A28 202Application Date: Dy ��
Amount Paid: a
pc� �_)q-D�
9 l �l o
Recsiat #: � 5 � '
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�aa�n.a-ama�.�•-�--" ma:a�mJ1 �ZL�a.71.�I�a
APPLlCATION FOR SERVICES
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ParcEl #•
1F 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) Permit requested by: (Ownedagent/prospective owner): Deborah M. Bowes, et al,
Home Phone: 336-599-0770 Address: 17 B a oc airy oa
Business Phone: 336-597-2251 Rogboro, NC 2757.
2) Name and address of current owner: Deborah M. Bowes, et al,
1714 Blalock Dairy Road
Rozboro, NC 27574
3) Property Description: Lot size: 1 ac. Township: Olive Hild�ubdivision: Lot # D
Directions to the property (Including road names and numbers):
4) P�roposed Use and Structure Description: answer each of the following questions:
a) Proposed J Existing � Type of Structure: Width: Depth:
b) Number of Bedrooms: 3 Number of occupants or people to be served:
c) Basement: Yes , No % Wili there be plumbing in the basement?
d) 6arbage Disposal: Yes . No g
5) Water Supply Type: Private g(new g or existing�, Public_, Community� Spring _
Are any wells on adjoining property? Yes R No _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No g
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED�� ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAfCED 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.
� /� 5�9�
r Owner or Legal Representative
05/21/2004
Date
PCHD, rev. 06127/02
�,��� ) f ���� ��. V
�._ . , C�. � ����
�na�n�ra��nnxn��n�.an.� �'��an.���n
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T�x M�p � � � P�rc�el � i .
Suihclivi�s�ion , .�a:;,���
Fha�se SecNt�ion Lot # �
Applicant: ��c`�� �Lh���i
r ,.,..,.:,,., _ _ . . . , . �
Permit Valid for
Type of Facility: _
# of Occupants�,
Proposed Wastew
Proposed Repair:
Permit Conditions:
Improvement Permit
i� Five Y ars No Expiration ��/ �
�j ,�- New �Addition Water 5upply Vu '��
�_ # f Bedroom��s- Projected Daily Flow 3(� � g.p.d.
.ter System: �0L4���h�"'Lw � Type: .
('..,.,���.L'��o, TYPe: �5
�7
Owner or Legal Represe
Authorized State Agent:
��
�4- ����- C� `
Date: �,� �9'Q``�
Date: ' "�
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Insp�ctions requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Ru[es j'or Sewage Treatment and Disnosal 5vstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: (�O�t���vv�-��Q l TYPe �� Wastewater Flow ��Oag.p.d.
New � Repair Expansion _ p� Soil LTAR: �� 2-� g.p.d./ ft 2
Tyre of Facility: �,$� ✓��z � Basement _ Yes Q No
Wastewater System Requirements
Tank Size: Septic Tank: ��e�^�gal Pump Tank: gal Grease Trap: gal
._
Drainfield: Total Area: ��7� sq.ft Total Length `'c� ft Maximum Trench Depth �-Q in '
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft �� G�
Distribution: Distribution Box � Serial Distribution Pressure Manifold
Specifications:
e�
Authorized State Agent: �
Permit Expiration Date:
Date: �—Z'�
The type of system permitted is �Conventional Innovative Alternative. I accept the s ecifications of
the permit. t /Z �9/v c�
Owner/Le�al Representative: ��'i�i� Date: �
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�l3?��I�l�►TyON. �
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�uthorizsd Staie Agent Date
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(`an�r�iy� oor��ai � � � Trenct� Depth `�-� in
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Sealant
� Riser ifi a licable
- Tan6c Outiet Seai
Perman�rrt iVlarker
. Paa�aa� �'ank
Waterproof ISealani
Riser .
