A40 153Site Evaluation Application
Fee Collected YES ✓
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1. Permit requested by:
Address:� �.�C
Home Phone �� : �i I O-
Date: � �
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APPLICATION FOR IMPROVEMENTS PIIiHIT
ownerlTruspective owner:
agent:
►•� I�o,cib•z, N C
2. Name and address of current owrier:
Business Phone 4�:
N�� CI �.,-��
3. Property Description: Lot size: �.la. AC,
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4. Tax map ��: �b� 1� 3 Township c-��Sh '�'r� uw�S h��
Subdivision Name: Y 1°�� �4 f- Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
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6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: o�
8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? ✓ public? _
Other source? (Specify):
Are there any wells on adjoining property?
11,
community? spring?
If so, identify location:
Type of structure or facility: Proposed: '/ Existing:
Type of dwelling: House: � Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes ro
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake a17. corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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 understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
�.Signed ner or Authorizen Agent
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Permit Issued �._
Permit Denied
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i�ACTORS - SITE EVALUATION _ AREA 1 AREA 2 AR.F.� 3 AREA 4
l. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, loamy, aye
Note 2:1 clay)
3 . SOIL STRUCTIJRE (12-36 in. )
(Clayey soils)
4 . SOIL DEPTH (i.n. )
5. RESTRICTIVE_HORIZONS (in.)
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�—� ervious Strata ock)
6. SOIL DRAI2IAGE/GROiJNDWATER
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(External & Internal)
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7. SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
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g. SITE CLASSZFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2�QiENDATIONS / COMMENTS :
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S.�:TE CLASSIFICATZON �IAGRAH (Znclude: Soil areas, property lines. roads, streams, gulZies.
Wet areas, fill areas, wells. water bodies, slope patterns, etc.)
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Apaltc:��on Date: 7'"��
timount Paid• tS'(�—
Recei #: � 1 ` �
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Person Countv Health epartment
Environmentai Health Section
APPLICATION FaR SERVICES
Tax Maa #: � � o
Parcel #: � ��
IF THE INFORMATION IN THE APPLICATiON FaR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Pertnit requested by: (OwneNagent/prospective owner): ��RQV �FIgN �JQVlS
Home Phone: 599—�SD7' Address: 3�Z .�5 f� E�P .F'o/
Business Phone: �oX bo�,, • C, z�s��
2j Name and address of current owner. D
_ 9 �
,L' � 7
3) Property Description: �ot size: � �ow�nsh p: �� �` �.�/ �� �- �
Directions to the'ro'erty (induding roar names anr numbers): I(dn/�rL/ �s^oaG%s L�� �
4) Proposed Use and Structure Description: answe� each of the followin,g questions:
a) Proposed �, Existing ❑ �
b) Sticic Built�, Modular �, Single Wd Double Wide �
��'�� c) Number of Bedrooms: �'� �.� d) Number of occupants or people to
e) Basement: Yes� No � if y s, # of basement fixtures:�_
fl Garbage Disposal: Yes �, No;�'
g) Dimensians of Proposed Strudure: Wdth��Depth:� ����� S� ��.,
be served: ��
5) Waber Supply Type: Private�new � or existing ❑), Public 0, Community 0, Spring ❑
Are any ells on adjoining property? Yes �o � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�onventional _Modified Conventional _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLlCAT10N
I hereby make application to the Person County Health Department fo� a site evaluation for the on-site sewage disposal system for
the above-described properly. I agree that the contents of this application are true and represent the maximum faalities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as appiicant, I am responsible for identifying and maricing property lines, comers and making the site accessible for the
personnel of the Person Courrty Health Department to conduct their evaluations. I understand that I am responsible for notifjring the
Health Department if my property contains any weUands as designated by the Army Corps of Engineers.
,,(� �� ? iy �
Owner or Legal Representative Dat
PCND, �y. �a�tiss
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WELL PE�tNIIT .
PI.EASE SEE A'I'I'ACHED PLAN FOR WELL SIZ'� I.A..YOIJ�
Tax Map #: �� Parcel #.� 5� Township
APPlican�
Subdivisiori: �.U���r'�I �a�e ��'� �Section: Lo� �
Location: �
N' a0� �` �r v � S {�'��
Tvne of Water Su��lv /'�iciivicival CommunitY Pubhc
Requirements•
Site Approved bp •
Grout�ng A roved bp ' � ��
Well Log
�
Well Ta� ,
Air Vent �
Hose B� �
Concrete Slab
Well Driller: �� ` �
Well Approved Bp: ���Date•
�� (� s
'�See 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 anp bu�d'mg foundation.
