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A40 270
`' � i �- , q001120 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # /-1- ?�v Parcel # Y'..�— Z 7� Zoning 1..o N TOwilShip _%L�.TY J�,F'� �Z '�'� Date Owner/Contractor ,�v�; �,�--,Y ,� �� �;� ''�- [ -- � `� _ Location/Address Sal s %%2 FL�'T 1Z� �"ci` �-t-�- •"� nIEA�Z. t=nlv o,�! LGFT S.R.# l/�'S� Subdivision Name Lot# Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is re or intended use ck�i� Well and Septic Layout by �� �=�� ���Dr ��''`JC� � Comments: �,��.t-�� i w�� rT� ius ��•' G,�J� ��'-i-�-� `/ t� y Date Installed by cTfl ?� Approved WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab � �1' Public Re lacement Air Vent � � Site Approved Required Well LQ� Well Head Approve Well Tag ��� Grouting Approved !�V � �9 � — � �� � Comr.l�nts: � � C • -�� Dat� Installed by r�pproved Tlvs report ;� based in part on infom�ation provid.ed the homeowner or his/her representative in the application sLi6rnitted for this pemvt The environmental health specialist is not responsible f�r false or misleading information contained in the application The environmental health spec�a!ist is also not responsible for concealed conditions on th.• property or for slafements in this report that may have resuited &om false or misleading , statements provided to him in the application Neither Petson Coutriy nor the enviroamental health specialist wairants that the septic tanl : systen± � v'sll continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\pemsitsam O i/95 ��:; <_ 1.0 �W�Soa GpUNfY!`,p�,E4y'ti V * � �i t ' * * t s � �Z : PERSON COUNTY . cpfQJ°"`°°""S��`� � o� � PERSON COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH PROGRAM , 325 South Morgan Street Roxboro, North (910)597-2204 � �' k�' Carolina 27573 �� � ��-�� �—�-�_ � � G �,� - I �� � � � �at�: _. 7 _ ..� � . 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ROXBORO, NC 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS , Name of Owner or Tenant Address pC �� l t-I ,��,� C� ��,County ��� l��✓D /� �.�� Collected By Date Collected � o Time Collected �� � Source: �Vell � Spring ❑ Well Tap ❑ Other ��;�C ; a�- 0 No Charge �harge J�� ***�*�*****�*******��***�**�*****�*�*****�********�*******************�* ********�**�*****�**�***********��**�*****�***�***��*******��***�******* Results Present Absent Total Coliform 0 � Fecal/E. Coli. 0 � Reported By Date l� I l� �