A23 773��� � G
Application Date: � � �3 � p� ���+5 /" ������
Amount Paid: �o!G� 0 0 '�i'�� • �
/ � �.
Receipt #: � �G 7�12z � � �' � ����
� I� �'��un.� �imr��rn�rv.n4s�rnd:�rn.� J�'��a-m.��R:)in
-- - -
A lication for Services
Services Re uested
Improvement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 (if> 600 d) Fee is de endent on the ty e of
Mobite Home Replacement or Building Addition Permit Revision
$150.00 (if site visit required) $75.00
ell
$30P.00/$200.00/$75.00
Tax Map: %� � 3
Parcel#: �
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
�plicant Info mation: �,
Name: 2 .,% "'� c� � +'
Address: P
i r i 1�� •2 �
�ame and address of cu rent owner (if different than applicant):
Name:
Address:
Phone (home): �LF - 02 � �� �i � ?
(work/cell):
Phone:
' 3) Property Description: Lot Size: �. �(n Subdivision:
Address and/or directions to Property: ,l1 �: ('�.�p C r. 1�A ;
Lot
� yes no Does the site contain any jurisdictional wetlands?
� yes � no Does the site contain any existing wastewater systems?
p yes �no Is any wastewater going to be generated on the site other than domestic sewage?
C] yes C7 no Is the site subject to approval by any other public agency?
p yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
�roposed Use and Type of Structure:
❑Residential
�New Single Family Residence Maximum number of bedrooms: �tr �/ Occupants: �_
O Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfi.mctioning System Will there be a basement? ❑ yes Cl no With plumbing fixtures? ❑ yes ❑ no
C] n-Residential
pe of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply� New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no
Please note any known ground water restrictions or sources of coritaznination:
If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Acce ted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
P
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is sul�sequer�ljy altered,�or the inte�ed use changes, all permits and approvals shall be invalid.
Signature (Ow�er/ �,egal Representative*
* Supporting documentation required.
.�/ —/
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
��' ` 4'" � ��1lJ �� ��
�� � � ����
7E�+s �-Yn �- � ����.��.Il. I�7I � �.11�77�
Tag Map: �3 Parcel:�
Subdivision
Phase/Section/Lot #
Applicant: �.cQr �'� %�Q�✓1�,�, �r•
Address/Location: j � - - _ _ -_ �-� , „ . _ � !I �_«
V Improvement Permit
Permit Valid for;�Five Y a,r�j l� Non-expiring __
Type of Facility:' �✓�� 1� New � Addition _
Number of: Bedrooms '3_ / Oc pants�Employees / Seats:
Proposed Wastewat r System:
Proposed Repair: uM,
VVater Supply: w'�r�
Projected Daily Flow: 3�� gallons/day
Type: �
Type: �
Permit Conditions: �-� Si � I-� �% 4Y�t
Autherized State Agent: /�.[r�_ �c OG,1 _ Date: /`Z��1�( 5
(X) Owncr or Legal Rep esentative• � Date: 3��� l- L_
The issuance of this permit by the Health Department does not guarantee the issuance of other required pertnits. It is the responsibility of
the applic�ntlproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina °Luws
�rnd Rules %r Setivag� Treatment and Disnosal Svstems'(ISA NCAC i8A .19U0). N�ither Person County nor the Environmental
liealth Specialist ivarrants that ihe septic s}�stem will continue to fanciion satisfa�torily in the future, or ihat t�e water supply wi�l
remair �otable. _ _ _ _ _ _ _ _ _ ____- _ .
Authorization to Cons#ruct Wast��vater System
See site plan and addilioMal attachn:ents (_�.
;t
Propos d Wastewater Systexr►: i t�C —� 5` , (*)Type �� Design Flow � 3�ga1./day
New i� Repair _ Exp sion _- Soil L"CiaR: j 3 � gal./day/ft2
Type of Facitir�: �`� j �► 3� P, Bssement: _ Yes � r�o
(*) Syste�ypes Illb, Illbg, IY, and V, require periorlic syste� inspections by the Ferson County Health Departrnent.
