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A34 8B�� G, �k_� �e r�� z Person C un y fteal h De�artment � :-�� ;�ge System Improvements Permit � Void After 5 Owner. _� I.003tlOI1�lICChOi1S: Permit # ' ^ SR# _� Name: Lot # L:ot:Size' Type of Dwelling: '– � Water Supply: . Private: Public: Community: Bedrooms: Gazbage Disposal � Basement �. � .:Basement Fixtures " i >INFOBIVIATION CER'I�IED BY Erivir'onmental`Health Specialis� i ' S -= REPAIR: ' RF.�V ' ' „ — — — � � � — — — — $ize of Sepric Tank: � �� gallons Size of Pump Tank: Nitrification Line: � � � ^ �.. Depth of Stone: 12 inches � � f� Max;Depth of Trenches: ' Alteinadve System: Conv. Pump �-, .. LPP Pump .._ � � � � � � � � � � �� '�� Date. Well BY Date. Se BY� ? Well should be 100 ft. firom any sewer system �_ Enviriinmental Heaith Specialist � ��T ' Environmental Health Specialist � •� iirii ATE OF'CO LETI (-�N ,..3 Contractor. ' �`g� Sx� � , ��P gT : _ _ _ ' �e _ ,' — — — — — — — — — — — — — — — — — — — — — — — — — `b Sewage System location, installation, and protecrion must meet state and lceal � reguiations. Septic tank should be pumped ouE every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Sephc�tanlc and nitcifcadon line must be inspected�:and approved-by a member of the Person County Health Departnient before any portion of the installation is covered and put into•use. If die site plans or intended use change this permit is subject to revocacion: �(G.S. �130 A-335� � , `�.ation of sewage disposal sewage system sketched on back. \ (O�) ;s i K- a � N � N O � Y c0 � � :+ y a y N � � � d� o � . � ,� . o ° a' � o ; d E � d F � � y � C 'd •� •- � y a� � �y Q � 6,� G R •y � � Y � O.-�-� F •• � c o a . � ^� � y � � �� a, , o y� � :, � � a; ; � �% V �: � a � •� � o ~ ' x a. u y d d . .'� +'' y � � d � � � . � a , � ,� y c�. � F� N ,� ' � c 2�"hr` �� A 14 3 4 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT Tax Map # ��/ Parcel # Zoning Township � Owner/Contractor Date -- -- Location/Address S.R.# � � � U � a Subdivision Name Lot# WO Permit Void after 60 months. Permit Void if not in compliance with zoning Permits may be voided if site is Well and Sept' Layout b�',�,q_ Comments: ��,�`;�f7" Date Site Approved Well Head A� Grouting Appi Comments: Date Installed by or Approved by. WELL SYSTEM SPECIFICATIONS Public Required Slab ;e nt Air Vent - Requir Well W a� , �I This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit "Ihe " environmental health specialist is not responsible for false or misleading infortnation contained in the applicatioa The environmental health specialist is also not responsib(e for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading statements provided to him in the application Neither Person Cowrty 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:�amipro�pencritsam O1/95 rev.1.0 ORIGINAL �� . : ��I��.�� : -��_ �, :..: _ .,:�:�: - :#��;�:=��=��-":=;- � -�--- � . ..,... . . ... IE�.��.@�$:�.:�.�:�:: - IE��:�.�� _ . Owner_ � �u.t^ / U.. Location: �o�,� � ('r�v Subdivisian: i Dri:l:ier DD » � A � Com��ny N�ame 'fr � � ' � • D�at�e Drillee! � Grout Log � � Tax Map � Parcel # � � Lot # • WeII Constraction Distance From n� Pmperiy Line (Minimum 10 feet) �, D�' Distance from Septic System (Minimum 60 feet) ( 0� Total Depth: _�� ft Yeld: GPM • Static Waier I,eveL- Water Bearing Zanes: Depthl(� ft/�7v ft� ft ft ft Depih: From�_to ft. Diamet�ec: ��/y in . 'I�e: Galwaniz�d Steel - � Weighx Thicl�ess: �'� Height above Ground: ; Drive Shae: � Yes No Any problems encot�nt�d wh�e� g� Xes � If `�es" give reason: � Gront: . - � - - � Neat Sand/Cement � Concrete GraveUCea�ent . -•. Annular Space Width • mches Water in Ann Space Yes �o Met�od of Grou� Pam�ed Pressune � Poured _�� Depih �_ to _�� Ft Materials IIsed: � - No. Bags Portland cement ' Weight o� 1 Bag � Pounds . If mi�dwre (sand, gravel, c�n&�) - Rario to - Liner: ID pla.tes: � Yes _ No 4 x 4 slab �_ No - -.,. Date Installed: Grou� DriDing Log Installed by: . Location Drawing �� m— '� �� a r�11'l�:'�' �, . . � ir;,�;*!�:�►A � �_71��,��'��!► .� .� � - �.