A23 8' Aaplication Date: J-) g-�i-% Tax S�dap #: /-1 � 3
Amount Paid: 20�
Recaipt #: �"� ��j 19 % Parcai #•
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APPLICATION FOR SERVIC��
IF THE IIdFORI11lATl�R1 Itei TF{F iAP�'l.lGA'�1�tPa1 FOf3 Afd IMPROVEiiIIEPd'9" P�I�t+Jll'P IS 6EVCOR�EC�", FALSIIFIED,
CHAIVGE9� ()R TFIE SITE IS /�L7�RED T'N�P� i'1iE INIP(�OVEiUIEPd'T P�[�Ni6T A�BD �UTHORIZ�eT1�OR! TO
CONSTRUCT SHALL BEC09VIE If�lV�ALI�.
1) Pemnit requested by: (Oarura� a�en pPospective owner): .S {�il ��
Home Phone: �lIQ- y7/- 8(o�i8 Address: �J S f
Business Phane: ql9-�l�- 811 N 57
2) Name and address of curcent oavn�r: .� �
� ?Q(ZEd e.sus Gh r .
SPm..(1ra NG 2��43
3) Property Descri�ation: Lot size: 7% 2$ Township: ��� Subdivision: !1 0. Lot #�Cl
Directions to the property (Including road names an numbers):
m c. �,�h ePs m i II R���o e
4) F�roposed Use ancl Struc$ure Descripteon: answer each of the following questions:
a) Proposed 1/ , Existing Type of Structure: � t15P __ Width: J� � Qepth: iD O
b) Number �f Bedrooms: � Number of occupants or peopfe to be served: 5
c) Basement: Yes_, No ✓ Wiil there be plumbing in the basement?
d) �arbage Dispasal: Yes , No ✓
5) Water 5upply Typ�e: Private ✓(new ✓ or existing�, Public_, Community , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indi�ate approximate IocatiQn on the
�site plan.
6) Does your property contaa�o pr�evic►usly icD�ntified jurisdic#ional vu�tl�rc¢�s? Y��� i�90 ✓
PLEASE MOTE THE FOl.LOWItVG:
� A PLAT OF THE PROPERTI Of� SlTE PLAP1 MUST BE SUBNiI"fTE� 1lVITH Ti-iflS �,�'PLIC�iIOR�.
9 PROPEFtTY L1NES AP�B[) CORief�RS 1�9UST BE CLEAi�LY MAFa4��D; .,
9 TNE PROPOSED LO�ATI��I OF ALL STRUCTURES MUST BE ST�►9�C�D C�9� FU-'�GG�L2.
9 TDiE SITE MUST BE READiLY ACCESSIBLE FOR Af�l EVALUATIOfd B1( THE HI�ALTFi I3E�'.ARTi�19��4T
STAFF.
I hereby make application to the Person County Healtli Department for a sifie 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�be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become in alid. .
�
or Le�al
5-��-07
Date
PCND, rev. 06127102
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Date; June 19, 2007
James Hill
P.O. Box 151
Rougemont, NC 27572
Re: Application for improvement pexmit for lot on Oak Pointe Dr. (5i� (�
Dear Mr. Hill,
nsurin� a healthy environment
The Person County Health Department, Environmental Health Division, on June 14,2007
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 4 bedroom facilitv with a design wastewater flow of 480 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 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-.1948, and the evaluation indicated that the site is UNSUITABLE for a ground
absorption sewage system. Therefore, your request for an improvement permit is denied. A copy
of the site evaluation is attached. The site is unsuitable based on the following:
Unsuitable soil topography and/or landscape position. (Rule.1940)
Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule.1943)
Presence of restrictive horizon (Rule .1943)
Insufficient space for septic system and repair area (Rule .1945)
Unsuitable for meeting required setbacks (Rule.1950)
Other rule:
These severe soil and 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 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.
For the reasons set out above, the property is currently classified UNSUITABLE and an
improvement permit shall not be issued for this site in accordance with Rule .1948(c).
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
m
However, a site classified as IJNSUITABLE may be reclassified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d).
A copy of this rule is attached. 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 scientist. 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 Offce of Administrative Hearings, 6714 Mail
Service Center, Raleigh, N.C. 27699-6714. To get a copy of the petition form, you may write the
Office of Administrative' Hearings or call the office at (919) — 733 — 0926. The petition for a
contested case hearing inust be filed in accordance with the provisions 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 WIT�iIN 30 DAYS OF THE DATE OE THIS LETTER. The
date of this letter is June 19, 2007. 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 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. You must send the copy to: Office
of General Counsel, N.C. Deparhnent of Environment and Natural Resources, 1601 Mail Service
Center, Raleigh, N:C. 27699-1601. Do NOT send the copy of your petition to your local health'
department. Sending a copy to the local health department will NOT satisfy the local requirement
in N.C. Gen. Stat. 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
Environmental Health Specialist
Person County Health Departrnent
Attachments (copy of•Rule.1948 (d)).
