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A35 48Application Date: �� g�� Tax Map: � 3� Amount Paid: 02 �• O0 Parcel #: � � � Receipt#: 07 02 � � 3 � �� - N��d / a 8 �� . _ _� �� ' � - � � 1��'� v1T� � .�-v Z��zn.^s�i�az^-.caua.sc-icn<c'suvit.-..zn�l �.�'�Y<c^_,..�a..119:::��za. � Application for Serviees (Septic Systems and Wells) Services Re uested 0 Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 g d) (Fee is de endent on the ty e of ❑ Mobile Home Replacement or Building Addition �J Permit Revision $150.00 (if site visit required) $75.00 ❑ Well Permit ( ptacement/Repair) $300.00 200.00 $75.00 ❑ Repair of Existing Septic System No CharQe � � �� '� il Services Requested t�ay: ,�� q �'� 9/� ��5�.(�L Name: / , � �.-�. � �tr"%'�1�� Phone # (home): � �%�� '� 4 Address: � � (work/cell): ��-',�, � . � 2� �y 2)Name and address of current o�i�ner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: 4) Proposed Use and T} pe of Structure: Residential Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No � 5) Water Supply: Private Well (Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes Lot #: (please show location on site plan) Note: A completed application nzusf also include: ➢. A platlsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of tlte `Lot Preparatioii' form verif}�ing that tlte property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): �� GU� �. ,J'��Cf�Ct/JTa� Date : 02� � � 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��-.,�'�,5� 1�1�1�.��1�1 ��- � � �� J�, �m-� y- �� .� �.�.ffi.11 7HI � �.11 � SI'TE �I�'I'Ci� Natne _��,,+�_ ��u t� �� Tag Map #�_ Par.�e1 �� Subdivisio � Sectian/Lot# _ �-- � ' ��.`"l=s� - A tho�ized State A�ent Date Systesr� �omponents r�epresent appmximcrte�co�stours ov�ly. ihe co�imctor rrsrrst_ flag the system�rior $o beginr�i�ag the i�stexdlrxtzon to insure that propergmde es mair�tuined S � ��i��-�c;l�� ,�1 S��acI�S .✓' . : , : � �. .. � .. . ... . . . . �� . occupadon�l a�d N�� Dlvi�' ofr'ablto 8e�ltfi • . . . � � . . . . . .. . ��loBY� $Piden�iologySection • INORGANIC CHEMICAL A1�tALySIS REppRT ' Prlvate �re�l rnter fafot�utl0� md r�commencl�tlons . c��: � . �� f �) Nama. SampleId.�iumber: �8��,%e� iocation; • Reviewer �� . � . - _..�„_ ANAY.YfiIS REPORT Your well water was testeci for 1S m�tals, plus nitrates, nit�tes, and pg, �'he results were e�,��ted using t� federal dru�lang wa�r standards, The�pH is a meas�re of tho acidity of tho watar. Drinking water may con ' substances that can occur naturally in water or �� m�uced into the wat� from man-made so ces. �(Z'hesa recommendations are based on iaoiganic chemical �ys�s only.) TEST RESiJI,TS AND USE REC4MMENDATIONS Your well water meets federal drinkYng water stauda�, your,�,ater can be used for drinking, cooking, washing, cleaning, bathing, and showeting. • �' •.• •• The following substance(s) exceeded federai drinldng tvate� standards. Your water can b� used for drinlcing, cooking, washing, cleaning, bat�ving, and showering, but aes, thefiic problems such as bad taste, odor, staining of porcelain, etc, may occur; you may want to instail a household water treatment sys�em to address aesthetic pmblems, The following substance(s) exceeded federal drinidng wat� standards: We recommend that your well water not be used for drinkin� or cookin� unless you install a water treatment system to remove the circled substance(s). However, it may be used far washing, cleaning, bathing, and showering. Re=sampling is recommended in months.