Wastewater System Requirements
Tank Size: Septic Tank j dd� gal.
Urainfield: Total Area � sq. ft.
i rench Width 3 fl.
Pump Tank � gal
Total Length � �Q � ft.
iVlin.Soil Cover � in.
Grease Trap � gal.
Max. Trench Depth � in.
Min.Trench Separation � ft.
Distri6ution: Distribution Box� / Serial Distribution__ / Pressure Manifold
Specificatioas: _ Se-e S/`r� t/%�A�vi
,�►uthoriz:,d State Agent: rL, � �✓V'Q,� Issue Date: /��-l$
Permit Expiration Date: /2- Zc�
7'he system permitted is: Conventional /Acczpted �/ Alternative / Innovative . i accept the co�iditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: 3-'i -/�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NG' 27573/ph: 336-597-1790 (rev 5/12)
� JAMES POINDEXTER
D.B. 274/156 -+
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NG N S7��58��5,,W �
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SITE PLAN
Name v�uY ��5 � v� r`^ ' Tax Map# �� Parcel#�
Subdiv io Section/Lot#
V �
Authorized State Agent Date
System components represent approximote contours only. The conlractor mustJlag fhe system prior lo beginning (he
installation to Insure that proper grade ts maintained.
Note: An Accepted system may be used fn place oja conventiona! system withdut permit authorizalion or modificalion.
��s�; �us � c (,
�,,►�: �� � �-� �
.`33 �p ��`7— �(lg�
Tax Map: �3
Subdivision:
���,sf �I��.���
- ������
IE �� u- � �,� m,� �, �.Il IHL � �. Il ¢ ]�
Parcel: �
WELL PERMIT
(New�, Repair_)
Lot:
Applicant's Name: C �-tAv �'PS � ; ✓I �,�, �✓:
Mailing Address:
Phone Numbers:
Location of Properfy:
�ere.�.� � a
e G�s /�i�'l
Permit Conduions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�1ew Well:
Location:
Grouting:
lA/� � (� n �—�Vell Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Date: % 2�� ! s
Certificate of Completion
Di.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
Well Driller:
Pump Installer:
Approved by:
License #:
License #:
Date: � 3��
Additional Comments:
Date Sample Collected: 'l `�` t�P Date Results Mailed:
EHS:
Person Caunty Environmental Heaith
325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 _ 11/26/13
�1�' ` � l f ���� �� V
' � � ����
��n.�-n.a-��a���n.��.Il Il: 3L �a�.IltGl�n
Applicant: ���►'�� S �� �'�
Location: , , . �
Tax Map ,�3 Parcel # �
Subdivision
PhaselSection/Lof #
# of Bedrooms 3
Oueration Pern�it �.
�
System Type (From Table Va): %%,
Type V& VI Expiration Date:
Product � a�
�g)� C
Type V& VI Renewal Date: �
This system has been instalIed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of ihe Improvement Permit and Construction
Authorization.
� � v✓'�
uthorized Agent) �
���
(Licens Contractor)
e ��4� ���
C '
�""
�I 17�
r
Scale �D'��
PCFiD, rev. 12/14/12
, ,�
�16 �,b��
5�2,,
S �S ��Z't
l}')cG-�t�S � -� � ! ��=�: .
�jrl3-l�
(Date)
�j_,3_��
(Date) �
,� �v � �-�' � a
SrGtve � ��v�
Y�'R
��t:
3�
Tax Map: �� Parcel #: �
�
Septic Tank System Checklist (�pe II-IV} System Type: �� C�`�`' �''�
� �
Se tic Tank In'tiaUDati
State ID& Date: 2—�-/ S c%�
' Capacity: Y D �v
Tee and filter �
Baffle �
Vent
�Riser `
Outlet boot ✓
Perm. Mazker � ,
Distribution
D-box (levels set)
Serial
Pressure Matufold
LPP
Notes:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
Apr08 16 09:46a Barnette Well Drillinglnc
WELL CONSTRUCTLQN RECORD
This fonn ean be usod for sio�Je a multip.e vrclls
l. Wdl ontrattor i�formalioa:
a���`� � . ���-�
WeU Coatrictor Name �
�3 3' 7d t�
Nc wai co�u,� c�c,�c� r��
Ba�ette iNell Drilling, lnc.