Water TiQht
� Chec� ValvelGaie Vaive
�IAnti siohon o e
,Alarm (visable and autlible
Electrical Cam �onenis
� Rate (qpm)
A raved Pump lV�odel
Block Under Pump
Pum Removal Ro e/Ct�ain
. � D'as�rabu�a��. Sys�en
Serial Distribution
Pressure I�an oi
Low Fressure �P� e
A r. Pi e i�rtate�iai anci Grade
Vaives
Trenc� Len th 3 ft.
Trenct� Grade
Roc� De�ti� and
Dams/S#e dov�nns ��c.
Pressiare La#er�ls �
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Siesve
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From� UVells Na� �D,
From Property 16nes
Structures/Basernents
ttc es / ratnage .a�
Surfac� W�ters
Pub(ic Water Suppiies
%�ticai Cuts (�2 ft.)
Water Lines
Ve�iicle�Traffcc �
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WELL PERMIT (Ne��Repair�
Taz Map: A�, Parcel: �� � Z
Subdivision: �� �n��a In�. Lot: 7
Applicant's Name:'� (�,r�,h ��.,ti.3�S
Mailing Address:
Phone Numbers:
Location of Property:
c� _. . . � , . ,
-�
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply. �
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit issued by: �/�Ytl�tu��� Date: �a/I`i�c�
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Locatiori: � w ol �l ��(�j �j
Grouting: 1
Well Log: �r�
Well Tag: J CS w, e I' a.., � O�1
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab: �
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller• G J^^ ^'` ^� S License #: �' S J
Pump Installer: G� ti.ti. ;,, c� S License#:
Well Approved by: �C/ "'" Date: G�/�' %�0 9
Date Sample Collected: Z,�Z�-�q
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date Results Mailed: 3- � 2-�OR
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
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i� ' ESIDENTIAL WELL CONSTRUCTION RECORD
5 �� � � �' S :
! r� �`� ` ,� North Carolina.Department of Environment and Natural Resources• Division of Water Quatity
� .�"°' � . - 2537
;'f '''�^°�•"" WELL CONTRACTOR CERTiFICATION #
, � ..
1. WELL CONTRACTOR:
Dennis Cummings
Weil Contractor (Individuai) Name
Cummin�s Developments, lnc.
We11 Contractor Company Name
S7REeT A�flRESS 360 Trollingwood Road
Haw River NG 27258
Clty or Town State Z'ip Code
3t 36 ).567-0800
Area code- Phone �umber
2. WE1L INFdRMA710N: .
SITE WELt lD #(�f appliwble)
WELI CONSTRUCTION PERMIT#
OTHER ASSOCIATEO PERMiT#(it epplic�ab{e}
3. WELL USE {Check Appiicable Box): Residential Water Suppiy 4c
DATE DR1tLE� �' � �— � /
TIME COMPLEi'ED 1��1 U AM �PM Q
4. WELL LOCATION.
CITY: �Slt1 ��Uf D counrrr� I�� �"SOn
�
I��� Srr�� h�t>►� �� � ane
(Street Name, Numbero, Community, Subdivision, Lot No., Parcel, Zip Code)
TO�(SGRAPHiC / LAND SETfiNG:
�tope B Vailey 6 Flat D Ridge U Other
(check approQriate box)
LATiTUDE ��� � Z�. j� c/ � May be in degrees,
minutes, seconds or
' CONGITU�E W^l �i � O7 •� 7 7� � a decimat fortnat
Laiitude/longitude source: x� GPS u Topograghic map
(location of welt must be shown on a USGS topo map and
attached to this form if not using GPS)
b. WEtL OWNER �.
owrvER's r�uw►E _ i- Y(��� �T—
STREET ADDRESS
r
City or Tawn State Zip Code
Area �e - Phone number
6. WEU. DHTAILS: / � � ,
a. TOTA4 DEPTH: /
b. DOES WELL REPLACE EXtSTING WEIL? YESB N09/
c. WA?ER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASlNG 1S � �T. Above Land StMace•' �
'Top of casing terminated aUor below tand su�iace may require
a variance fin accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �� METHOD OF 7EST Air Rotary
f. DISINFECTION: Type HTN Amount ��?7
g. WATER 20NES (depth):
From To � From To
From To � � From To
i
From To From 70
7. CASING: Thicknessl
, � Depth �3 F� Df� �� Wei�( ted 1
From+j_ To
From To Ft.
