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A31 47A�alicatlon Date: /Z j o% Amount Paid: , O Receipt #: �'� T� M�ti #� �4- 3 I Parcel #: '� � �� _ _ -.-� � � �� v�` � �navaa�oaa-^�-^ ��m�. ��oaw_��lia APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORIxECT. FALSIFIED, CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHOF�tZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agentlprospective owner): Home Phone: 3.?6-.27Y q/��' Address: /�D.O°�f �%� Business Phone: fe�ra �� /Y. �, 2) Name and address of curren owner: �u �%� �. / �' ��'►^ �`a �Y l(jU I _�f �/,ar�;e�-oNf ---- /h�u rd�k /Y1,' 1/t . � C' � 3j Property Description: Lot size: tacr�Township: Directions to the property Including road names an umbers): a� � 9 ta c a� �,� c� eN, .�� 1Q Subdivision: Lot # e 4) Proposed Use and Structure Description: answer each of the following questiqn�s: a) Proposed _, Existing c�Type of Structure: l,^ a%/-e r,r.l o�; .� A��,.�eWidth: la � y� Depth: b) Number of Bedrooms: � Number of occupants or people to be served: �_ c) Basement: Yes_, No � Will there be plumbing in the basement? d) Garbage Disposal: Yes No � 5) Water Supply Type: Private c�(new _ or existing�, PublicJ Community� Spriing _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site pian. 6) Does your property contain previousiy identified jurisdictional wetlands? Yes_, No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED 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 th e on-site sewage disposal system fo� the above-described property. I agree that the contents of this application are true amd 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. / Z �� D e PCHD, rev. 06127/02 `�� ' � � �J �� -�" sa�-aa-�,..,.�,.,,ra�aa��.]1 IF�o.m.�l��a WELL P]E�MIT . PI.EASE SEE A�'TACHED PLAN FOR WELL SITE LAYOUT Tau Map #: � � Parcel # � Township APPlicaa� U u V � � �c�M Subd.ivisiori: Secrion: Lot Location: � �� --� �ds�c C�i�-(�� !�, � ,�(� - Tvue of Water Sun�lv: �quirements• �Individual Commututp Public Site Approved bp ✓�--�� a-F `{'� Groutti�ng A proved by ✓ C� /�-� � g w� �g c:� ia-� Well Ta�, Air Vent � Hose B� Concrete Slab Well Driller: ��.•7�a:J Well Approved �p: Date• �+°5ee Attached. Site Sketch'�°k 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 build'mg founda�on. Other conditions• PC.�ID, =ev. 09/07/Ol . ��' � �� . . . � •��Y1rL1{� ^1` . � �• V �� 1E.��-�,�-, o��.]t ]E��IE� � � 1,t1 e ( s��.�� - . I�7a�e (�( I i C'�T �� P,� 5� Taz I1�iap #�.,�Pa�rc�l #�' S • � Section/Lot�#' , - 1� �3 � �irthori�eri S�e Agent �- . ' Date� . . .5'�t c,oa�bottear�ie a�r�s�t �sa�c�a�te`�rsrs o�g►. �"�e c�r a�t,�lag �e ysta�es�r � b�eg�g' �is ' #o aarsasae #Arat�argsa�7e ss � �k✓t �� 5 �v�►'ca� 5�� S� �rv� • . � C��- � _ . � �re � � Sr�fe . 51��r�' . � �,�.e �C�s �� - . � �jr� pa K ��.e�- � .•, - � • ' 1 � - C�('�ie � f�► � �'��, se� �9 f 12�'Ul �� S �� ao � �.�� -��r ' �._, :. � ��.� �� o � . ► �- ' �-��T�� `° p�'Ia� �� .�,LL� ��.�-��,�,.-„ ��.� ��.Il��. D�o D��(lod 1 O Owner: Location: � Subdivision: Well Log —� � Tax Map � Well Construction Pazcel # � Distance From nearest Property Line (Minimum 10 feet) � 5 Distance from Septic System (Minimum 60 feet) (Q a Total Depth: I�S ft Yield: ��_ Static Water Level: `—=�— ft Water Bearing Zones: Depth ft�I'� ft ft 11� « Casing: Depth: From �_ to � 3 ft.