A35 110Aoalication Dat�: 16 -�'�
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APPl.ICATION Ft3R SEiiVIC�S
Tax Man #•
�3�
Parcal �• i � �
�IF iHE INFORNIATI�(d IN THE APP�1C�►TfOPI F�R AM INlPRt]NEAAEAIT PERMIT iS INCORREi:T. FALS11FiE�J.
CHANGED. aR THE SITE 15 AL7'ERED. THE�N THE IRAPROVEiIAENT PERMTI' AAID �►UTHORIZATION TO .
CONIBTRUCT SH�►LL BECOME lNVALID. �
1) Permit requested by: (Ownerlagentlprospecaive owner): S q M �l C�0�. @,4-� � o����r�
Home Phone: �� �R7 �8�7 Address: •- ��l �Ye� �
Business Phone: ��q �C-7�8(0 7 3 �
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2) Ydame and �ddress o� currer�t owner:
. � ��- �
C �
3) Property �escription: Lnt size: i��a Townshlp: Subdivision: Lot#
Direc�ons to the property (lncluding road names�and numbers): �•
<114� Art � PP� �A � I
4) Proposed Use and Structure Desaription: answer eacti of the following questinns:
a) Proposed . Exis-ting �e of Structure: Width: � De�th:
b) Numbec of Bedrooms: Number of occupants or people to be� served: -
c) 8asement Yes . No Will there be plumbing in #he•basemenYl
d) 6arbage Disposal: Yes No _
5) Water Suppiy Tj�e: Private new _ or exlsting�, PuDiic_, Community� , Spring � '
Are any wells on adjoining property? Yes Ido _ If yes, please indicate approximate locaiion on the
site pi�n.
6y �oes your property contaie�_previously identifled;urisclictional wetlancEs? Yes No
Pi.�4SE NOTE THE FOLLOWING:
7 A PLt�T O� THE PROPEi2T( OR SITE PL�►id �AAUST BE SUBMITTE� WRN TF1lS APPL1CAilOfd.
➢ PROP'ERTY LlNES :4AID CORNERS NIUST 8E CLEA�iL.Y MARdCED. •,
9 THE PROPOSED L�CATION t3F A►Ll,. STRUCTUi�ES flAUST BE STAiGED OR FLAGGEi3.
9 THE SITE MUST BE REJ�DIL.Y ACCESS18t,� E�R AN E1/ALUATl�N BY THE HE�►1.TH DEPARTiIflEidT
STAFF. �
I hereby make appiicatian to the Person Caunty Health Department for a site evaivation for the on-siis sewage disposal
system for the above-described property. 1 agree that the cantents of this appl'�cat[on are true and represent the maximum
faciliiies to be plac�d on the property. I understand ifi the site is altered or the intended use ct�anges, the permit shall
became irnalid.
Cwner or l�gal Representative
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Qate
PC�iD, rev. 061271a2
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sy� �„�� „�,��t �pro������u� �zy. The contracto.r mus�. flag' t�ie s,'stem prior to
beginning the instaAation to insure that�impergrade is maintained
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PI.EASE SEE A'I"I'ACHEI) PY.AN FOR W�I.L SITE LAYOUT
Tax Map #: � 3� Parcel #� �� Township
Applican�
0
Subdivision: Section• Lot•
'I'�e of Water Su��l� � Individual Communitp Pubfic
Requirements• �
Site Approved bp
Grouting App oved by ' S� Z
Well Log
We11 Tag_,
.Air Vent �
Hose Bib
Concrete Slab
Well Driller. 4� �`�'k�-
Well Approved Bp: "� Date:
�See Attached Site Sketcii'�*
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions•
PCHD, rev. 09/07/01
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IE�.����� ����.Il IE��.�.71¢]� Do�-0 � "°��� y- �.
Owner. �
Location: L�
Subdivision:
�iroki I�og
Tax Map,�� Parcel # 1L
Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: � ft Yield: �_ GPM Static Water Level: � ft
Water Bearing Zones: Depth %/o ft� ft ft
bs P"' �� P �-
Casing:
Depth: From � to ft. Diameter: ___(�__ in
Type: Galvanized Steel —
Weight: Thickness: �/�p'� Height above Ground: ,�� in
Drive Shoe:�. Yes No Any problems encountered while setting casing? Yes No
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annular Space Width
Method of Grout: Pumped _
Materials Used:
No. Bags Portland cement
Concrete�_ GraveUCement
inches Water in Annular Space Yes No
Pressure Poured Depth to Ft.
Weight of 1 Bag
If mixture (sand, gravel, cuttings) — Rario to
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
Pounds
Location Drawing
From To Formation
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County H ith Department.
Signature of Contractor ; ID#� Date �( a Z
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�mawn��dr�c�n.�m-�s��rn�,a� ��""��,�����a
Date: � / ( /�
Name: D �c `�► So �
Address: ( �S �`�
C o,ro C ?S?
Re: Bacteriological Test Results
Dear Wel! Owner:
TaxMan:�s Parcel: 1��
Your we11 water was sampleci on �/ � i�, and tested for both total and fecal coliform bacteria.
Your water sample test results are noted below:
� No coliform bacteria were detected in the sample. Your well waier is safe to use for drinking,
cooking, washing dishes, bathing and sho.wering, based on the bacterialogical results only.
Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total cel ferm b�cteria �rz naturally found in the soii. Fecal celifor�! bacteria arz as�ociated wi±h
animnal anr]/or human waste. The presence of eit�e; total or fecal coli:orr► bacte: ia in vrell ��ater 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 colifor`n bacteria are present in your water sample, the water
tnay not be safe for use. Young child, en, the elderly, and the individuals with compromised immune
systems are especially vulnerable ana► their physicians should be not�ed of the test results.
A we:l t,§at tests positiv2 for total or fecal co:iform bacl2Y:li S%10�IG� b2 pPOACY:v disinfect2d and retested
ri� or to resumin normal use. The well may be disinfected using the enclosed disinfection procedure. A
wetl contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly
flushed out of the system, please contact the Heaith 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,
, �x�%r
Envirenmental Health Specialist
�'erson �aunty Health Department
(rev. 4/20/16)
Person Count-y Em�ironmerrtal Heaitii, 325 S. tiiorba;i St., Suite C, Roxboso, NC 27573, Phcr�e: 33L-579-1790, Fa�c 336-597-7808
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant ����Sd�✓
Address �t�� G � ��lf��G �` County
Collected By
Date Collected
� / Time CQllectsc# /�'i: ��
Source: oWVell ❑ Spring ❑ Other
Location: t�" liouse Tap ❑ Well Tap ❑ Other
❑ No Char e harge
9
..............................................................................�
******************************,�*********************************************
Total Coliform
Fecal/E. Coli
Results
Present
0
❑
Reported By � �' � �
Date Reported �i '�� � �
Report Calle �YES ❑ NO
Cailed To .
Absent