From To Ft,
8. GROUT: Depth Material . Method
From !� To T � Ft Port Cemt POur
From 7o Ft.
From To Ft.
8. SCREEN: Qepth Diameter Slot Size Materiai
From To Fk in. in.
From To Ft in. in. �,_„
From To Ft. in. {n.
10. SAND/GRAVEL PACK:
Depth Sfze Material
From To Ft
From To Ft
From To Ft.
11. DRItLtNG tOG
From To Formation Description
��
-���� �.��-
� K l�j'' .
' X t
12. REMARKS: ;�`':� � �
� �'PM �" . , ��' _ � �
/ � ���� �,.� h � � � � � ' � �
� s, , .
1 DO HEREBY CERTIFY TFiA7 TH�S WELI WAS CONSTRUCYED IN ACCORDANCE WITH
iSA C, WEIL CONSTRUCTtON STANOAROS, AND TNAT A CAPY UF THIS
R D BEEN PRO T TFi� WEIL OWNER.
�
.�-. l-/ -�q
SIGNATURE OF CERTIFiEO WELL CO i'RACTOR DATE
!,[� (1() � S� l,l f ln ��� s
P TEFtI t�OiNAME OF PERS�N COk TRUCTING THE WELL
Submit tl�e originai to the DEviston of Water Quatity within 30 days. Attn: fnformatton Mg�, Fam GW ta
1617 Mai! Service Center - Raleigh, NC Z7699-1617 Phone No. (818) 733-70iS ext 568. Rev. 3ro7
Report To:
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
Name of System:
Deborah Bowes
133 Smith Hill Ln
StarLiMS Sample ID: ES022509-0068001 Collected: 02/24/2009 11:55 J Smith
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Received: 02/25/2009 08:45 Angela Heybroek
ES Microbiology ID: 2114 SampleSource:: Nevir Well ° : Well Permit Number:
GPS Number. ; Sampling Point: Well head �' ,: A28-202
,
Sample Description: F �
Comment:
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://sloh. state. nc. u s
Phone: 919-733-7834
Fax: 919-733-8695
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result - Analyst Date
Total Coliform,Colilert Present - Joy Hayes 02/26/2009
E. Coli,Colilert Absent' ' Joy Hayes 02/26/2009
Report Date: 03/03/2009
�
Reported By:
Page 1 of 1
Susan Beasley
�'�°, � �-'�'. �,. '-,vr:.....�
�`-"� �;� . .-�
�._,,=�:;
MAR � 5Zoo9
� 4J•
0
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
�
North Carolina Division of Public Hea�tli � � � � � � � -
Occupational and Environmental Epidemiology Branch; Epidemiology Section
INORGAI�TIC CHENIICAL ANALYSIS REPORT
Private well water information and recommendations
Coun : ��� Name: U° '-✓ Sam le Id Number: ��� ��
�j' . .p _ ._ .
Location: Reviewer ��1i2
ANALYSIS REPORT
Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the
federal drinking wa�r standards. The pH is a measure of the acidity of the water. Drinldng water may
contain substances that can occur naturally in water or can be introduced into the water from man-made ,
sources. (These recommendations aze based on inorganic chemical analysis only.)
TEST RESULTS AND USE RECOMMENDATION5
Your well water meets federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering.
The following substance(s) exceeded federal drinking water standards. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering, 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 esium
Man anese Selenium Silver Sodium Zinc H
_ The following substance(s) exceeded federal drinking water standards: We recommend that your
well water not be used for drinkinQ or coolcing, unless you install a water treahnent system to remove
the circled substance(s). However, it may be used for washing, cleaning, bathing, and showering.
Iron
Nitrate/Nitrite I Selenium I Silver I Sodium I Zinc
Re-sampling is recommended in months.