� ;.. Re-sample for lead and /or copper. Take a first draw, S minute, and 1 S minute sample inside tha house (preferably the kitchcn) and if possible a�rst clraw, S minute and a 15 minute sample at the - well head to deteimine the source of the lead and/or copper. Contact your local health department for re-sampling assistance. UTHER CONSIDERATIONS � Routine well water sampling for the abova substances is iecommended every two to three years. Sample your well water when thero is a lrnown problem or conta�mination 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 loc�l halth department for more lafordutlon or H to httas//wvvw, I�,r g�e�pc/enl/olilhefactsheet.html March 10, Z009 � j North Carolina State Laboratory 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: Oakley, Louise Address: 936 McGhees Mill Rd 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 Location of sampling point: Well head Remarks: Permit # A-35-48 Date: 10/19/2009 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 1:00:00 PM Parameters Results Units Date Analyzed: Silver <0.05 mg/I 10/20/2009 Alkalinity as CaCO3 87 mg/I 10/20/2009 Arsenic <0.005 mg/I 10/20/2009 Barium <0.1 mg/I 10/20/2009 Calcium 18.9 mg/I 10/20/2009 Cadmium <0.001 mg/I 10/20/2009 Chloride IC 5 mg/I 10/20/2009 Chromium <0.01 mg/I 10/20/2009 Copper <0.05 mg/I 10/20/2009 Fluoride 0.81 mg/I j 10/20/2009 Iron 0.14 mg/I �` 10/20/2009 Hardress as CaCO3 (Ca,Mg) 62 mg/I 10/20/2009 Mercury , <0.0005 mg/I � 10/20/2009 Magnesium 3.5 mg/I 10/20/2009 Manganese <0.03 mg/I 10/20/2009 Sodium 13 mg/I 10/20/2009 Nitrite as N <0.10 mg/I 10/20/2009 Nitrate as N <1.0 mg/I 10/20/2009 N� �I �! ZU�y Lead <0.005 mg/I 10/20/2009 pH 7.3 Std. units 10/20/2009 Selenium <0.005 mg/I 10/20/2009 Sulfate <5.0 mg/I 10/20/2009 Zinc 0.21 mg/I 10/20/2009 Date Received: 10/20/2009 Today's Date: 11/13/2009 Report Date: 11/12/2009 Ref: 14882 Login Batch: 11 �QQ��/� '�l� Reported By: �.�'�L��..�-"V� Sample Number: AB96745 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. r T Alkalinity Arsenic Calcium Chloride Copper Fluoride Hazdness 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/I 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 Report To: ` o�� L�Q 60 North Carolina State Laboratory Public Health Environmental Sciences Microbiology Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 StarLiMS Sample ID: ES102009-0035001 � �� ) �� ES Microbiology ID: 10349 GPS Number: Sample Description: Comment: Name of System: Louise Oakley 936 McGhees Mill Rd Collected: 10/19/2009 13:00 Received: 10/20/2009 09:07 Sample Source: New Well ' Sampling Point: Well head P.O. Box 28047 306 N. Wilmington St. Raleigh, NC 27611-8047 http://slph. state. n c. us Phone: 919-733-7834 Fax: 919-733-8695 J Smith Angela Heybroek Well Permit Number: A35-48 Environmental Microbiology - Colisure Profile Method: SM 92236 Test Name: Water - Colisure Analyte Test Result Analyst Date Total Coliform, Colisure Absent Joy Hayes 10/21/2009 E. coli, Colisure Absent �' —�` Joy Hayes 10/21/2009 Report Date: 10/23/2009 Reporte y: Susan Beasley ��. 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. t. ^ • r 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 � ��. �� l� ►�� ___.. _� �- � � �.� �. �� I�-;.�:��;�.�:m �_a-:�.�.a-�.�.�.11 1L--i �.�.�1�:�h. �i�I�I:� P��..1�/l�i�' (P��av_�e�� : a3s ��: �$ 5�n�d'n�Ilsa�a�: �a�: �-��g��Ile�a��'s i�1��: L u' e., e I��ai�in� A�la��ess: Q 1 � c �'fla�n� idaaambe�: � �c� - S9 /D �Qs�»aid �'ona'i8ao�a�: 1,► See attached siie plan for p�•oposed well location. � ?) All applicable State and Cozrnty reo lations goverNing constrzcction and setbacks apply.