Loading...
A30 39��i�,,.,Ye sy� �,�� Application Date: ���J �� . Tax Ma :#c v O Amount: Paid: ;- -� _ . : 3 � Receipt#: � � �;•:,y�*�'�, . , Parcei'#: �� �1�. i ��� ���� �� � < <� �---- -�- � � ��-� . . ��.����� ��:��h ��m�� APPLICATION FOR SERVICES fF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFiED, CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTFtORiZATION TO CONSTRUCT SHALL BECOME INVALID. � 1) Permit requested by: Owner/agent/prospective owner): ' -O�, Home Phone: — Address: � �� Business Phone:�,�9 9 —5�6�,� ' � 7.s�f- � c e�/ �98 -!5 �� ,� 2) Name and address of curren owner: , �►�1 3) Property Description: Lot size: �,Township: �_ Subdivision: Lot#: 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: Depth: b) Number of Bedrooms: Number of occupants or peopie to be served: c) Basement: Yes _, No _ Will there be piumbing in the basement? d) Garbage Disposal: Yes � No _ 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 the property contain previously identifled jurisdictionaf wetlands? Yes _ No _ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L1NES AND CORNERS MUST BE CL.EARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED 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 foc 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 unde�s nd if the site is altered or the intended use changes, the permit shall become invalid. i ,> „ ,� �--� ` > � Owner or Legal 1,-3-�/ Date PCHD, rev.10/17/01 _��.ss ��I�.��� `!'- ''`'� � � �l�T�� ���a�.�������.� ���.��� WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Ta�c Map #: ,��� Parcel #�_ Township r� Applicant: 1�CC�i0.C'C.� �.l � ►�-�P�,�' —� ,� ; �I> �Q �Ej C � Subdivision: Secdon: Lot: * - --� ___ � Q � .. � (t 1 1 ii /1 l7tiGC � M '� � n h" �n.�[ ( Ir, I � J ? Ty�e of Water Su��ly: VIndividual Community Public Rec�uirements• Site Approved by /��i lZ''I �-�/ Grouting Approved by /�'� l�"��'�l Well Log �%,i.� �' I�� a I Well Tag Air Vent Hose Bib Concrete Slab WellDriller. �• ������,'u��so�z Well Approved By: Date: '�See Attached Site Sketch** �Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any buildin� foundation. Other conditions: PCI-ID, rev. 09/07/01 ������ ������ _'- ����� ]���a-����m.��.IL IE�T��.Il�:I� Name ��l jd,�Ol,�`f� V�l 1'�� �iP��� Su division thorized State gent SITE SKETCH. Tax Map #�..Parcel #s� Section/Lot# (�-D3-�O 1 Date System components represent approximate contours only. The contractor must, flug the system prior to beginning the installation to insure that j�roj�ergrude is maintained Scale: Nd��.. Q �� � ��� PGHD, rev. 09/12/Ol �a��: ��'1.2�? I � Ow; ei. � �.,oc��ion/Dixections; Y�R5UN COUNTY ENVIRONH�NTAL H�A�'1H WELL L00 -- � ) ��'l� l�iT�l�l.� SR# , Subdivision Namc; �`'� �� Jnlling Contractor: � ���K�a �U�"" ��"" <"'� � � ,v✓FT.Y, c�QNST�U J+s�:ncc hom Ncares� Properry Linc Di�wncc from Sourcc of ` .''�C�1:u�l�T� . -,.. T;,�1 �ep,th; `i L. Ft� Yield: � GPM Static Water Level Fc, tii�a�cr Bearing Zones: Depth c F[. Fc._ Ft. C�sing: Dcp�h: From�_�o Ft. Diamc � � Inches '; `.''t��: Stcel � Ga]va.nized Sceel � If Sceel, does owner approve: Y�s No 1Veigh�: Thickness: � ` Height Above Ground: Inches Drivc Shoe: Ycs No . � Wcrc Problcros Encountcrcd in Setting thc Casing? Ycs No � ;.` "ycs" givc rc�.�or�: G;�u,; Type; Neat Sand/Cemen� Coricrete Annular.Spacc Widch _,_.�nchcs Wa�er in Annular Spacc; Yes No_._. Mzthod, Pumped � Pressure,_ I�oured •,�_ Dep�h: From O_ to � F�� Materials Used: No. Bags Portland Cement Weight of .1 bag�lbs. If mix�ure (sand, gravcl; cu�tings) - TZatio: co . ID Platcs: Ycs '� I`Io,__ 4 x 4 slab Ycs ✓�. No :� i �REBY CERTIFY THAT THE ABOVE XNFORMATION TS CORRECT AND THAT TH;S WELL WAS CONSTRUCTED iN ACCORDANCE WITH REGULATIOi�lS SET ���'�'H BY TNE PERSON COUNTY HEALTH DEPARTMENT, , , ' �` � ( Z-(2�o I Signat>>rc of Con�t'act • Da�� ��t {` ' I� j � � E ,�-• � ` 5._..r'� }'' � 't ! f`S f I�i 1 ! � � J ! F � � j � 1. �'� p rti�i �k t � ' ,�" i � F i 1! �:�� i LJ `�' � f LJ �� t. �� i i f,t i � ( t� �1 '.. i�, f Y 4 P M r--• . F . �": � � .`-�� � �:^;.�^ � t s-.f _ � ^` `,a � ? 'e, l�� ....� !�?. � t� � i � , � � J�� 1 `t j ! '' ��� � :,e it; ..� �.—� �,:i i ....�' �� 'L.! ��Z �i � �• E e � i �/ �' � ','' `�! f.. E J �i l�' k For Anorganic Chemica/ Con�aminants County: e ►� Name: t,Jar ►' 'e Sample ID #: ��—� Reviewer: qw�e,� l.�� TEST RESULTS AND USE RECOMMENDATIONS Your well water meets fedsral dr�rilcing water sta.zdards for inorgunie ch�rnfcals. Your water can be used for drtnktng, cooking, washing, cleaning, bathmg, and showering based on the inor�anic chemical results onlv. You may have otner water sampling results that are not talcen into account in this report. 