A27 101c� �
Yerson Coun�y Health Department
Existing Sewage System Report For: M bile Home Keplacement ;��"
�dition �
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Requestee: � D 1"1 (l� � S Home Phone#
��a�( rn; �� (� ; l � _� •-- Business#
`Pax hlap# ��� � � (
Original Permit Located
Septic System Designed For: -
Residetttial Business other (speci�y)
# f3edrooms � # Employees Other
Uate Installed �1- � Water supply \
,., _ . .. _ � . n
'Pype of System
Nitritication Line �O� l ) k � �� }�(O�
v
Tank Size
Certified Operator Required l
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On site wasL-ewater disposal system showes no visually apparent
malfunction on �/�V/ L �_ .
Yermission is granted to:
According to the attached site plan.. -
Comments:
Environmental Health ���5�4.
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E PAYIE MIU�ERSOM
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nc department
of health and
human servees
�r�vate V�Ieil I nform�tion
and �s� �ec�mmend�t�or�s
Co�ant��: i ; O ni
Sample ID #: Z' — b
For Ir�orgtanic Cherr,ica� �ont�min�nts
Name: � . � ;�,��
Reviewer: �
TEST R�SULTS AI�1D IJSE RECO�MENDATIONS
1. 0 Your well water meets federal drinking water standards for inorganic chemicals. Xour water can be used for
drinking, cooking, washing, cleaning, bathing, and shower.ng based on the inor�anic chemical results onlv. You may
have other water sampling results that are not taken into account in this report.
2. ❑ The foltowing substance(s j exceeded federal drinking water standards orthe North Carolina 2L calcuiated 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 remave the circled substance(s). However, it may be used for
wash;ng, cleanirg, t��trZng a.n� sl-����ering'�ase� on t►'�;, i.norQ��iic ch�mi��l:esults or:lv.
Arsenic Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Maneanese Mercurv Nitrate/Nitrite Selenium Silver Magnesium Zinc � pH
3. [V�a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/l. Tne 1Vo�'ih Carolir.a �ivisiun of Fublic Healdi recommends inai only individuais on no or low sodium restx:cted
diets not use this water for drinking or cooking. It may oe used for washing, cleaning, bathing, and showering based on
the inorQanic chemical results onlv.
11 b. Levets over 30 mg/1 may pase aestnetic probiems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-samplir.g is recommen�ed 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 following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
c�akirg, washing, alear,ing, �athing, and showering based on iY12 Ii10YP�siY1C C%tCiitiClll /'CS[1IIS Ol1Iy, but aesthetic problems
such as bad taste, od�r, sta�r.ing of porcelain, etc. may �ccu�. You m��� want to ir.stal! a he�!s�h�!a water treatment system
to address aesthetic problems.
Barium Cadmium � Chromium � Fluoride � Iron
Man¢anese Selenium Silver pH � Zinc
For more information regarding your well water results, please call t1:e Nori/i Carolina Division of Public Healt/r at 919-707-5900.
0
North Carolina State Laboratory of Public Health 3�2 D�st�ct�Drive
Environmental Sciences Raleigh, NC 27611-8047
htta://slph. ncpublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Repo!� To: H. KELLY lVame of Sys�em:
PERSON CO ENVIRONMENTAL HEALTH ALISSA CHAPMAN
325 S MORGAN STREET
1524 MILL HILL RD
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES060216-0060001 Date Collected: 06/01/16 Time Collected: 2:15 PM
Date Received: 06/02/16 Collected By: H Kelly
Sample Type: Raw Sampling Point: Outside tap Well Permit #: A27101
Sample Source: Well Temp. at Receipt: 4.9 GPS #:
Sample Description:
Comment:
Ne�'�Il�ll I �RrQfi�e;
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 29 mg/L
Chloride 7.20 250 mg/L
Ch�omi�m < 0.01 0.10 mg/L
r�►,.,A� < n n� � mai�
.�
Magnesium
Manganese
M�rcurv
Selenium
Silver
TQtal Hardness
Report Date:06/14/2016
< 0.10
< 0.005
-----2� -
< 0.03
< OA�O:
2.00
< 0.1
7.6
< 0.005
< 0.05
Page 1 of 1
0.05
0.002
N/A
0.05
0.10
Reported By: Deddie .�tanco!'