%.06�1iQy i`�3IIIC
Z W�SI Gotutraction Pumii H: � 2�
L7rr dl alopflaable r�e!! rwwrruaion pe�mits (i. r. Cawuy. SiotG Varin+aoc. etc�
3: R+dl Uu {chcck wd4 u�se):
af�g►;cuiauac oMun:cipauP�►btio-
�Gcolhetmal (EieatinP���nB S�PPLY� �identia! WaLerSupplp (single)
QIndu¢trial/Commacial RRcfidcoual WatuSu�sF�Yt���
336-598-9275
�� ` �G� � ��'Y}
£lAquifu Rcc6argc OGco�indWrattr RcitiCdiatioa
DAquifcrStacagcandltccovay ❑Salinity�actiu
❑Aquifa Test �Storrn.waterYkainarg�
❑fixperimenta[TechnoEogy E]Sufuidenc,eConcco[
LIGeGtlxermal [Closed Loop) �'[lao�r
❑Gcothamal (Heatin�CntiFing Ret�m) flOth¢(ci�lain nndcr l�2[ R:eo�arl�s)
a� ��r��:� co�►A�u�a: S'� � r6 wa�:m# %� Z�
Sa. 'Wdi Locafion;
L'f�iQ 2% s d�.`�c�,�.�i r� •
FacilitydQwt�crNama Facitiy IDIR(ifqppticab[c)
r��Si� F' �f/� �%t CfjF'r� f\L�
e�yu«t a�. �ry. �a�v �
P� � SO,,� � �
�,n� r� �a�uuo4�o. C�>
Sb. Lsawde and Longit�deio.degrCes�miautafucvodsbr dearaaf degr�a�
(�!'weQ 6a14 «�e F�Itoag 's saefioiaw) .
3� - 3r -- � z N 7 �' -- 0 3- i/ .�
'6'Is'(�rcEt�ewell(sj: [$R.�in�xntat or �'Catiaporaiy
ti Ls this�� re�rsir Lo sa e�Sting:�scU: dYet or G]Ai�
(�dirrs tr a r�pd ,hlloWk�rovti wt!lcomnvezmxir�'ornxY(on ,m.c(upl�irt firt aolurcaj'!he
repair+rqder k1! K�� udian orea �ke.bcti ofdrLtform.
&.Nao�ber o! wells wnstsuefed: �
For wullipSt frqecriar or AwrHcrer su�y welLc ONLP wi�lt ilia sbntt wnt4Kcfiae, you a+n
s�mlrnirefaxr.
9:Totsi"we3ldept� 6clowlandsurficG �� � (ft�
�'orR+uftipLc s�clls fulall deprhs ifdrffenrir (anmrilA!-3CZOQ �crtd I�IpO�
ID. Statie �eiier tevel bclox toP bf easiog: 2.� (fC)
lf�.rle►il.riahov2 msbrg; t�.te ^+'
p.1
For Iotcna[ Uu OtSI:Y:
Cl;ii'A�R 7ANFS ,
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Ct fY.
ft ft G
L
i$�OifTEli<(',�S�+IG(foi'.luufti-rited:w _ .URf3[NFR tf, . liobt't'.,..: .
FRO�St 7'0 DUM£I�R 71(iCl�PFSS MA'[PXL4L
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��az,�+�or.cm�� w� c� ��.
fTy slgnbtg �B fam. ! l6eruby art�y dmi iA�c �waU(.kJ wur (ac�c} eoxrtrrdrd itr a000rdcnce
viAr f3.[ N�'itC OZC ALi70 or lSd NCAC Q�C.QZOD Wd! Cururiricaon 3tanddKLr mid rGnf o
�PJ''9�tlLit ismidlaas beaipivvidad mt dbe rrl! ar�er_
73. 5itc diagiym or flidditionaLweU def�ls: .