�L �u . � �� ' � , � . I hereby certify tha_t the above• infoimatian is co�rect and that ti�is well was cons�cted in accordance wi� regulations set forth by the Person CountyHeatth Depar�nent ' � Sigaxtare of Conirxcbor (/ /)' 'Z--� �—� ID # � `� Date . � � - . - Petmp Installmeut Pump Tnstallation Contractor_ �_ State Registration Numbei: Pamp I�pt�: o St�ic W Level: ZS ft �— Pttmp Make & Mo 1: (3?.�(f-`C.-f" P� Size and Ratin��hp � gpm T hereby certify ti�ax this pwm�p was installed and ti� well hr.ad coinQleted accarding to the Peison Coemty Well Rnles in effed on this date and that a capy of this record has been �ovided to�ve well owner. . � Pamp Insiaaer S�gniatare �., L`'�� l}ate: ;�� PCFID rev O 1/27/04 Application Date: �� "� � �� Tax Map #: � J� Amount Pald: 1 �� ry (� Receipt #: I 7 3 6� '. Parcel #: 2i �J C�-� ��_..5� I.�I-�I�� " � = -L � � �� a .�{,-{1- �aa�raa-�aa��-'--�• �eaa��.I� g�o�.71��a �V`1j (_il , `� � r }J APPLICATION FOR SERVICES C.R�Y� �..� el � IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEiIAENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � 1� ) Permit requested by: (Owner/agent/prospective owner): ��Q� � %r�l � �i� Home Phone: � 7�6= ,S'"iT-�r-,�c� Address: /,6 .� Business Phone: �� k�h��'► a. v✓ � �. a-�� )tj- 2) Name and address of current owner: 3) Property Description: Lot size: Township: Subdivision: Lot # Directions to the property (Including road names and numbers): 4) 5) Proposed Use and Structure Description: answer each of the following questions: a) Proposed _, Existing , Type of Structure: Width: Depth: b) Number of Bedrooms: Number of occupants or people to be served: c) Basement: Yes , No Wiil there be plumbing in the basement? d) Garbage Disposal: Yes No Water Supply Type: Private _`� (new _ or existing�, Public_, Community_, Spring _ Are any weils on adjoining property? Yes_ No _ If yes, please indicate approximate location on the �site plan. _ � 6�oes your property contain previously identified jurisdictional wetlands? Yes_ No_ � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF: I hereby make application 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 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. Owner or Legal Representative � �= D � Date PCHD, rev. O6l27102 'i ��`?� )� �� "'- �� , IG��3-o� � .e��.71 IE �L�.m.Il�7E9. SITE PLAN - Name �p,1� �i � Tax Map #�1'azcei #�� Subd�e Secriou/Lor# � , � z 2 ,r o(, A orized State Agent — DauT—�_ Syarem cvmpaaenrs rep�saot appmsimate contours only. T3e cuauacrormuseilsg t6e sysrem pdor w begmnrug thelas�ladoa m iasate tGatPmPergrade ls maiataiaed Scalc 1"b'�" '� J�2� �Q�� l� PCi3D_ rev. 09/12/Ol .�. \ OQ �� Q � \ �C.1\ C � � �� . �, �,�� - GERALD W.. STEGALL D. B. 146, P: 246 1 N N' .. � � _._______.__.___ ...,..._.._ _._...__ ___._____ _.__:.�_' ,...... .. . _ • . � X` x___ X— k— _ , , � ti- ' X x---k_--- X __ X -__ � � � z X-------Y . z—�_ " I f�- x —x— x–�.. I �. S85.°00'00"E X x �_ � i .. ,�. 538.00' _ � i � � . � � _--x NS ' , � � � i . + ,,. 42.0' ., x. _ ' � � � � W EL'_ Q ( x ' _ 5 166.8' � i �,. },. 1SF N ' . � 34 E� o .. 5��y. wM�E�,P � ' x �. . �. •6 ��,. �` 2ez. _ . � 4! . � � . ` � t'� . - � o �� / � GERALO .W. STEGALI: � o . J� { /. . D. B. 148, R. 246 . "� u'. : � 'T ^ �. / I ' a. � � � n � � � POLE ' O p N • i ' � �_ 04H0 ELEC. SERV.�_...... o. .. p � ` A xPQLE ��':_. ---""`_•... ' � p W � r m ui � f �. 8: 149, P. 543 4 � o, N �. , + :. - � ` � � � . x � ► I ' - ` � ''r? , � ` — � . �� . . . , , - , �- �� , �.. � �`,� ; , -_ , , , , � �` ,2. ��` � � � �Rq�E� � ,, � � � ` . � QRI�F � �, \ \`` — —' — — — — — CHOPPED �1NE FOUND ' - ` ` � � � \`� GONTROL. ,. 3 � �` �' .: CORNER-. N85°00'OO..W 538. 00 ` TOTAL 05 3 • . � ' :< _ . NS . �,. : I _ _ : __ . . _. - . ': `. � • . . � - � �. � JOHNATHAN FI.EETW00D =� D. B. 163� P:. 650 � � 0 � �� . �� .�iGG _._^ �� is�� LEGEND � �� . NaT i_ FOUND� Application Date: �� (� IU Tax Map: �3 � Amount Paid: Parcel #: � Receipt#: �,`-.� S�- �I�1�$�� = =�-�--,�. c� � � � � � 1L�i 1i7i�Y71 ]Z'� �[7s Tta. *�'TMT� c3 �rn -�.,r�z►, ll 1�I. JI ac�,.