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, S minute and a 15 minute sample at the
well head to determi.ne the source of the lead and/or copper. Contact your local health department for
re-sampling assistance.
OTHER CON5IDERATION5
Routine well water sampling for the above substances is recommended every two to three years. Sample
your well water when there is a known problem or contamination in your area, after repairs or replacement of
your well, or after a flooding event. Contact your local health department for sampling instructions.
Contact your local health department for more Information or go to htta://w�vw.eai.state.nc%ai/oii/hsfactsheet.html
Mxrch 10, 2009
North Carolina State Lat�oratory of Public Health
Department of Health, and Human Services
P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047
INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM
Name of System: gowes, Deborah
Address: 133 Smith Hill Ln
Zip:
County: PERSON
Report To: Person Co. Health Dept. ATTN:
325 South Morgan Street Ste C (336) 597-2371
Roxboro, NC 27573
Courier: 02-33-15
Collected By: J SMITH Date: 2/24/2009
Source of Water:
Source of Sample:
Type of Sample:
Type of Treatment:
Type of Analysis Private
Time: 11:55:00 AM
Location of sampling point: Well head
Remarks: Permit # A28-202 «-� � � � ��� - � � � � �
Parameters Results ' Units =-'Date Analyzed• '
Silver <0.05 mg/I -- 2/25/2009
Alkalinity as CaCO3 161 mg/I 2/25/2009
Arsenic 0.003 mg/I 2/25/2009'
Barium <0.1 mg/I 2/25/2009
Calcium 47.5 mg/I 2/25/2009
Cadmium <0.001 mg/I 2/25/2009
Chloride IC 15 mg/I 2/25/2009
Chromium - - - <0.01 -- -- mg/I - 2/25/2009
Copper <0.05 mg/I - 2/25/2009
Fluoride <0.20 - . mg/I 2/25/2009
Iron 0.91 ' � mrf'1 2/25/2009
Hardness as CaCO3 (Ca,Mg) 165 mg/I 2/25/2009
Mercury , <0.0005 = � mg/I ` 2/25/2009 �'�-�
Magnesium 11.2 mgll 2/25/2009 �j�'�
Manganese - 0.57 mg/I 2/25/2009 �,.� ��
Sodium 12 mg/I 2/25/2009 �
Nitrite as N <0.10 mg/I 2/25/2009 ,�
Nitrate as N <1.0 mg/I 2/25/2009 ''�?'�
Lead 0.005 m g/I 2/25/2009
pH 7.1 Std. units 2/25/2009
Selenium <0.005 mg/I 2/25/2009
Sulfate 5 mg/I 2/25/2009
Zi nc <0.05 m g/I 2/25/2009
Date Received: 2/25/2009 Report Date: 3/10/2009 Reported By:
Today's Date: 3/10/2009 Ref: 2777 Login Batch O�.Q2QQ70 `; Sample Number: A685829
Explanations
Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purposes. If
coliform bacteria are Present, the water is considered unsafe for drinking purposes.
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.
Inorganic Analysis:
Recommended limits for drinking water. Sample should not exceed levels listed
below.
Alkalinity
Arsenic
Calcium
Chloride
Copper
Fluoride
Hardness
No established limits
0.01 mg/1
No established limits
250 mg/1
1.3 mg/1
4 mg/1
No established limits
Iron
Lead
Magnesium
Manganese
Nitrate
Nitrite
pH
Zinc
0.30 mg/1
0.015 mg/1
No established limits
0.05 mg/1
10 mg/1(as N)
1.0 mg/1(as N)
Not less than 6.5 units
5.0 mg/1
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant Q�CeS +��1 �f 5
Address (� ►'vli{'`� 1 �I �Yt� County ��aYSoh
Collected By ��
Date Collected �� Z-D 'D�' Time.Collected %% : 3a
Source: Well ❑ Spring ❑ Other
Location: ❑�Iouse Tap Q'Well Tap ❑ Other
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Total Coliform
FecaUE. Coli
Results
Present Absent
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