A32 44The District Health Department
CASWELL - CHATHAM - LEE - PER50N CO�NTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Date �—c�'.�
Owner: � � �,�r�rl�)
Location: l
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Contractor: �
Wate: Supplp: Private Public
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Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal,
washing machin other sutom tic appliances /
Size of tank: � Nitriflcation line:
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and locai 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-
PROVEII BY A MEMBER OF THE DISTRICT TH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE I S L�TI�N � COV-
ERED AND PUT INTO USE.
Date approved: I Sign� '�`"'
Sanitarian
Well:
Sewage Disposal: Counter �� ' �
signed '—
BY� (Owner or his represe tative)
CertiScate of Complelion .
Date Approved: �� �
ian
' (OVER)
Location of well and sewage disposal facilities sketched on back.
� � AUTHORIZATION FOR WASTEWATER SYSTEM CONST.RUCT�ON
(Void sixty (60) months from date of issuance)
DATE: i� IlVIPROVEMENT PERNIIT #: � f�/g �
TAX MAP #: �4 3 Z PARCEL #: `�L/
OWNER/OWNER'S REPRESENTATIVE: �,e v�� T�'.�,�i�
LOCATION/ADDRESS:
/OD i '% ,��c>>ZbLc iC/J /LL �i �T� - i�G�OsS ' /��2!'T�l
�-/e� w/�i.�JS R.Zo<; STbi2=
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
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CONDITIONS
LOT #:
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #�/ 8. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
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Person Requesting:
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
1489
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A 3� Parcel # h�h'
Zoning Township �v.�N y f��z��
Owner/Contractor �a vi �l T� �z y Date ,.Z _ ii - 9 t�
Location/Address �on �sr7 f�v�� ��� ���� _s .z�� � i# � �Z � s s
%RoM //Awx�•vs i�,zvs s�-or2c S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area p� � � � Size of Tank C x � s i�,�I !� �
SFD Mobile Home � Size of Pump Tank ,�c/,�
Business # of Bedrooms� N'itrification Line �x is ; �,cr4 3st� � x�
Max Depth Trenches
Permits may be voided if site is altered or intended use
Well and Septic Layout by � �' r�
Comments: ,�,�r, :� � >,�� �_ ,�•ro,�.c.�_,�, .
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Date�,��_ Installed by�,� i s r�,�./� Approved by ���� � ����-t� -
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ell Permit Paid ❑
Date �
WELL SYSTEM SPFjQIFICATIONS
u-Publ'c eauired Slab ,
A.ir V
ell Tag
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
heaith specialist is not responsible for false or misleading information
contained in the a�plication. 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 environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:lamipro�permit.sam O1/95 rev.l.l
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APPLI�ATION FOR SERVICFS
.:.___.__
Improvements Permit.(EstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
�Tnprovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
�v2— 1—" 1 �
Reinspection of Existing System (Loan Closing)
RepaidReplace existing Septic System
Permit for New Well
_ Replace Exis[ing Well
1. permit requested by: . 7. Dimensions,or Proposed Structure: �
owner/prospective owncr/agcnt: ►� V i n ��r. Width: � 4�
. . . ► �..� � Ll . . .� I > I� ; I I � 2 Depth: `7�
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; �,s ►�l c. ��7 5� � g. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
tha� this sewage disposal system is intended to serve?
ome Phone #: 3(n9 �� ��� 1 c f �,�,� C� ;.�
usiness Phone #: ��'� �--- "'`��-
Name and address of,current owner: 9. Water,supply t}�pe:
p�� e, rivatei�public ❑ community ❑ spring ❑
�i4^1-e Q S Q VJo1i P
Are any wells on adjoining property?Yes`.� No �.