�a.. ll�7�a Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) � Construction Authorization $200.00/$300.00 (if> 600 d) Fee is de endent on the e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition 0 Permit Revision $150.00 (if site visit re uired) � $75.00 ❑ Well Permit (New/Replacement/Repair) Repair of Existing Septic System $300.00/$200.00/$75.00 o CharQe 1) Services Requ�ste�l�� Name: � �L r� Address: 2)Name and address of current owner (if different than app ica Name: SGt �'� � �u� Address: C�� 6�rvu-� K,J � ��,�-n �tc a�s � y - �i"ione # (home): (work/cell): i �� („ a�"� ►Y��'L C��/ Me �G)PaJ {li' �M�- � s�G�d�l� �, f G s1�7,Y'��' Su Z�o,� ,��% L/""` —�.�•�� .a �� -' � �r� 3) Property Description: Lot Size: �`' � Subdivision: �� Lot #: �'` `� Address and/or directions to Property: �Huc, Ls� -►o ca-n� - L � /�'�`G� s �M.�`�i . i2 �rn � �c �� 6ns,,,o - 6'� �f- '?�.� 1.- � l.� � � G1are � .r�. c m / a-�'-� , 4) Proposed Use and -ype of Structure: Residential Business/Type: Other Number of bedrooms 3 / Number of people served (seats/employees): 3" L/' Basement: Yes � No (with plumbing: Yes ✓ No _� Garbage disposal: Yes No 5) Water Supply� Private Well (Proposed Existing _, Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comnleted application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): �i�" "" 1 Date : 3� S a U/c7 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ... - `- _:� �� n�-nn ��nn��n�n��.� ��:��n.�_iL�n_ March 29, 2010 nsurin� a healthy environment Re: Application for repair permit for Sarah Tuck at 1641 Oak Grove Rd. Health Department file: Tax Map # A34 Parcel # 8B Dear Ms. Tuck: The Person County Health Department, Environmental Health Division on March 18, 2010, evaluated the above-referenced property at the site designated on the plat/site plan that accompanied your repair permit application. According to your application the existing system is serving a four 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 including related statutes and Title 15A, Subchapter 18A, of the 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 there is not an on-site subsurface repair option. The remaining soils are determined to be UNSUITABLE for a ground absorption sewage system. Therefore, your request for a repair permit is denied. The site is unsuitable based on the following: Unsuitable soil topography and/or landscape position (Rule .1940) X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941) X Unsuitable soil wetness condition (Rule .1942) Unsuitable soil depth (Rule .1943) Presence of restrictive horizon (Rule .1944) Insufficient space for a renair (Rule .1945) Unsuitable for meeting required setbacks (Rule .1950) Other (Rule .1946) These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, into surface waters, directly to ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, the Health Department has determined 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 additional property or a surface discharge system. phone 33C.597.1790 fax 336.597.7808 325 South Morban Street, Suite C, Roxboro, NC 27573 For the. reasons set out above, the property is currently classified UNSUITABLE, and no repair permit shall be issued for this site in accordance with Rule .1948(c). 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. Department of Environment and Natural Resources regional soil specialist. A request for informal review must be made in writing to the local health department. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 431-3000 or from the OAH web site at www.oah.state.nc.us/form.htm . The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 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 The date of this letter is March 29, 2010. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal 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 Off ce 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 petition 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 local health department if you need any additional information or assistance. Sincerely, �� Justin B. Smith EH Specialist -..,. • � . . . . . � . . . t . . . ' . . . •..- • � , • . • . � � � � ,' . � � �. �• � p - � � � . o �� ,. ��; �� . � . . . � � � � . • � ��' • �,.31� , �, . � � • �� . � � �� . � � � � ' . ��.. �. � ~ . . � � . : � � ,�. � . . . �� .. . , . . . �� ' . : � � � '; . � � � � � . • � x��y'� . � � �. � � .�� ,; . . � � � �,��; '� . . � � � � . � :� . h� :i , �. �� ' 1 ' � • '�•�j . 