mg/L
Potassium
Selenium
Sodium
Strontium
< 0.01
7.7
< 1.00
�
139:0
<
17.00
m
0.02 m
20.0
Thallium < 0 0001 0.0002 mg/L
Total Alkalinity 201 mg/L
Total Dissolved Solids 300 500 mg/L
Total Hardness
Total Su
um
12
<5
m
m
nc < 0.10 1.00
Page 1 of 2
Report Date:11/17/2016
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
CAMA = Coal Ash Management Act
Page 2 of 2
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http://slah.ncpublicheaith.com
Phone: 919-733-7308
Fax: 919-715-8611
Reported By: Deddie .9Konco!'
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
Report To: H. KELLY
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph. ncpublichealth.com
Phone: 919-733-7308
Fax: 919-715-8617
DONALD CHAMBERS
4300 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331 EH
StarLiMS ID: ES111416-0043001 Date Collected: 11/09/16
Date Received: 11/14/16
Sample Type: Raw Sampling Point: Outside tap
Sample Source: Well Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 2:30 PM
Collected By: H Kelly
Well Permit #:
GPS #:
Hexavalent Chromium (Profile)
Analyte Result CAMA Screening Unit Qualifier(s)
Level
Hexavalent Chromium < 0.05 0.07 ug/L
Report Date:11/23/2016
CAMA = Coal Ash Management Act
Page 1 of 1
Reported By: Deddie .�toncol'