A40 117The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
i .,
Water Supply and Sewage Disposal
IMPROVEMENTS PERM�T�p`�
Da f" �
Owner:
Location: � �
�L� ( S S
Contractor: w
Wai�er Su ly: Priv L�.-� public
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Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other a tomatic appliances ~�
Size of tank: �d0 Nitrification >i*+P� ,� � �3
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 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 DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PUT INTO USE.
Date approved: _
Well:
Sewage Disposal:
By:
� �Signed �
Sanit rian .
Counter-
(Owner or his representative)
Cerfificate of Complefion
Date Approved: � ^ ` By:
a tarian
(OVE
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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PERSON COUNTY HEALTH DEPARTIVIENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIDLOGICAL WATER SAMPLEANALYSIS
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Name of Owner or Tenant ���G, i� ����,
Address� �jr0� W,�� � , County (�� `
Collected By �s
i
Date Collected N–(c��( � Time Collected 2� 4S
—�-
Source: 8'Well ❑ Spring ❑ Other
Location: ❑ House Tap 0 Well Tap
0 No Charge I�'Charge
C�Other
........................................................................�
**************:�**************��**********�****************************�*
Total Coliform
FecaUE. Coli
Results
Pre�s,ent Absent
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❑ �
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Reported By �i'� �
Date Reported 'T�,�����
Report To:
Vorth Carolina State Laboratory of Public
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Healtl- 3°2 o°st280o��e
Raleigh, NC 27611-8047
htta://slah. nc�ublichealth.com
Phone: 919-733-3937
Fax: 919-715-8610
Name of System:
CURTIS MCGHEE
96 GATESWORTH RD.
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ESO41613-0005001 Date Collected: 04/15/13
Date Received: 04/16/13
Sample Type: Raw Sampling Point: Outside spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 2:05 PM
Collected By: J. Smith
Well Permit #:
GPS #:
Inorganic Chemical I (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 6 mg/L
Chloride < 5.00 250 mg/L
Chromium < 0.01 0.10 mg/L
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 4.00 0.30 mg/L '
�Lead < 0.005 0.015 mg/L
Magnesium 2 mg/L
Manganese < 0.03 0.05 mg/L
pH 6.3 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 6.20 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 39 mg/L
Total Hardness 24 mg/L
Zinc < 0.05 5.00 mg/L
Report Date: 04/19/2013
Page 1 of 1
Reported By: Debbie Moncol
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APR 2 5 2013
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ihe District Health Depar�men�
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Suppiy and Sewage Disposdl
IMPROVEMENTS PERM T q
f� ?�t Da r
Owner:
�
Location: � � �
[s°Z'r � � `+o.'L � � S �
Contractor: �"'� L
WaYer Su lp: Priv� .�L�� blic �
t�) ��.�� ��^� l�
5ewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other a}ttomatic appliances -�—
fj.� C�C3 ,,� ' '? ,, .
Size of tank: A�� NitriBcation line:
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
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 DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IN5TALLATION IS COV-
ERED AND PUT INTO USE. •
Date approved:
Well:
Sewage Disposal:
By:
`� � � � �
Signed_ (�s�.�s �
Sanit rian
Counter-
eigned
(Owner or his representative)
Certificafe of Completion
�r�--�� �. - ,. �"
Date Approved: ` �� �� BY: •
a tarian
(oVE 7'
Location of well and sewage disposal facilities sketched on back.
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