If so, identify location:
. Property Description: Lot size:
Tax Mag#: �- � 2-
Parcel#: y" q'
Township: � ta �� 6 r �
Directions to propercy: �t'a
ames,�tc.%� �r"
�n.rncc �1-�nvr� f�Fii,J 1��
Road # & Road
� iv� c e�
10. Type of structure/facility: Proposed: �,Existing: Q
Type of dwelling:
House: f� Mobile Home: C^�usiness: ❑
,Type of business:
Number of Employees: � �
Number of bedrooms: _
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No�f so, # of basement fixtures:
6. Number nf occupants or people to be served: 4' RNERS OF ALL
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CO
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOIl COunty Health Depat'tment for a site evaaluali�a ion ahe �e ite
sewage disposal system for the above described property. I agree that the contents of this pp
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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this a��ication shall become void and all fees paid forfei[ed.
''C�'�� 1---'
Owner or,A�it�orized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
S ignature
Date
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< 3» . ' :FXCTORSSREEVALUATiqN z ..;s A1tF.A7 1-: ;.� AAEX2 ' ` ,±.:'ARFA3..;; ��Q ,
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1. SLOPE (%) S S ps pg
PS PS
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2. SOILTFJC7URE(12-36IN.) 5 S S S
(SANDY, (.OAMY. CLAYEY. NOTE 2:1 CLAY) PS PS � ps
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3. SOiL S7RUCil1RE (12-J6 IN.) 5 S S S
(MYEY SO(LS) � U � U
S g S S
4. SOIL DEP77� (IN.) PS PS pg PS
U � � �
S. RESIRICTIVE HORIZONS (iN.) S S S S
(IMPERVIOUS STRATA. ROCK) PS PS � ps
U U U U
6. SOILDRAINAG&GROUNDWATER S S S S
(FJCTBtNAL R IN7ERNAL) PS PS PS PS
U � U u
S S S S
7. SOILPERMEABTLTfY PS PS PS PS
(PEACO[AATION RATE) � U p U
8. AVpII,AB(.ESPACE S S S S
PS PS � ps
U U U U
9. SiCECI,pSSiFICAT70N(SEEBELOW)
SOIL SERIES
S-SUITADLE fSPROViS10NALLY SUITAIILE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSLFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fil]
areas, wells, wa[er bodies, slope patterns� CtC.) C:IAMIPRO�DOCSVIPPSEC.SM FINnNCE.PC
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„Amount paid. �� � �r��"���
keceipt .�� ' �r�Q� Date
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Permit requested by: .
ner/prospective owner/agent: �r V� n T�r�
dress: IL�Os1 N��r-II� N�;IIS (�
ome Phone #:31��1 - �� ��
usiness Phone #: +�o � �
7. Dimensions or Proposed Structure:
Width: I � X �30
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
Name and addre&s of current owner: �� e G S 9. Water supply t� pe:
� Gz.too�e. _ private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
If so, identify location:
Description: Lot size: � o�e v e s
Tax Map#: � � �
Parcel#: y `� -
Tnwnchin��i us ��i . F�rK .
. Directions to property: State Road #& Road
� C.'11,��- GiC� O S 5 �'Y 0 M
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Number of occupants or people to be served: 3
10. Type of structure/facility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C�'Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ �
Basement? Yes ❑ No If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOI1 COunty �ICalth Depat'tment 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 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of [he property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this appl�cation shall become void and all fees paid forfeited.
Owner or Authorized Agent
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
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1. SLOPE (%) S S S S
PS PS PS PS
U U U U
2. SOII.7FJCTUREU2•36IN.) S S S S
(SANDY, LOAMY. CIAYEY. NOTE 2:1 C1AY) PS PS PS PS
U U U U
3. SOTL STttUCil1RE (12•161N.) S S S S
(MYEY SO1LS) PS PS PS PS
U U U U
3. SOIL DEP7}i (IN.) S S S S
PS PS PS PS
V U U U
3. RESTRICTiVE HOR20NS (1N.) S S S S
(iMPERVIOUS STRATA. ROCK) PS PS PS PS
U U U V
6. SOILDRAINAGE/GROUNDWpTER S S S S
(EkTQtNAL A IN7ERNAL) PS PS PS PS
U U U U
7. SOIL PERMEABtllTY S S S S
(PERCOLOATION RATE� PS PS PS PS
U U U U
E. AVAR,HBC,E SPACE S S S S
PS PS PS PS
U U U U
9. SR'ECLASSiFICATION(SEEBELOW)
SOIL SERIES
S-SUITADLE PS-PROVISIONALLYSUITA6LE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property ]ines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope patterns� C�C.� C:\AMTPRO�DOCSU+PPSEC.ST1 FWANCE.PC
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Yerson Coun�y Health Department
, �/ . .