You m8y asc tiie badc of thiS pagc !o providc additioctsf wdl. sitc dctails or v�il
�dion defa�'Ls. Yoa may a4so-ariaclt,addiuibaal pages if na�s.saty.
su�-rnz� uvsr�icr7ons
Z4a. For Afl' Wdl� Submit this.Swtxn w�hus 3a days of CamPldion of wdl
ooQisttucticai tbthc'fallcn�atg:
�i1Pi510d10�wA1t[`QR�lij',�4.{Q[Ht8aOP rrOCESSItIf��W�
1617 MulSerria Ceater, Ra�eic�h,ik��?699-1617
21..BoeeLot� diaiaeter (ia) Z4b.. For inicdio+ �eUs: In additiou to sendinp, d�c fonn tu [he addt'�5s in 24a
/j �L 9bove� atso.3uTstm[ a cx�py of this forra titithin .30 days of bo�aplction qf w�ll
LZ �Vell CoaSlruC600.metLud:, /Yrr� i� / l�i� /� C�uchO[1t0 tiiC foilOzvic�;".
(�e auge , rdacY. �1e: df�eci 2ash. ore.) %-- Tkxisiouof Watt; Qoalitp,. rraa���a.���c�aa eoa�,�t r,��m,
FflR'FYATBR SUPPE.Y WEL[S QNLY- 1636 Biul Sesvioc Csater, Rafe�6, NC 27b99=tfi36
i3a: '1'idd (gpm}. �- _ h�efh4d oCtest BIOYYIi2Q Rtinttte 24c Far�i'nlsr,Sunb1V �.lniettioa �Veils: In addition bo seading die£8[m tb
ihd ai1�(es) s6ovq also dubaiit oae oo�y of this fam initlrin 34 days of
136. fsi�afcctiaa typc HTH rlumuat '�fryL �'iU�i �Pfetion of welt wiutnsction to the crxti:Cy� hcaitfi dc{�rlinuit af tl�e caunty
v�fiu�e caistriiLtad.
r.�._ r_ar_t 1�i.,.et� (•nM,1��, nrnarrmencerf Eavi�varornt ud Nan¢al Raazcxs -�ivis+aa of WwrQuality Reviudlaa. 20 t3
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- = ,= i^'j �;y � i �,.,. �3 '•' r� r '` � E��� �'��"~i ��, 4 1 a : ��-. C'-a ��-;
:, , a ., �- � ._ � : , � �._,I `�; �� E � s�i f ��
� t_ .....�: ��� �t�� k �'� �1' ../' e€ r�i e c l.� t�
For Inorganic Chemical Confaminants
County: rSa ,� Name: a ��-PS �.- r-
Sample ID #: � -- Reviewer: Q� ,T
� TEST RESULTS AND USE RECOMMENDATIONS
1. 0 Your well water meets federal drinking water standards for inorganic cdemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inor,�anic chemical results onlv. You may
have other water sampling results that are not taken into account in this report.
2. ❑ The following substance(s) exceeded federa) drinking water standards or the North Cazolina 2L calculated health
levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and
cooking, unless you install a water treatment system to remove the circled substance(s). �iowever, it may be used for
washing, cleaning, bathing and showering based on the inoreanic chemical results onlv.
Barium � Cadmium � Chromium � Copper � Fluoride � Lead � Iron
Mercury Nitrate/Nitrite Selenium Silver Ma�nesium Zinc nH
3. � a. Sodium leve(s exceed the U.S. Environmental Protection Agency's�(USEPA) Health Advisory leve( for sodium of
20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or (ow sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and shawering based on
the inorganic chemica[ results onlv.
❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5. 0 Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably
the kitchen) and if possible a first draw, 5 minute and a I S minute sample at the wel! head to determine the source of the
lead and/or copper.
6. �The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv, but aesthetic problems
such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treahnent system
to address aesthetic problems. �
Barium � Cadmium � Chromium _�_Fluoride � Iron
Maneanes Selenium Silver pH � Zinc
For more information regardingyour we!! wafer results, please ca!! the North Carolina Division of Public Health at 919-707-5900.