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�.�'Pt_lC�T10N FOR SERV{�C��
IF THE IIdFURP�lIEdTI�J�9 1F�JI TQ-Q� 6AF'F11...l��.�TYd�)P�I FCJF; ,�°�f� Il11iPROV�{ifa��d"6' 8�'��3��i1'T la 9�a°Cf7�k���T. F�1L.^711Fd��3s
CHAiVGE�. OP� 1"H� S9T� IS /��Y�:f��f�, �"�-i�P�! ��9-B� 16t4GGPROVEiUIlE4�'i' P��;���i�"r,�P�� f�,9��1-I�.l�l��f'I��!! TC)
CO�ISTP2l1CT SF6�►I_L_E3E�f���i� I���i"�O1.�R�,
1) Permit recgue�te�9 &��: (��a�� ���c��a� � Q�a��a: g��e��:iv�e ov�n�r): �yC11Y1 �,� �'�l ��
Home Phone: �lI q- y7 /-�(o� Address: ��L
Business Phone: �19-G�lt/-5811 �/Y►On� lI/C <�?7��7�j
2) P+9arr�e �nd acdai��ss caf c�ar��r�ft aa�rw�a��: n� fl�6c.? l_ t.(��
a e Su5 L h
SPm�r a N� �73�F� _
3) Pro�aerty i]esc�e�ation: Lot size: �� Tatnrnship: In. �{ _ Sut�r�ivision: Yl GL Lot#�Gl
Directions to the property {Includi�ng road r�ames an numbers): � �C �o
Fmc.t�h�PS mill 12��, �fo Lak i��P nn L�Ff-
4) P'roposecl Use aQi�1 S�ructkaaa'� ��scrig�ticsa�: answer each of the fo{lowing questions:
a) Proposed 1% , Existing T, Type ��F Structure: I-f � U S(? __ Width: S D Depkh: tD U
b) Number of Bedrooms: �_ fVumber of occupants or people ta be served: .� _
c) Basement: Yes_, No ✓ Wiil there be plumbing in the basement?
d) �arbage Disposal: Yes , P!o ✓
5) Water 5upply T�p��: Private ✓(new �/ or existing�, Public_, Gommuniiy_, Spring __
Are any wells on adjoining property? Yes_, No _ If yes, please indi�:ake approximaie location on the
site pl�n.
6) Daes yo�r prvp�a-i� �ora��8�a �a����a���9y i�9�.ratifer� jurisdic#ianal �s�s���a�ae�s? >f��� ��� ✓
PLEASE NOTE THIE F��.L�VNI�9�G:
a� � PL,AT ()F T9-a� F'RC�9��3�.Tf O� :�A`T� P�N MllST BE SUF3tVi!'�"T�� 1l�P�'1'6� �"F8@ i,�1�'�'�1�,�,�"�0�9,
A PROPCF�TY LIPIES ,�P��! ��'Jl'�P�1�i�� �U�T BE CL�i�LY RII�f�b��Q, ,
9 TH� PROi�fJS�D �.U��T9�P� �9� s�LL �TRUCTURES MUST B� �?���p �9�� �'N�-'a�f�'�i.�,
9 THE SITE ilJdltlaT �� ���9�.'Y ��CE ;5lBL� FOR ,O,M E�lALUl�,Tl�D��1 f3�1 i'F�i� E-11�6A�Ti 8 ILII�&�'��RTi�k�1�,T
STAFF.
I hereby make application to the Persan County Healtfi Department for a sit� evalua#ion for tt�e an-site sewa�e dispa.�al
system for the above-ciescrib�d propert�+. 1 agree that the contents of this �pplication are tru� and repr�sent the ma�cimu.m
facilities � be plaied on the prop�eriy. I understand if the site is altered or the intended use ct►�nges, the permit shaii
0
or Legal
S- � �—c� ?�
Date
FCHD, rev. U61Z7J02
.,.�.� ._ _,_ � � ����
�Il��Il71'c�R'11IYI1CfLc�lliltL�"l.11 ��c(?�h.�t(:�'IL
October 29, 2007
James Hill
P.O. Box 151
Rougemont, NC 27572
RE: Site Evaluation Application Dated 5-18-07
Dear Mr. Hill:
nsuring a healthy environment
The Person County Environmental Health Department has a policy that states any
application, which has not been acted upon for 3 months becomes void, and any fees paid
are then forfeited. Our records indicate that an application was filed on 5-18-07 for an
onsite wastewater (septic) permit. Our Department conducted a site evaluation on 6-11-
07. No other communication has been received from you concerning this property. Due
to the date of this letter the time allowed will be extended. If action is not taken by
November 19, 2007 the application wiIl become void and all fees forfeited.