�xisting Sewage System Report For: Mobile Home Replacement ;•�"
Addition �
Requestee: ��- (^V �� (� I �-� i, �/ Home Phone# �co7 �'%b'�
1�o `��l r��l eT � ��S �U Business#
� L{ �Q� � 2 �� � �5 �� ��`I � 'Pax Map# /`t' �
Location/Directions: � l.l. t'O�%� �� ���• �' -� I Uv57'
Original Permit Located
5eptic System Uesigned For:
Kesidential ✓ Business
# I3edrooms _� # Employees
Other (speci�y)
Other
Uate lnstalled Water supply � Gt.%�
'Pype ot System �SU���.�(1��� V✓��1
Nitritication Line �SZ� � �� �
Tank Size
0
Certified Operator Requoired ` `��A
On site wasL-ewater disposal system showes no visually apparent
malfunction on 3/ ��( �g
Yermission is granted to: � V\J��. (1
According to the attached site plan.. -
Comments: � �� � (�l `��P �
Environmental. Health S�i.
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DATE
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'1F THE I�1F�t��{IIATiON �1 THE APPL:�C�AT[QN FOR AN (14�PRQY'�i1RE�lrt' R�2MiT iS lNCOfZRE�3. F E�iED,�
CHANG�, QR THE 511'E IS ALT�REn. THElY i'WE lM�i�OYEAA�.NT PEWIAR,�Nq. AUiHORlZ�ATIUN TO .
�QN�TRUCT SHAiL B�CaI�iE INVA�D. -
eo,� v�o",, C
�� P�rm� �� by: �own����ve �j: �v�e � q� � -
Home Ptyona: �� A►cidreas: �� �1►vTi oc N C�+ r� n� �i�
6tSsi�lBSsPhORe:33�S��-SF,'S9 T1rn3E2c,41cE� NC a�5g.3 �„Q� . 0
2) Name and �dd�esa af cuerNst awn� A R T�+ ld R�o a rF2 F� F c�n
3) F►ropaty ppacriptlon: Lot size: � Trnmishlp; Subdlvlsinn; N I A _ Lot #►�1 r�
Dh'eciJans to the P�P�Y ilnduding r�aad names•and num��s): S �. i�a� N_ t�� o�t �a' i�cS o�� S,� ied �
fJGRoS,�ROr+� �R,v!!i.✓S SToRE SE� �(a c�L
4) Propo� Usa ar�d Structure Ds�criplion: answer eac� of the fdiawing questians:
a) Propoeed �, Eclsiing ._..� TYP� of Structure: � r F r'R�► m rnb o u��► ,� Width:_� aepth: Z�
b) Number at 8adrooms: 3 Number cri occupanis ar people to be served:
c} 8esesnent Yes_ _. No , C�,. W111 thare be plumbing In the�basetnent7��
d) 6arb�ge DiepoBal: Yes _ , Nc ,�!
�) Wab�r SuPPh/ '�IPs: Privabe X(ne�w �/ or exlsting�, Ptsblic_, Commc.u�fty� . 5prtng --.--
Are any weils an adjoining property? Yas� No ` If yaa� pi� ind[cate app�axlmata location on the
'stte pi�n.
6) Daea your proparty cvrrtain��vioualy 1dss�tMed Jt�dlctlanal w�aHatxl�? Ysa_ Nv,_,,_
" .��lt �. � . •1.L .