Qther conditions:
PQ-�, rev. 09/07/Oi
�,p�s�ication Date: I b ' � � �0.�
.�mount Paid:
Recaipt #:
i ax iUlap �• !V' "► v
P�rc21 �: ��3
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APPl�1CAT10P! FOR SE32VIC�S
IF Ti-IE IN�+�RM�►T10RI IN TiiE APPL9G�►T1OPl FtlR �R! If1APR��/Ei�IER�T PERi�JI� !S IRlCORRE+�T, �ALSI�BE�,
C�ld'aNGED O�t THE S1T� IS e4LTE�2ED. T�Ei�! �HE InflF9ROVE�i�EA1'!' �ER11�IT Ai�D AIJiHOiZIZ�i'1�N T�
COiVSTRUCT SHALL �E�Of�IE IiVVR`+LID. �
1) Permit requested by: (O�vnerlagent/prospective owner):� o� �ir/rr1 ��}r//S
Home Phone: �-G�o7 Address: 7-0 ,�� � �
Business Phone: �"3( -S'�Z-1403 �+ ��� t ` ?s 5r
, 2) �arne and ac�dress of current ow►ner:
�j ff��opeety Desc�ipicon: Lot size: �•�2 Township:��"_'f_ Subdivision: Lot#
Directions to the property (Including road names and numbers):
�)
5)
�roposec! lDs� and �tPuciur� �escripiion: answer each of the following questions:
a) Proposed _, Existing Type of Structure: Width: De th:
b) Number of Bedrooms• � Number of occupants or people to be s ed: .� L j�, � ��
c) � a s e m e n t: Y e s � No Will there be �lumbin g in the basement? /� co��
d) 6arbage Disposal: Yes � No � �
lfVater S�pply T�pe: 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.
�) Does your propeety c�ntain previously ic�enti�ied jueastEi�ionai wetlarnds? Yes_ No1�
PL�SE NOl'� THE F'OL1.01fllING:
9�► AL.9►T OF T�9E ��d�PE�iTY OR SIT� F'LAN i�iUST BE SUBI1�ITiE� lAll�l T9-!IS ,�►PPL9CATi0�l.
9 PROP�l�TY L1NES AND COR6l�E�S MUS''!' BE CL�A►13LV iVIARt4ED. ,
9 T6-!E PROPOSED LOC�►TI�N OF ALL STRUCTtlRES flilllST �E ST�►tCE� OR �LAGG��.
9 T�E SITE MUST BE �DIL`l ACC�SSIBL� ���t .4N EV9�ILUA�lOt11 BY TDiE li�LTFi �E��RTidiE�lT
ST�►FF.
I hereby make appfication to the Person County Health Department for 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 macimum
facilities to be placed on the property. I understand ifi the site is altered or the intended use changes, the permii shall
oecome inval�d. _
or Legal Representative
/U,�=4,5�
Date
PCND, rev. O6l27102
0
Application #:
Tax Map #:
Parcel #: I 5 3
Person County Health Department
Environmental Health 8ection
SITE 3KETCH ..
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.Appli ant's Name � Subdivision/Sectionll.ot#
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Authorized State Agent Date ,
Sys�em componen�s represent approxtmate contours only. The conlractar n�astJlag the system
rlor to be lnnln the lnslaUntlon to lnsure that ro er rade !s malntalned
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SCale: `___.�_.�=-D I
prt4lfl rav_ '1[1/'12199 �
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Cs:w� r t: �, a�., r. s. u nrn « n r tl .�s � l: �i — �r. �� G f� s,
'�'ax 1'�1a}� #�_ �arcal # �5�3
�xist�ng Sewage Syst�a �$e�ort ��r.. I1�iobile �ome Replacameut
�ddition . iyper
Requester. �_ <l"2� f ��/i✓ %�S �ome �'hone# 3�' �%�9 �5�7
2f� �iDVi✓��ZGI �2oo/G� �i{( � _ �usiness # 3�'S�Z-�� �
o �/l'. 7.7� �� �
Location: � �
Original �.'eunit I:.�cated: Water Supply: '
Septic System �esignesi �or. ✓ I�esidential �usiness �ther
# Bedrooms # Employe�s �tizer
System Type: 'I'ank Size: Nit�ificatioa Line:
Date �nstalled:
Certifiesi Opezator Required: /✓�
On-site wastewater disposal sgsteffi shows no visual signs oi malfuncta�n on D/ �
e
g'Qrr*+,qsion is granted
Commeuts•
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Envitonmental �eaith Spes,i �ate:�.,=,yL��
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Applicant:
Location:
*5
T��x IV1��� , '� P�rcel #
S�uihcf!ivis�ioia � i�, '
Ph:a•s�e Sectior�_ Lot �
Improveanent Permit
Permit Valid for � Five ears _ No Ezpiration �
Type of Facility: , New � Addition Water Supply �t/'e ��
# of Occupants �C # of Bedrooms Projected Daily Flow � iso g.p.d.
Proposed Wastewater System: . �a �1 � .