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�Sra�n�o�anna�na��.� �a:�.�i��a
Date: (� /�2�/��
Name: �/y�. � ��,/ Tax Map:�2Parcel: I� !
Address: "'
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Re: Bacteriological Test Results
Dear Well Owner:
Your well water was sampled on �/ i/� and tested for both total and fecal coliform bacteria.
Your water sample test resulis are noted below:
No coliform bacteria were detected in the sample. Your well water is safe to use for drinking,
cooking, washing dishes, bathing and showering, based on the bacteri�lagiccl results only.
� Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total col form bacteria are naturally found in tlte soil. Fecal coliform bacteria are associated w:th
animnal and/or huma.n wasie. T�he, presence of either total or fecal coliform bacteria in well water 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 sam.nle, the water
may not be safe for us� Young children, the elderly, and the individuals with compromised immune
systems are especially vulnerable and their physicians should be not�ed of the test results.
A well that tests pasitive or tvtal vr fecal coliform bacteria should be properlv disinfec!ed and retested
n• ior to resumin� norrnal use. The well niay 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 Environmenta.l 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)
Pers�n County Environmental Health, 325 S. Morgan St., Suite C, P.oxboro, NC 27573, Phone: 336-579-1790, Fax 336-547-7808
North Carolina State Laboratory Public Health
Environmental Sciences
�icrobioloay
Certif cate of Anal; s�s
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NG 27573 .
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES060216-0076001
� ������� ������ ��� ����� ����� ����� �l��� ����� ���� �����) ����� ����� ����� ����� ����� �I��� ���� ����
ES Microbiology ID:
CPS Number:
Sample Description:
Comment:
Name of System:
ALISSA CHAPMAN
1524 MILL HILL RD
ROXBORO, NC 27574
Collected: 06/01 /2016 14:15
Received: 06/02/2016 08:05
Sample Source: Well
Sampling Point: Outside tap
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
http:!/sipti. ncuublictiealth.com
Phane: 9i9-733-7303
Fax: 919-715-8611
H Kelly
Angela Heybroek
Well Permit Number:
A271 Q1
Environmental Microbiology - Colilert Pro�le Method: SM 92236
Test N�me: C�lilert
Analyte Test Res�lt Analyst Date
Total Ccli�orm, Colilert Pres�n! Denise Richardscn 06/03/2016
E. coli, Colilert
Report Date: 06/03/2016
Absent
Explanations of Coliform Analysis:
Denise Richardson 06/03/2016
Reported By: Susan Beaslev
/ r
.� i�� �
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.
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The District' Health Department
Oran4e, Pesson, Caswell, Chatham. Lee Counties
Water Supply and Sewage Disposol
IMP OVEME S PERMIT No.
, � ; Da
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Owner:
Locatio � -'`� � •
�
r
Contractor: "-
Waler Supply: Private Public
�^
Sewage D�sal Faciliiies: No. bedrooms Dishwasher, Disposal,
tuashin_�lriaeh� ) th ;, �ttomatic appliances
1 _:: ,.; .f. _
Size of tank: . Nitrification line:
Other disposal facility:
Water supply and sewage disposal facilities lo on, i s allation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall 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-
PftOVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
,
, � .:. - - •
Date approved: Signed � "
Sanitarian
Well: ,� ` -
Sewage Disposal: Counter- ,,�4 ��: �� ,�'.�'n�i�t ;:.
signe'
gy; (Owner or his representative)
�/
Cerfificate of Com e� on s�
y __ � � BY. ;,.E%
Date Approved: Sanitarian
.._. (OVER) . _
Location of well and sewage disposal facilities sketched on back. ,_
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� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
1 supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
� at later date, Note location of water supplies on adjacent lots.
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a NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�5 suppIies, etc. Note special problems existing on lot. Wr.ite in measurements in order that installations may be located
� at later date, Note location o�F water supplies on adjacent lots.
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