�S�jDiameter: � � c. in Type: Galvanized Steel r/ Weight: � cs�Y6' Thicl�ess: �vlFY Height above Ground: 1� in Drive Shoe: vYes No Any problems encountered while setting casing? Yes ✓No If "yes" give reason: Grout: Neat: Sand/Cement � Concrete GraveUCement Annular Space Width inches Water in AYn lar Space Yes � No n Method of Grout: Pumped Pressure Poured Depth � to 2� Ft. Materials Used: No. Bags Portland cement Weight of 1 Bag 7� Pounds If mixture (san , gravel, cuttings) — Ratio � to i ID plates: _ Yes No 4 x 4 slab _ Yes _ No Drilling Log I.ocation Drawing From 7Co Formation O 1 ob �S � t� r o '? U C��r' ,` 3 � ,' d - 0'''''4� y � 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 Health Department. Signature of Contractor ' ID #,�,Z o�/ Date / .« o PCHD rev O1/16l02 �� '�� nc department af health and human services �� ^ � ;t' �:� � � �,�� ` �-� � � � ► I �� p � ��! �: ��. � �� ,- � ,y ¢' �-� � � � �`' � ^� �-; � E � � ; � ��, � � � � � j }� �{; �� ,�� pJ4y�� ;�� .�,� i �._.. � I �� t� {� � �t � � �� ,i f E ,R `�..�� '�.i Sample ID #: For Inorganic Chemical Contaminants Name: 'j�, Reviewer: S, � � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may have oth r 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 inor,�anic chemica[ results on[v. Arsenic Barium Cadmium Chromium � Copper � Fluoride � Lead � Iron � an�ean— e�l Mercurv I Nitrate/Nrtnte � Selemum � Silver � Magnes�um j �inc j pri 3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. 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 the inorganic chemical resu[ts 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 inor,eanic chemical 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. Baxium Cadmium Chromium Fluoride Iron Man�anese Selenium Silver pH Zinc For more information tegarding your wel! water results, please cal! the North Carolina Division of Public Health at 919-707-5900. � North Carolina State Laboratory of Public Health 3�12 Dist�ct Drve Environmental Sciences Raleigh, Nc 2�s„-so4� htto://sloh.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: Name of System: PERSON CO ENVIRONMENTAL HEALTH THERESA FORE 325 S MORGAN STREET 1081 CHARLIE LONG RD ROXBORO, NC 27573 Courier # 02-33-15 HURDLE MILLS, NC 27541 EIN: 566000331 EH StarLiMS ID: ES071916-0042001 Date Collected: 07/18/16 Time Collected: 2:00 PM Date Received: 07/19/16 Collected By: J Smith Sample Type: Raw Sampling Point: Bathroom sink Well Permit #: Sample Source: Well Temp. at Receipt: 4.5 GPS #: Sample Description: Comment: New Well 1(Profile) 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 66 mg/L Chloride 92.00 250 Chromium Copper Fluoride Iron Lead Magnesium Manganese Mercury Nitrate < 0.01 < 0.05 < 0.20 0.16 < 0.005 18 0.560 < 0.0005 < 1.00 0.10 1.3 4.00 0.30 0.015 0.05 0.002 10.00 < 0.1 1.OU m m m H 7.8 N/A Selenium < 0.005 0.05 Silver < 0.05 0.10 mg/L Sodium 26.00 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 180 mg/L Total Hardness 240 mg/L Zinc 0.45 5.00 mg/L Report Date:08/01/2016 Page 7 of 1 Reported By: Cin�fy Price North Carolina State Laboratory Public Health Environmental Sciences �ilicrobiology 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: ES071916-0058001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: THERESA FORE P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 http://siph.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 1081 CHARLIE LONG RD HURDLE MILLS, NC 27541 Collected: 07/18/2016 14:00 Received: 07/19/2016 08:11 Sample Source: Well Sampling Point: Bathroom sink J Smith Angela Heybroek Well Permit Number: Environmental Microbiology - Colilert Profile Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley o7/20/2016 E. coli, Colilert Absent Susan Beasley 07/20/2016 Report Date: 07/20/2016 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.