Proposed Repair: �v�.v
Permit Conditions: Sp� � ��C S�� � �
Owner or Legal
Authorized State
Type: �
Type: .ZT. Q
Date:
Date: � �D
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbpropezty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potabie.
Authorization to Construc� Wastewater System (Required for Building Permit)
* See site plan and additional a#achments (�.
Proposed Wastewater System: ��n,�P,,,,,-i-i �� � Type �� Wastewater Flow Y� g.p.d.
New � Repair Expansion Soil LTAR: � i� g.p.d./ ft 2
Type of Facility: ��1Z �S � Basement �Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: �I� �� gal Pump Tank: gal Grease Trap: gal
Drainfield: Tota1 Area: �� sq ft Total Length ��ft Mazimum Trench Depth _� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Sepazation: � ft
Distribution:
Specifications:
Distribution Box � Serial Distribution Pressure Manifold �
�e_ S� � S�e �e�
Authorized State Agent: �`CS�►'�- � �'�V Date: 5 a��' S
Permit Expiration Date: � � � � —���
�
The type of system permitted is `�Conventional
the permit. �
Owner/Legal itepresentative:
Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
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Applicant:
Location:
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Tax M��p � � Farcel �
Subd`ivis�ion :�. ' �""
Phase Sect�ion Lot #
- Qperation Permi# ,
System Type (In Accordance With Table Va): �-�- a
THIS SYSTEM HAS BEEN INSTALLED' IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL NSA OF THE u MPRO EMENT PERMIT TAND CONSTRUCTION
AND ALL CONDITIO
AUTHO I T10N.
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Authorized State Ag�{it �� ��D Date
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Installed By: ��"✓_� � 5 Date: _
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PCHD, rev. 07/29/02
�n SEPTIC TANK INSPECTION CHECKLIST (Type il - IV)
Tax Map # l�t L�o Parcel # �5 `� System Type (Table Va)
Owner/Applicant Subdivision
Address/Location Sec/Phase Lot #
Septic Tank nitia Date �tri icat�on ines n�t�a ate
State ID/date 5.2-2 S�e��- S Trench Width '� ft.
Ca aci al. � Trench De th in.
Tee and Filter T,rench Len th ft. �
Baffle Trench Grade
Sealant Trench S acin
Riser if a licable � Rock De th and Quali
Tank Outlet Seal Dams/Ste downs etc. �--
Permanent Marker Pressure Laterals -^
Pump Tank -- Hole Spacing ---�
tate ate o e ize -^
Ca aci aL Pi e Sleeve �--
Wate roof /Sealant Turn-u s/Protectors ..�
Riser Required Setbacks
Water Ti ht From Wells
Pump From Property lines
Check Valve/Gate Valve Structures/Basements f
Anti-si on o e itc es raina e a s
Floats/Switches Surface Waters
Alarm visable and audible Public Water Su lies
Electrical Com onents � Vertical Cuts >2 ft.
Rate m Water Lines
A roved Pum Model Vehicle Traffic
Block Under Pum Ad'acent S stems
Pum Removal Ro e/Chain - Easements/Ri ht of Wa s
Distributiort System Other
Serial Distribution Easements Recorded
ressure Mani ol erti ie erator ontrac
Low Pressure Pi e' -. Tri-Partate A reement
A r. Pi e Material and Grade
Valves
Comments
pchd rev. 3/13101
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c���J�T°��
IE�-d-��-��,mm ����.Il IE�L��.]1�I�
Dr�U[k�r �D � 3O9
��� (�.�(K(�1'�UJII-�-II�NIStl�U�1�C
� �o� �-- � o - O�t
n�,1 Grout Log
Owner: L�'1c.� � c�.� .S Tax Map �� Parcel # �'rJ 3
Location: 0(a t 1 S
Subdivision: E.3 Lot # 'rJ
� Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Se Rti�c System (Minimum 60 feet)
Total Depth: ��SU ft Yield: �5 GPM Static Water Level: 3� ft
Water Bearing Zones: Depth �� ft \ So ft ft ft
Casing: 't �p �� in
Depth: From C� to "12- ft. Diameter:
Type: Galvanized Steel ✓
Weight: Thiclrness: (%38 Height above Ground: in
Drive Shoe: Yes No Any problems encountered while setting casing3 _Yes • No
If "yes" give reason:
Grout:
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width � Z inches Water in Annular Space Yes � No
Method of Grout: Pumped Pressure Poured ✓ Depth � to 7� Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) - Ratio to
ID plates: ✓ Yes _ No 4 x 4 slab _ Yes _ No
Liner: �
Depth:
Date Installed: Grout:
Drilling Log
Installed by:
Location Drawing
From To Formation JCe��
3 i3R� v` � q S
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IINI
I hereby certify that the above information is correct and that this well was constructed in accordance with regularions set forth
by the Person County Health Department.
