A28 93PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �'1�u� �h��
Address y(;(� (�lA�o�K U�7���'� �_ County �Q�SDh
Collected By � S
Date Collected � 2' (�' l( Time Collected 3` 2's
Source: 0 � ell ❑ Spring ❑ Other
Location: �ouse Tap ❑ Well Tap ❑ Other
❑ No Charge L�'t;harge
........................................................................�
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Total Coliform
FecaVE. Coli
Results
Present Absent
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Reported By � �„�, �L�^G� �� l �
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The District He�et�h Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Wa�er Suppiy ond: Sewage Di,sp`osai
IMPROVEMENTS PERMIT No � -
-�'�'� Dat �- "' � � �'
Owner: �� j%1��� t�' � f �c w� s�
Location: �
..� •'��7 �= � ! � �
Contractor: ` , r m , �
Waler Supplp: Priva�e' ` �Public•
•- , {
j� ! / / r y,
l��YI-1-iA/� (�F.�tit i"-i i�9�1 ��V l; �ic�u I
Sewage Dis�osal Facilities: No. bedrooms .,.Z— Dishwasher,
washing machine, other sutom�tic , appliances —
Size of tank: � f� n U��-' � Nitriftcation line:
-- --�".i:._ .
Other disposal facility . . . _ ._ _._.. . _ . . -- J � � . .
Water supply and .sewage disposal facilities location, installation_a�id-''
proteMion must meet state and local regul�tions.
Septic tank should.be pumped out every 3 tu 5 years and_shail:be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank. and nitrification line MUST. ESE. INSPECTED_.AND..AP-
PftOYE,D BY A MEMBER OF THE DISTRICT HEALTH.DEPAR,TMENT
STAFF BEF(�RE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND "PUT - INTO USE. � q
- - ' `�%N"E'h!"
. ,,� � � � .
Date approved• Signe,�;
WeII• Sanitarian
... "'— . .��
Sewage Disgosal• Counter-. . �
By. signed �
(Uwner or his representative)
Certiffcaie o� 'Completion
..,, .
Date Approved: - By:
Sanitarian
��VER�
Location of well and sewage disposal faailities sketched on back.
. _ -. . �� � �anCy
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