� 3,� Permits expire � years from the date of issue. �t3�er ��aadi�iors�/�'�raa�aen��: Gt l �1 Gl l n Ci ! S� aG�C t _ ��r�aa� �s5a�� b�: ��: g -Z� �d 9 ��i��'��'��1��'� ��+ ��1�� +`�'��f� I�� ✓`�� n�g�e��n�an: EHS/Date Location: � Grouting: lo -5-0� Well Log: Well Tag: —5 Pump Tag: Air Vent: ID-l�' "�4 Hose Bib: Casing Height: Concrete Slab: �..,�� i��5��o�: EHS/Date Installer: Depth: Grout: �� n�e��: EHS/Date �Completed: 1Viethod/Nlaterial(s): _ `b'��1� ��fl��r: Gtrn�i�e� �a�E�� #: Pump Installer: i,icense#: � ��I�1� ��ppr��e�l �uw: ��ge: /a-!� -a `� Noti `P� Date Szanpl_e Collected: /d -�q -� Pe:son C�unty Envi:-o:unental i3ealth _=� �. Ylcr7an St.; Suite C Roxnoro. NC ?7573 Date Results Mailed: 1�-1q -vg Phone: 336-�97-1790 r'zs: =30-:97-�803 sn�os Oct 05 09 02:16p Keith L. Barnette 336-598-9275 �- 3 � - L� 8 � � ,RESIDENTI�4L wr_LL CONSTRUCTION I2ECOR[) North Cam{ina Department of Enrtiranmcnt and Natural Rcsourcxs- Di��icion af Water �?ualitp 1�V�f,,[, CONCRACTOIt C�RT(F�CATION # J� �' ? � � Z. W¢L CdMRAC70R: I�U✓i s l�arn{�-� WeEf Cmtractar (Ind"rvidualj Name • � 8arnette Well Drilling 1nc. Well Cocttractor Campany Name STREET AflORESS 6't 1 Bamette Tingen Rd. Roxboro NC 27574 City or Ta�nm State �ip Code � 33fi � , 599-0015 Area code- Phone numbe� 2 WAilNFO}21dATlOtt strE w� �o s��r,po�� N1A STATE W FLL. PERMIT�f(rf �pp6ade) N!A DWQ or DiHER PERMIT #('d appticable) Nfa wEu. us� �cn� a�i� epoX}: Res�r� waeer s�,v�+r � DATE ORtLL.ED � �� l T1ME CalAPi.ETEO 3 1 n� AM p PM � 3. WELI. LOCATfON: • c�rv_ l��Xb nro caunmr I� c��on �cG-�c�s r�.{� ��z. �oX �36 (s+:en nt=rne. Numeers. cocnmurudy, s�,nanssian. Lra No.. Pa.ce�. Z� Code> TaPOGRqPfilC 1 LA O S�iTING_ Oslope ❑Vailey �Flat ❑Ridge O��* f�� _��,� � Aiay be in ae�+ees, LATEiUPE 3� minuces, suonds or LONGCfUDE • �n a dcttimal fnanat Latitude/longitude source: ❑GPS OTopa�aphic map ibcatiort o! w�eJ mirst be slanm on a USGS topo map and atl-athed lo tha (wm �nol using GPSJ � WELL OWNER OWNiER'StdAME L�f�tS f/ �Lt��i"� STREE� A�DRESS _�?s b f h G�1'il EG'S M% �� I2� �ZO��ara l��i Z7i%� C itp or Tavn State Zip Code r�6 ,- s��- sy�o Area code - Phone number 5. y1tELL DEfA1LS: a. TOTAI. �EPT}i: S� n • b�. QOES VYELL RFFIACE E7GSTING WF1L? YES �N� CI e WATEitLEVELSelawTapaECasing_ 2� Fi'. (Use "+' it Abwa Tcp d Cx:ing) d. 70P O� CqS1AiG IS �-5 FT. AGwe Land Surface' ''iap d casicg Le�mir�ated atla' below kvid wcface may require a� i� aomrdance u�[h 1.riH h1CRC 2C .01'18. e. Y�r� [sp��: � METHOD OF TESF S1ow 20 min p.1 f. DtSINFECTION: Type �i-{ o,mount .25 Cup g. WATERZONES (deplh): From �R P 7o L z From Ya From 7o From To From To From Ta 6, CASfNG: Thicknessl �P� ai�meler VeleigtA Ma�eriai Fran] �,� Tc�9yL____ Ft,—�-��— _186 GaIV From Q 70�7� Ft a�� $L�Z ( � Frorn To Fc � 7. GROUT: OepfSt Materiat t�tqd Frorn�i _ To �i 4 Ft GravellCement Paured From To FL From io Ft 8. SCREEN: Depih Uiameler From To Fi. i�. I%AFtom To Ft. in. 6rom To FL in. SlatSize Mateliat �. in. in. 9_ SAFIUIGRAVELl�A((�C_ Depth Size Matetial From Ta Fl N/�rom To Ft Fmm 7o Ft 10. DRILLING LOG � m Zp za �Q � lZ. REMARKS: For�a tion Description �t1CC i�G�c�Pn _5�� ^ �G �r�� ( ov � aa r�sv c�as�r Tw+T �us weu was cvwsrnuc�o N n�conna�c� wmi +su r+c+�c zc, weu coNsntucroa srnHp�Ras. ca�o -owra coP,r oF nas aewau was eeEer rRo+wEo ro� wEu oww�a. . �'� �Q_r� � y StGNATURE OF CERT{FIED WELL CONTRACTaR OATE Trc� �i5 (3�r�eF�-� PRINi'ED NAME OF PERSpN CONS7RUC77NG THE W ELL Submit the origir�al to the Division of Water Quality withiq 30 days_ Arin: Informatian Nlgt, F� �_�a 1 fi17 Mail Service Center— Raleigh, HC Z769S-iS17 Phone No. (919j 733-7015 ext 568. Rev 7ro5