Signature of Contractor
ID# 2309 Date � S'" � �— 64
Pump Installment
Pump Installation Contractor:
Pump Depth: ft Static Water Level:
Pump Make & Model:
State Registration Number:
ft
Pump Size and Raring: _
hp gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to the. well owner.
Pump Installer Signature Date: PCHD rev O1/27/04
Report To:
North Carolina State Laboratory of Public Health
Environmental Sciences
Inorganic Chemistry
Certificate of Analysis
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
P.O. Box 28047
306 N. Wilmington St.
Raleigh, NC 27611-8047
http://slqh. ncpublichealth.com
Phone: 919-733-7834
Fax: 919-733-8695
SONYA SMITH A40-153
20 COUNTRY BROOK LANE
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES110812-0021001 Date Collected: 11/07/12
Date Received: 11/08/12
Sample Type: Raw Sampling Point: Rear spigot
Sample Source: Ground Temp. at Receipt:
Sample Description:
Comment:
Time Collected: 09:25 AM
Collected By: D. Smith
Well Permit #:
GPS #:
Inorganic Chemical 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 17 mg/L
Chloride 9.10 250 mg/L
Chromium < 0.01 0.10 mg/L �
Copper 0.19 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron < 0.10 0.30 mg/L
Lead 0.006 0.015 mg/L
Magnesium 4 mg/L
Manganese 0.04 0.05 mg/L
pH 6.8 N/A
Selenium < 0.005 0.05 mg/L
Silver < 0.05 0.10 mg/L
Sodium 7.60 mg/L
Sulfate < 5.00 250 mg/L
Total Alkalinity 64 mg/L
Total Hardness 61 mg/L
Zinc 1.30 5.00 mg/L
Report Date: 11/19/2012
Page 1 of 1
Reported By: �e�ie �%%ta.rcol
1.E�EIVL]G
NOV 21 2012
BY:
1. � �� �
�. � i �
�,..�. ,�� � � � � l�J ��. � � �
�t ='3tT1�'711C"QDTC7T.ItirIl.ct:.IC]L��Z1.� ����A.11��
Date: Z � (o l�
Tax Map:� Parcel: 1�� n
Address: �� �ok��c, t��►-�ullf f�.,�.
Re: Bacteriological Water Sample
Dea.r j�!� .�Ql/'r S
Your well water was sampled on l2 � r3 ��, and tested by the Person County Health Department for biological
contaaninants (total coliform and fecal coliform bacteria).
The results of your water sample are as follows:
� No coliform bacteria were found in your well water and therefore your water can safely be used for
drinking, cooking, washing dishes, bathing and showering.
_ Total coliform bacteria were detected in the sample.
_ Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are naiurally found in the soil and fecal coliform bacteria are associated with animal and/or
human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or
repaired well has not been properly disinfected prior to being used; or that contaminated groundwater is entering
the well. The well should be properlv disinfected usin� the enclosed chlorination nrocedure. A well contractor or
plumber can assist you if needed. •Once the chlorinated water has been thoroughly flushed out of the system, the
Health Department should be notified so that tr.e well can �e re-sampled. If the well water continues to tzst
positive for coliform bacteria, then there may be a problem with the water source or with well construction. A well
contractor or the Health Deparhnent can assist you in identifying the problem and finding a solution.
If coliforrn bacteria are present in your water sample, then the water may not,be safe,to use. Young children, the
elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should
be. notified of the results. Water can be disinfected by boilingfor one minute. '
If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from
8:30 am to 5:00 pm.
Sinc re ,
. � �t'�'.�/
Environmental Health Specialist
Person County Health Department
Person County Environmental Health, �25 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790
Revised (11/13/08)
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant ���
Address o� u,����►� k-� �-, .
Collected By �"_�
County �VSc��
�f � �-� �3
Date Collected /Z`� /3%(( Time Collected �`�S
Source: �Well ❑ Spring ❑ Other
Location: ❑ House Tap ❑ Well Tap `�Other (�u��� �'���`'�"
❑ No Charge �harge
........................................................................�
****�*�****�********************�****�*******�**************************
Results
Total Coliform
FecaVE. Coli
Present
0
J
-'.. -
Reported By (/�
Date Reported � �1 � 5 � � `
A sent
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