➢ A pI.AT OF THE PROPEI�7Y Oft SRE PLAN MU57 B� SUBMIITED 1N[TH 7NiS APPLICA'TICN.
➢ PROPERTY LINES AND CORNEits MU$T BE CLEARLY lW\Rl�D. •,
➢ 7HE PRaPOsm LOCATtON OF A1.L STRUCTUFZ�S MiJST 8� 3TAlCE� OR Fi.AGGED.
� THE 9iTE N113T BE lZEADILY AC�E3SiBL� FOR AN EVALUATION BY 77-IE MEALTH DEPART{fAEA1T
STAFF.
I hereby rrtake appllcation to the Pe�san CouMy Hcalth Oepartmeni for a site evait►atinn fiar the on-sita saw�ge diaposai
system for the above-descnhed prvperty, I agree that the cantentas of thts applbcaiicn 3ra true and re{�re�t tt�e maxtmum
faciiittes tA be piacad on the pro�erty, ( undetstand i# the site is �terBd or the ir�tended use crianges, t�e permi� shall
became Irwalld.
Cwner or Lsgal
16-I1-6�
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1. Y� amst sn�it a s�e gisa. w�h y�o�tt s�. A�m.pie a�e plsa �od a�e-p�u. �,ett sm
�. Hc snnc m�sd m� yau � tn aha� 1a ti� saoe pt�m- C�ec3� t#� a�f �e yaa d� t� a�
tbee utcp�n: ' �
2
3. �dac�e � Pmo�,y 3imee. AIl ga�ptd.y i� vvrthia 2,50 fret af t�e gaopoeed hnoaa si�e �nat he de�p .
� madm�d �ad sa�dly �e aa poao�� linea_ Tf�m. �a pn�poeirag %� sabdiv�de y�our Pd°QPmY=9'�
mwac �e =be pa�Qosed l�aciti�oa aaE�ll ne�► p�opeay liaa.. � -
4� 3f tl�a lox s�oo �c3d� ca�ves+ed �h uza; SI1es vs�, �, �� a�erm�l ti� yr�n �mad
ia daot � tl�a � ti� z peraoa c9a gr.t na� th lat 9ad mave �aaotnad fir�p I� �OU CL��B
YOiT� P�P�C, BS CA$EP�}I.. NO�'r0 DL�1'C�BB Ti38 �r 301I.i 'Izei aould
adveaeiy � t�e �me af �as e�a�a. Ifyau �ave�s�aT q�atioaa, P'bove all � 1}eesoa
Caaa�p � O�ce's (33bj 3971'79Q. •
S. b�'s� ii�wa �ed �snaae ai�. Z1� �o�os� I�a si� cc� �at bn atti�ci oat aa thc poape�p�,and
a�st �aaaa�r m� �e �e p1s�a sad�ir� s�sh th� �ema.
G_ I'osr t�e hri�t ar�a� siga � yonr a�me oa a mct to t�c nosd s� i�at �ve �a �r po� p�ttp,
?. Q7hea �yoa L:v+� a�p�t�d ti�eae i�rme, si�n t� s�amt beiaa md �s�a it � pemm Cauaty
. . A�th 9t Z�B C.o�s� St Boo�a�n, ATC 27573. 'I� s�ut � se:�n �
� t�t yiriux lat bras i�an �mep�sd �ag m t�se sostioocxiQas. Once �n rtceivo �ie
�tti�on„ zve �A a�av�� f� accive a�. A�ocas�n e� be p�oeaaed iarh� undc= ti�t
��Llo��vas ��d.