If you have any questions concerning your applications, please contact Justin Smith of
the Person County Environmental Health Department at 336-597-1790.
Sincerely,
�
��--- '��
Justin B. Smith
Environmental Health Specialist
Person County Health Department
phone 33C.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxbo�•o, NC 27573
► ��� ��; ������ :
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Applican�
Location:
T��K N1a� ! � �rc I � :
Su�bd�ivisian
h�:5e:'Secfii�an.'Lot �
7
I�pra�►ejaent �ermit
Parinit `�alfd �or �'ive 3�eaa� lYo �iration
al / ��/' ��
Type of Facility: ' Y �•� S' � New �/ Adclition � Water S�app�Y 'l�1�L—
# of Occupants �(� # of B drooms Pro' cted Daily Flow 3 .p.d.
Proposed Wastewater S Z Type:
Proposed Repair: • Type. .
Permit Conditions• �
� . A► idl Q �f A S . . - �.
Owner or Lega1 Representative Signaiure: � Date:
Authorized 5tate Agerrt: � � Date:
The issuanc.e of tlus pem�it 17y the Healt3� DepaltmeIIt � does not guatautee the 7csnanet of other pex�mts. If is the �sponsib�lity of the .
aPPli�P�' owner m in sure that all Peison Co�mty Piannmg and Zonmg and Bui`Iding Inspeitions requsemessts aze met This
%mprovement Permit is snbject to revocation if the sitc plan; �pl"ai''or� the intended use changes. 'The Improvement ]Permit is not
a�ected tiy a change in owner'ship oi the p;opertp. This permit was is�ued in compliance with the provisiflns of the North Carolina, .�
`Laws and Rules %r Sewa�e Treabnent and 1Disnosal Svstenss' {X5A NCAC 1�A .1900). Neither PErson �ouniy: �or':`ttie-` �� �
Environmental �ealth Specialist warrants tttat the septic tank spstem w�71 cantinue to fnaction satisfactorily in the fntnre'or:tliaf.
the-water supply w�l remain potable. � �
� Authorization to Constrnct �astewater System (]�equia�ed for B�illaling Per�it) �
* See site plan and additional attachments (_�. . . -.
Proposed W�stewater System��� . , 1�'pe � W Z water �1 ��.p.d.
New -/ R e pair E x pans ,� soil La g p
Type ofFacility: �ri�a�e. �eSr�ent�P � � Basement_Yes (=AFo�
�astewat�� 5yst�m ��airemen#s
Tank Size: Septic'Tank:' Od0 g� Pnmp Tauk:� /b00-- gsi Grease Trap: -�o'. �
Drain,fieid: Total Area: /35o sq ii Total I.eength � ft ' N�'a�ffinffi Trench Dept9a �� am '
G.
�rencii �Vidth �_ ft 1Viin�nm Soil �over. _�_ in M'in'imum Trenc� Separation: _��#t
Dista�abniion: Distri7bution �og Serial �2istribntiom� ✓Pressare 1�Ianifold .
Spe�fications• • � � = -.
, , .
ri i ti S .
�utlaorizeai Sta.te Agent Date: .
Permit F�piration Date•
The type of system permitte3 is Conventional Ac��ted �Alternative. I acc�t the spe�ifications of the
Permi,t• � .
(�v�aei�li��g�l �e�r�s�.ntatiqe: Date:
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March 20, 2008
Alma Wallace
200 Ephesus Church Rd.
Semora, NC 27343
RE: Site Evaluation Application Dated 5-18-07
Mrs. Wallace:
�.
nsurin� a healthy environment
The Person County Environmental Health Department has a policy that states any
application, which has not been acted upon for 3 months becomes void, and any fees paid
are then forfeited. Our records indicate that an application was filed on 5-18-07 for an
onsite wastewater (septic) permit. Our Department conducted a site evaluation on 6-11-
08. We have not yet received the recorded plat showing the soils area. No other
communication has been received from you concerning this property. If action is not
taken by Apri110, 2008, the application will become void and all fees forfeited.
If you have any questions concerning your applications, please contact Justin Smith of
the Person County Environmental Health Department at 336-597-1790.
