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RSON COUNTY HEALTH DEPARTMENT
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WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # Parcel #
Zoning Township a �
Owner/Contractor ; �G..� Date� �� � �
Location/Address r7 q �� �- �s-R�
S.R.#
Subdivision Name ___ Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Area Size of Tank
SFD Mobile Home Size of Pump ank_
Busines # of Bedrooms Nitrificatio ine
Max De Trenches
�' Pe � Void 60 months'�
� Pe 'ts ma be vo d if site i
� W 11 and S ptic Layou
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� omments
Date Installed
V� d�f not in pliance th zoning regulations.
�or i}►te ed use chang . � n /'1
Approved by.
WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab
�blic Replacement� Air Vent
te Approved Required Well Lo�
ell Head Approved Well Tag
�outing Approved
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Date � v�stall� by ' Approved by
This report is based in part on infonnation provided ihe homeowner or his/her representative in the application submitted for this pernut The
enviconmental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the endvonmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pennit.sam O1/95 rev.1.0
ORIGINAL
The District Health Departme�
CASWELL - CHATHAM - LEE - PERSON COUNTIES ''"°�-s ,�,
Water Supply and Sewage Disposal �
- MP . ^'•lEMENTa PERMIT o
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Owner: , _ _ '
Location: - �
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canc=eccor:
Waler Supply: Private � Public
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Sewage Disposal Facilities: No. bedrooms �`� Dishwasher� Disposal,
washing machine, the uto atic appliances • l
Size of tank: � NitriScat�oa lin�: � ��
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� ��� Other disposal facility: •
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wate�upply_and. setyag�dis sal. tacilitier location,,.instaliation and
protection must -rneet state anc�local regulaUons. -
Septic tank should be pumped out;every 3 to 5 years and shall be maIn-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DIS�`RICT HEALTH DEPARTMENT
STAFF BEFORE ANY�PORTION- OF�THE INSTALLATION IS COV-
ERED AND PUT INTO USE. '
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Date approvc�d• Signe �
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Sewage I�isposal• � ��`�- , ."r' � � •
� Count r-
gy. r aign • - � ,�,a.-
,- '(Owner o his"representativ � _.
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i Cezlfi'icate of Completion � ,
Date Approved: �'�� gy;
� Sanitarian
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Loc�tion of well and sewage disposal facilities sketched on back.
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �('�Tp�� h�asd
Address �p � � n � (�( � rbY� �� . County (;
Collected By
Date Collected 5' f�, �� 3 Time Collected f�; 4d
Source: �'VVell ❑ Spring 0 Other
Location: � House Tap
❑ No Charge C�'Charge
❑ Well Tap �her
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Total Coliform
FecaVE. Coli
Results
Present Absegt
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Reported By
Date Reported -rj I �'7 12C'� �3
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