2. 0 The foIlowing 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 ci�cled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inorFanic chemical results onlv. Arsenic � Barium � Cadmium � Chromium Copper Fluoride Lead Iron Manganese � Mercury Nitrate/Nitrite Selenium Silver Maenesium Zinc nH 3. � a. Sodium levels exceed the U.S. Environm�ntal Protection Agency's (USEPA) HeaIih Advisory levei for sodium of 20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or (ow sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering ba�ed on the inor�anic chemical results onlv. ❑ b: Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, etc. ' 4. � Re-saanplin� is recommended in months. 5. 0 Re-sample for lead and /or copper. Take a first draw, 5 minute, and I S 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 inoreanic chemical results onlv, but ae�the±:c problems such as bad taste, odor, staining of �orcelain, etc. may occur. You may want te :astall.a household water ireatment system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride � Iron Manganese Selenium Silver pH � Zinc �or more information regarding your wel! water results, please ca!! the North Carolina Division of Public Health at 919-707-5900. North Carolina State Laboratory of Public Health Report To: ADAM C. SARVER Environmental Sciences Inorganic Chemistry Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH K3'k�'i �`� [�7 :Zrl 1. �� �:� �� 1 Name of System: P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://sloh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 HOWARD WHITFIELD 6917 BURLINGTON RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES062816-0029001 Date Collected: 06/27/16 Date Received: 06/28/16 Sample Type: Raw Sampling Point: Well head Sample Source: Well Temp. at Receipt: 9.4 Time Collected: 11:20 AM Collected By: A Sarver Well Permit #: A30-39 GPS #: Sample Description: Comment: New Well I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium Cadmium Calcium Chloride < 0.1 < 0.001 5 < 5.00 < 0.01 < 0.05 2.00 0.00� 250 0.10 u Fluoride < 0.20 4.00 m Iron < 0.10 0.30 1�1 Mang� Mercu < p. i < 0.0005 0.015 0.002 Nitrate < 1.00 �o.00 mgi� Nitrite < 0.1 1.00 mg/L pH 7.0 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 6.40 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity Total Hardness � 20 Zinc 0.21 5.00 mg/L Report Date:07/07/2016 Page 1 of 1 Reported By: Deddie .r'�lonco�' �� � � ,� , � ,� � �* ��^ �� `�' � �� ��. � �C�;��.���d;��x���z� ���.��.�1 lE��t�:: �=1�:11,� Date: �/�/� Name: � �" "` W �' ���'- Address: r ,SGr %tit � r,-o S ' Re: Bacteriological Test Results Dear Well Owner: Tax Map: 3� Parcel:� Your well water ��as sampled on �U /�� / i�0 , and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: � No coliform bacteria were deiected in the sample. Your weil water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are r�aturally f�und in the soil. I'ecal coliform bacteria are associated wit;� animnal and/or human waste. The 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 sample, tlte water may not be safe fos use. Young children, the elderly, and the individuals tivith conzpromised immune systems are espe�ially vulnerable and their physicians should be notified of the test resadts. A well that tests positive for total or fecal coliform bacteria should be properlv 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, � ��.r2� Environmental Health Specialist Person County Health Department (rev. 4l20/16) Persen Coun.ry Em�ironmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences f�icrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES062816-0094001 � ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ���� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: HOWARD WHITFIELD 6917 BURLINGTON RD ROXBORO, NC 27574 Col lected: 06/27/2016 11:20 Received: 06/28/2016 08:19 Sample Source: Well Sampling Point: Well head P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta:/lslph.ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 A Sarver Susan Beasley Well Permit Number: A30-39 � Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 06/29/2016 E. coli, Colilert Absent Susan Beasley 06/29/2016 Report Date: 06/29/2016 Explanations of Coliform Analysis: Reported By: Susan Beaslev / � � 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.