1� . • . • ' . �' . . . ,. s � �. ,F � I . � k. •' � �: �, ' . . . • . , ' . . • v � �� ' .�r ,t, . I�I � � ' Y � . � . j; • �. � • ` • � t ,. .�,;I� �. � . • c ,•. . � • I . , 1 '::,� � �" . • . l . � • 'j�' •i . . . . � - �. , �i � . A4.�Ji . • • � • � � � ' � ,1 •�.. • i . • • � . � ' � ` � . + �� , . • ' • � �- } O . • . 'S� O . • � • A : . '•r � . 1 • . . , ' . . • . . � ' ' ' � . , � ' . • • �� `""'� , . . � � �~�'� � � ��.��r ��.�.��72iL'Y';l:l�'+CD,�IitTCA^S�i[��:�it,171 �L .1L�C.,2:L:1`1:1�� Date: � 0 J�/�_ Name: Tax Map:�_ Parcel: 8� Address: � t Oc�K (�jrro�P �.. �p,x�osro t�f C� 'L?$%y Re: Bacteriological Test Results Dear Well Owner: Your well water was sampled on 1Q_/ 25�_L1¢__� 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 results on[y. � 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 samp[e, the water may not be safe for use. 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 positive�'or total orfecal coliform bacteria should be properlv disinfected and retested prior to resuminQ 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 336-5�7-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, � �f"---� �� Environmental Health Specialist Person County Health Department (rev. 4/20/l6) 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 � �1 Address /� T� �� 'f�'��- ' a County Collected By � Da#e �ollected ��ro15��o Time CQilec#ed �`�� Source: �Well ❑ Spring o Other Location: ❑ House Tap ❑ Well Tap �Other ��^" �� ❑ No Charge �6harge ..............................................................................� **************************************************************************** Resuits Present Total Coliform Fecal/E. Coli ❑ Reported By - Date Reported 1 � ' z (v �'� Report Called �(ES ❑ NO Calied To =�-�•-� ��•��'�b Absent i Date �� t`""^"� � + , - ,,� �,...-.,,�+ .�^+ �' �'�Y �� i��n.vrri r�aupn�n�rna�.irs+�:,�.�1 I��r�� l��n / �1 / `'7 /� Name: / � �7 �.c'� Address: 6 �} .�e. D7(' uro 'L 7S? Re: Bacteriological Test Results Dear Well Owner: Tax Map:�3 ` Parcel: $� Your well water was sampled on �� / 2/��°, and tested for both total and fecal coliform bacteria. Your water sample test results are noted below: � No coliform bacteria were de:ected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and sho:,�ering, based on the bactgrialogical results 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 ancL�or human waste. The presenc� 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 irtay not be safe for trse. 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 positive for total or ecal coliform bacteria should be properly 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 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. ' Smcerely, � � �� 5�.�,��s �� -�� yr�e� ,,�e,c. ( l�t�� }— r�� w�� ` �,,�(� S f'%S �`�-s , 1� t�-� C'�n�-e b ac� Environmental Health Specialist Person County Health Department (,`��uq�, (rev. 4/20/16) Person County EnvironmeMal Health, 325 3. 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 � r I ' i✓� � Address � � � �n/� c� �'� � County �� J� b wo C �?.5-� y > 1 Collected By Date Coll�cted ��` 2' l% �'ime Collected l(• �� Source: �Well ❑ Spring o Other Location: ❑ House Tap o Well Tap [�Other � �� w�� ►"�S�- o IHo Charge �iCharge ..............................................................................� **************************************************************************** Total Coliform Fecal/E. Coli Results Present ❑ ❑ Reported By Date Reported � ' � ' � � Report Called Calied To ❑ YES ❑ NO Absent PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD ROXBORO, NORTH CAROLINA 27573 BACTERIOLIOGICAL WATER SAMPLE ANALYSIS Name of Owner or Tenant `' �-+ I T Address ��D� t� � County �'�.bvw { ? S? � Collected By _oll`-'S Dats �ollected ��Z��fo Time Callectec� Source: �Well o Spring ❑ Other /c : ss Location: o House Tap ❑ Well Tap ❑ Other �� 1.✓�e�� ❑ No Charge C�Charge ..............................................................................� **************************************************************************** Total Coliform Fecal/E. Coli Results Present ❑ ❑ Reported By Date Reported �� ',� Report Called ❑ YES ❑ NO Called To Absent �, �