North Carolina State Laboratory of Public Health 3�12 Distnc�Drve
Environmental Sciences Raleigh, NC 27611-8047
http://sioh. ncaublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: ADAM C. SARVER
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
Name of System:
CHARLES POINTER JR
9191 MCGHEES MILL RD
ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343
EIN: 566000331EH
StarLiMS ID: ES051916-0068001 Date Collected: 05/18/16 Time Collected: 10:05 AM
Date Received: 05/19/16 Collected By: A Sarver
Sample Type: Raw Sampling Point: Well head Well Permit #: A23-77
Sample Source: New Well Temp. at Receipt: 4.5 GPS #:
Sample Description:
Comment:
New Well I (Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
Arsenic < 0 005 o.U� u mgi�
Barium < 0 1 2.00 mg/L
Cadmium < 0 001 0.005 mg/L
Calcium 45 mg/L
Chloride 10 00 250 mg/L
Chromium < 0.01 0.10 mg/L
Iron
Lead
Magnesium
Manganese
< 0.05
< 0.20
< 0.10
< 0.005
7
0.053 5
1.3
4.00
0.30
).015
0.05
m
m
Mercury < 0 0005 0.002 mg/L
Nitrate < 1 00 10.00 mg/L
Nitrite < 0 1 1.00 mg/L
pH _ 8.1 N/A
Selenium
< 0.005
Silver < 0 05 0.10 mg��
Sodium 11 00 mg/L
Total Alkalin
Total Hardn�
Zinc
Report Date:06/03/2016
< 5.00 25U m
< 0.05
5.00
Reported By: Deddie .9Konco�'
Page 1 of 1
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.l�',aiCTIZY'II.tL':iDRhlllt'a.�'L;.il���1.� ���l�C=�.:�ti:��
Date: `� / ( /�
Name: C�A+r 1rP d; n �r.
Address: l4� /�lC k-?,PS �` I/ •
S'�Pr�ara �t/c �R 3 �( �
Re: Bacteriological Test Results
Dear Well Owner:
Tax Map:� Parcel:�
Your �vell water was sampled on S/�'�/�, and tested for both total and fecal coliform bacteria.
Your water sampie 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 only.
� Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total col�orm bacteria are naturally found in thE soil. Fecal coliforrn bacteria are assaciated 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, t/te water
tnay not be safe, far use. Young children, the elderly, and the i�zdividuals with compromised im�nune
systems are especially vzrinerable ar.d their physicians should be notified of the test resu?ts.
A well that tests positive or total or fecal 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 plurnber 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,
�Pvv`e.�
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person County Environmerrtal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808
North Carolina State Laboratory Public Health
Environmental Sciences
Microbiology
Certificate of Analysis
Report To:
PERSON CO ENVIRONMENTAL HEALTH
325 S MORGAN STREET
ROXBORO, NC 27573
EIN:566000331 EH COURIER #: 02-33-15
StarLiMS Sample ID: ES051916-0103001
� ������� ������ ��� ����� ����� ����� ����� ����� ���� ������ ����� ����� ����� ����� ����� ����� ���� ����
ES Microbiology ID:
GPS Number:
Sample Description:
Comment:
P.O. Box 28047
4312 District Drive
Raleigh, NC 27611-8047
htta://slph.nc�ubiichealth.com
Phone: 919-733-7308
Fax: 919-715-8611
Name of System:
CHARLES POINTER, JR.
9191 MCGHEES MILL RD.
SEMORA, NC 27343
Col lected: 05/18/2016 10:05
Received: 05/19/2016 08:16
Sample Source: New Well
Sampling Point: well head
A. Sarver
Angela Heybroek
Well Permit Number:
A23-77
Environmental Microbiology - Colilert Profile Method: SM 92236
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present Denise Richardson o5/20/2016
E. coli, Colilert Absent Denise Richardson 05/20/2016
Report Date: 05/20/2016
Explanations of Coliform Analysis:
Reported By: Susan Beaslev
If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water
has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample
received and should not be regarded as a complete report on the water supply.
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