8. T� ����o aw�ate y� pa�Ct3r, �ve f�ad �t it is �ot pae�d ss,o�iag �+ t�a
i�snmct�oma, �a �L 1� 9oue �tiot� oa �m�ive a�mc. We vv77!'�.mm yoQr �daa � acsive
.- st�t�ss �Lea we havn c.a�Cm �tieu t� p�oogatf �n p�Qsoed prapedr Yaa �L be�atified �£ t�ie
� oc�o�,.9ad ya� � he �aoad. t� aio� ' Halth S�octiaa a,pan �gleboa af sise
g�o�tioiti `Yaar �� be �dl�d ia ti�e v�es �u tb+e �� �xived.
4- .�7'�� �'9' �� ��tt:e �Led, pn ahoaid c�II au o�Ce:tya�e a�iaatcea�mce
�a���.���a«��a���aa�a��������
.e� ��x���a� �a ma �.so a.m. �a��o�a �
� S:flO p.m. �ot (33G) 597-1790. , . .
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Mad as c}�iv�er i4� �� p�� C�tyr Apj�
• 20-B C.�omx� . .
Ra�a�n, NC 21573
� 7�, «y �. w,«��MS � .�«��r�r�,�a�
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November 14, 2002
Arthur Porterfield
C/O Home Headquarters
55 Antioch Ch. Rd.
Timberlake, NC 27583
Re: Application for improvement permit for Wastewater system for property at Hurdle
Mills Rd.
Person County Health Department File: Tax Map #A032, Parcel #044
Dear Mr. Porte�eld:
The Person County Health Departrnent, Environmental Health Division on November 8, 2002 evaluated the above-
referenced property at the site designated on the plat/site plan that accompanied your improvement permit
application. According to your application the site is to serve a three bedroom residence with a design wastewater
flow of 360 gallons per day. The evaluation was done in accordance with the laws and rules governing wastewater
systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of North
Carolina Administrative Code, Rule .1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940
through .1948, the evaluation indicated that the site is UNSiTITABLE for a ground absorption sewage system.
Therefore, your request for an improvement permit is DENIED. The site is unsuitable based on the following:
1. Soil depths to saprolite unsuitable (Rule .1943).
2. Unsuitable soil characteristics (Motphology) (Rule.1941)
3. Soil wetness conditions indicated by chroma colorization (Rule .1942)
4. Available Space (Rule.1945)
These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated
sewage on the ground surface, in surface waters, directly into ground water or inside your structure.
The site evaluation included consideration of possible site modifications, and modified, innovarive or altemative
systems. However, the Health Department has deteimined that none of the above options will overcome the severe
conditions on this site. A possible option might be a system designed to dispose of sewage to another area of
suitable soil or off-site to addirional property. For the reasons set out above, the property is currently classified
iJNSUITABLE, and an improvement pemiit shall not be issued for this site in accordance with Rule .19480.
However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABLE if written
documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may
hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as
PROVISIONALLY SUITABLE.
You have a right to an informal review of this decision. You may request an informal review by the soil scientist or
environmental health supervisor at the local health department. You may also request an informal review by the
N.C. Deparhnent of Environment and Natural Resources regional soil specialist. A request for an informal review
must be made in writing to the local health department.
You also have a right to a fonnal appeal of this decision. To pursue a formal appeal, you must file a petition for a
contested case hearing with the Office of Adtninistrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714.
To get a copy of a petition form, you may write the Office of Administrarive Hearings or call the office at (919) 733-
0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statue
130A-335 (g) provides that your hearing would be held in the county where your property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative
Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. Meeting the 30 day deadline is critical to
your right to a formal appeal. Beginning a fotmal appeal within 30 days will not interfere with any informal review
that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by
law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Department of
Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of
Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health department. Sending a copy of your petirion to the local health department will
NOT satisfy the legal requirement in N.C. General Statute 150B-23 that you send a copy to the Office of General
Counsel, NCDENR.
You may call or write the Person County Environmental Health Department if you need any additional information
or assistance.
Sincerely,
Adam C. Sarver, RS
Environmental Health Specialist
Environmental Health Division
Person County Health Department
�.:
ADDRESS :
L�CA.TION :
Dat e
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Date: � v /�_/�(�
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Re: Bacteriological Test Results
Dear Well Owner:
Tax Map: A'3Z Parcel:��
Your well water was sampled on �/1�/�, and tested for both total and fecal coliform bacteria.
