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A28 155, �� - - � � he District Health Departmenf Oraage, Person, Caswell, Chatham, Lee Counties SEPTIC TANK PERMIT Dat ` " � ) r Name of owner: �L�� 1� s � ��,�, Name of contractor: ,—�''�� A i' Address and Dire �ti� r . . �� f � Person or firm doin� installation: Address ' � ' " No. of persons to be served , Bedrooms 1, 3; . Additional appliances to be used: Disposal, dishwasher, washing machine ' � Recommended: ,Septic ta �% �f Nitrification line: ` Y �-' � /� --� i Above recommendation based on information received and observed soil condition. Septic tank and nitrification line musi be inspected and approved by a member of fhe District Health Department siaff before any portion of the installation is covered. Date Approved: , I�— �., � � sy: 3 Signe� Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer Countersigned (Over) • � � • � • � • -• • •� • .• • •�- • .- • •- � •• .. � � �. � �. i ��,t 1i'a:. 1;i+tla� i��A��l�iri r...rrrii ��r�i��■I�Irlll■��11rI1��1111�r� ►�i1L��► ��!��■■I��■�� 5�� l��l�■ ■��■■��■ ■��i�� ■��L�'�il■■ ��■�■�� ■ ��■ ��■O�■��II�� _ �_ ■ �i��■ �� !�'��1�■ �� ■■� ■■ �� l��IiliiM�i� �1 ��■ ■��lll�� MI1�i�� ■�� ■��I�� E ,1��■�� ■■ ■�■��■��i� ■��■� �� i■��'!l:;�;.�� ■�■�5�� ■�■[!��..re��l��l�:.�■��■ �� •+s��_.r.�_... �■..r�� The Distr-�r�. M.ealth Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. Date�'� %� `�- `� �ct �C�i/v1r1�1 Owner: Location• � • • � �� ' � �5 �%��c�, Contractor: �^, ��zt, � ��`� Water Supplp: Private 'f'� Public Sewage Disposal Facilitiea: No. bedrooms � Dishwasher, Disposal, washing machine, other utomatic appliances Size of tank:� � NitriScation >i*+p� �%Od 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 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 INSTALLATION IS COV- ERED AND PUT INTO USE. Date approvedY ��J � � Well: Disposal:. A . /� ��i Signe Sani ian Counter- � signed '�� (O er his representative) Cer3ificate of Completion Date Approved:l�'�_ By: a i aria (OVEB) Location of well and sewage disposal facilities sketched on back. �� 1 � � � ��y � �L/ � �� 1L lE��n��¢�,Il IH[��,Il�l� Date: � / � / l �v Name: � CA�2�L: � Tax Map:�-253 Parc�l:�l� Address: o � ��z.�c.� '�.p . � Re: Bacteriological Test Results Dear Well Owner: Yuur weil water was sampled on �l � i i(P , and tested for both total and fecal coliform bacteria. Your water sample test results are notzd below: i� No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacterio[ogical results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total col fnrm bacteria are n�.turally found in th� soil. F�c�rl colifnrm b?dteria a.re associ�t�d �v:th animnal aaicJ�r human waste. The presence of either total or fecal coliform bacteria in wetl water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, the water may .not be safe for use. Young childrer., the elderly, and the individuals K�ith compromised immune systems are especially vulnerable and their physicians should be notified of the test results. A_ well that tests positive or tot�l or fpcal co?if�rm bacteria should be �ro�e; l• disinfected and retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure: A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flusl-.ed out oi the system, please contact the Healtn Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� - C��.��if� c� Environmental Health Specialist Person County H:,alth Departm,.nt (rev. 4/20/16) Pers�n County Envi:or.mentsl Hez{th, 325 S. b.organ St., Suite C, Rcxborq *:� 275,'3, Phone: 336-579-1.i90, Fax 330-597-i808 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant �A2�i- Address �� G �t�,�_'�, � County ��125v � i�� . Collected By � , �%� �_ —�-� _ _ Date Collected �j,�lT/� �, Time Collected iD'- �o Source: �'Well o Spring ❑ Other Location: ❑ House Tap �Well Tap ❑ Other 7� ' �- -�s s � No Charge ❑ Charge � �� .............................................................................., ************�****�************�********************************************* Total Coliform Fecal/E. Coli Reported By Date Reported �"Z "1 � Report Called Called To Results Present ❑ � ❑ YES ❑ NO Absent � : ' � 1l � �,. � �� ' � � �.! �. V � � ��n�n�ron�n�aa��a��m.� ��.Il��in Date: � /�/1� Name: �'G�, /�/y G',��s� �d Tax Map:�� Parcel: l�� Address: r�— ��r��' � Re: Bacteriological Test Results Dear Well Owner: Your well water was sampied on �/ %/�, and tested for both total and fecal coliform bacteria. Your water san�ple test results are noted below: No coliform bacteria were detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacterio[ogica! results only. l� Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are n�turally found in the soil. Fed�l coliform. ba�ter�a a.re a�s��iated :vith animnal an�/or human �vaste. TI:e prese:��e of either tota: or fecal coli:orm bacteria ir� well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water samp[e, the water may .not be safe for use. Young children, the elderly, and the indiveduals K�ith compromised immune systems are especial[y vu[nerable and their physicians should be notified of the test results. A well tha> tests positive for tot�l or fecal colifer,m bacteria should �ve n; operlv disin�ected ar,d retested prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly �lushed out of the system, please contact ttie Health Department to request a re-sample. For additional information, p(ease feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, �� sGl�� . Environmental Health Specialist Person Cour.ty Health Department (rev. 4/20/16) Persen Counry Envi:onmental Health, 325 S. �lorgan St., Sui;c C, Roxboro, NC 2;573, Phone: 33G-579-1790, Fax 336-597-7508 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant �.i��- Address 1 �JO G'j � :'` � �G� County � �"'��.�d N �i �� ' %'"fl. Collected By Date C91!ected Tirt�e Collected j: 1 S Source: �1Ne11 ❑ Spring ❑ Other Location: ❑ House Tap [D�vvell Tap ❑ Other ❑ No Charge harge ..............................................................................� **************************************************************************** Results Present Total Coliform Fecal/E. Coli Reported By Date Reported �' � �- � lo Report Called `�YES ❑ NO Called To , '� � � � � '�� ■ Absent ■❑ � � 0 5�.75� PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant r"'-�; ''r -- ��,�� Address 130q' �� :G�[ "�,�,:� � County Qr�-. Collected By _�- Date Collected � Z7� t Time Collected 2�; � D Source: C�r�Vell ❑ Spring ❑ Other Location: ❑ House Tap �'Well Tap ❑ Other ❑ No Charge harge ..............................................................................� ***************************************************,�************************ Results Present Absent Total Coliform �Q \ ❑ �" Fecal/E. Coli � � Reported B Date Reported �o1y %� Report Called �(ES ❑ NO I� Called To �i � �r�,G, �� _