Your water sample 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 bacteriological resu[ts only.
✓Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are naturally found in the soil. Fecal coliform bacteria are associated with
animnal and/or human waste. The presence of either total or fecal coliform bacteria in 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 sample, the water
may not be safe for us� Young children, the elderly, and the individuals with compromised immune
systems are especially vulnerable and their physicians should be notified of the test results.
A well that tests positivefor total or fecal coli%rm bacteria should be properlv disinfected and retested
prior to resumin� 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
flushed out of the system, please contact the Health 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,
�� -
Environmental Health Specialist
Person County Health Department
(rev. 4/20l16)
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, fax 336-597-7808
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �„u � j..�c►�
Address IDOS7 ra�p. �� (LS �;. County
Collected By -� S
Date Collected 1�Jv_— rcQ Time Colle�tgd �:�b _
Source: Gz�IVell ❑ Spring ❑ Other
Location: [Dh�use Tap ❑ Weli Tap o Other
o No �harge e�harge
..............................................................................�
*************************************,�**************************************
Results
Present
Total Coliform
Fecal/E. Coli
Reported By
Date Reported � 4//� /`�
Report Called �,fES o NO
Cailed To `���� � ��* �
❑■
Absent
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- � � � � St3ti�lSlTi L����1ATI�N
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DEi'A.2TMENT OF ENVIRONMENT, HEALTH,
AND NA'I'URAL R�SOURC�S. � �
DIVISIDIY OF EiVVIRONMEN'�'AL HEALTH � •
� � Slir.rs _.._ af--
PRt]PL•It'I'Y ID �:
o�� or• �vnLUA�ox: ��
couN�t: -
_p.; .ti::r.:• •:�;�;� a�.. ..'ti: . . . .:•_.::.� ' ' j,OCY OTHER .
`' � . .. — � gOIL MO[ZI'I�I�
��' ' � � � PROF�L� FACT�I�S —
•d: ...:. :�>•'• ' '• .. (.19dt) . .. .
f � :1940; '°. • : . . � • . .I94Z PRO�II.E
E.. �LAND-:' �.:; •'HOAt '• ' - . I9�1� . . SO1G .19�i3 .I956" •19�'t �155
� � SCAPIn; � = `• ZON .1941 � COPlSIS r [Lrt � tiYE'L1V�R! SOIL 5APR0 . � dc LT.�A
�• �.POSITIONJ;- ;:p� �U�� MINEILiLAGY COLOR DEP'fII . �►� 1lOEttZ •
SLOPL y:•'- . �(� j. • :TE:C'TUttE.
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DEP.A�2�r�IT OF ENVIRONMENT AND NATi7RAL RESOURCES .
bIVISION OF ENVIItONMENTAI: HEAL•TS . . � . . •
ON-SII"�.'i WA�'TEWATER SECIION
' � Si��/��. �+ V�iJA'�.'IOlv� -
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Sheet_of
PROPEtT17D �: � ,
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OWNER:. ���-P� � `� APPLICATION DATE �
ADDRES3t . � DATEEV'ALUATEi3:
PR�POSID FACII.TiY: PROPOSED DESIGN FLOW (.I949): PRQPERTY SIZE:
LOCATIOPT OF . ! PROPERTY RECORDID:
WATER SUPPLY��� 0 Pnblic ❑ Well ❑. Spring Cl Other: - .
EVALUATIO1�f�METHOD: �'.�g�H�B 0 Pit ❑ Cat � . ' �
TYPE OF WAS'TE'WA1�R: �ewage _❑ Industrial Pmase ❑ Miaed
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Ayat�ble specx � 1945� �,S �.�.�-J 9TTE CLASSIFICATION (.1948)•
system Ty�s� _ , EVALUATED BY: �
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