Sincerely,
�
�
Justin B. Smith
Environmental Health Specialist
Person County Health Department
phone 336.597.1790
fax 336.597.7808
�25 South Nlor�an Sireet, Suite C, Roxboro, NC 27573
Application Date: % S// (',�� 3 Tax Map:
Amount Paid: -2U � � �' � Parcel #:
Receipt#: ,570(2 S
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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 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 No CharQe
1) Services �equested by:
Name: EAL G��Am ��-c-s' Phone #(home): �Gl�'l -`�� ¢ Z� FFrcE
Address: (�O C3 o x �Z� � (work/cell): 5q �- b 8b �
Ro x8 oc� N c 2Z ��13
2)Name and address of current owner (if different than applicant): ����'
�—
Name: AI,IM� �. W� LLl�G�' Do,�.��-n �,.s .� l 5'ZM A�I �-�-2
Address: 20 0�PHE �t � S Gf(C12cH �o�t-D 230 lC C� � STE,� ��� i/L,
S�iY1o2A ,, ,U C Z'l3 43 Fl ski E.�v' iLI.E� k`� �-aoZ3
3) Property Description: Lot Size: (0 �— Subdivision: Lot #:
Address and/or directions to Property:
S�E f�TT�IcN � -�� L 5 •
4) Proposed Use and Type of Structure:
Residential )C Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes X 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 X (please show location on site plan)
Note: A completed application must also inc[ude:
➢ A pla1/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 verifying that tlte 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): �Gc�C � . Date : % � 4 - � �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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PLAT OF SURVEY FOR
SAMUE L M. OAK LEY, J R.
& JAMES E. STOVALL
CUNNINGHAM TWP., PERSON COUNTY, NC
JUNF 1989, HALL-HAMLE�i & ASSOC.
NLAL C. HA�ILET� I. 24G5
._.,._ ... ..�,
CURVE DATA
�ELTA FAUIUS nFC IAN CND. 80.6.
33°51'S5' '1tlI.'l6 662.66 Y39.31' nB6•O4'OS'E
77°44'd6' R36.'it 31'I.11 188.08' S38•19'35'E
36°39'12' 228.93 136.33 �1.35' S19•dt'74"a
)5°13'13' 150.00 92.6< 6'1.85' S1'!•18'13'N
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/ OAK POINTE DRIVE , � I
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Date: August 1, 2011 ` ' -�Q 1�,� I ,� W a�
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Semora, NC 27343 Kc+tFuCl�� �'1�' �'��
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Re: Application for improvement permit on Oak Pointe/Oak Cove Dr.
Mrs. Wallace,
The Person County Health Department, Environmental Health Division, evaluated the above-
referenced property at the site designated on the plat/site plan that accompanied your
improvement permit application on 7-24-11 and again on 7-26-11. According to your
application, the site is to serve a 3 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 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-.1948, and the evaluation indicated that the site is LJNSUITABLE for a ground
absorption sewage system. Therefore, your request for an improvement permit is denied. The
site is unsuitable based on the following:
X 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)
X Unsuitable soil depth (Rule.1943)
Presence of restrictive harizon (Rule .1943)
Insuffcient space for septic system and repair area (Rule .1945)
Unsuitable for meeting required setbacks (Rule.1950)
Other rule:
These severe soil and 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 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.
For the reasons set out above, the property is currently classified UNSUITABLE and an
improvement permit shall not be issued for this site in accordance with Rule .1948(c).
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
However, a site classified as UNSUITABLE may be reclassified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d).
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 scientist. 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
Service Center, Raleigh, N.C. 27699-6714. To get a copy of the petition form, you may write the
Office of Administrative Hearings or call the office at (919) — 733 — 0926. The petition for a
contested case hearing must be filed in accordance with the provisions 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 Au�ust 1, 2011. 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 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. You must 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 your petition to your local health
department. Sending a copy to the local health department will NOT satisfy the local requirement
in N.C. Gen. Stat. 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, �
�r�a%�---�
Justin . Smith
Environmental Health Specialist
Person County Health Department
�� l
� �.{ �
��_ �"`�' �l./ � ����
I��ndnmo�ranvca��a��.Il IHI��.Il��a
Date: ��/ !� /�!�
Name: —� � i r_,4 ��p � Tax Map:� Parcel: �
Address: 7� 1 �,I GG� ),Jj,i l j, iZp.
_ o �.
Re: Bacteriological Test Results
Dear Well Owner:
Your well water was sampied on {o /�{ / t!o , 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 onlv.
>C Total coliform 6acteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are nzturally f�unc� in the soil. Fecnl coliform b2�teria axe associ�+�d �v;th
anim.nal and/or human waste. The pres�nce 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 use. Young children, the elderly, and the individuals x�ith compromised immune
systems are especial[y vulnerable and their physicians should be notified of the test results.
A well that tests positive for total or ecal codifarm bacteria should be properlv a'isinfected a:zd : etest�d
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 offce
hours are 8:30 to 5:00, Monday through Friday.
Sincerely,
��
�� `��
Environmental Health Specialist
Pers�n Count�y Health D;,partment
(rev. 4/2U/16)
Persen Counry Er.viroa:ne�tal Health, 325 S. Morgan St., Suite C, Roxborq N� 27573, Fhone: 336-579-1790, Fa�i 336-597-780&
OCT-O6-2016 08:40 FRO�-HEALTH DEPT
3363226099 T-368 P.001/001 F-971
pERSON COUNTY HEALTH DEPARTM�NT
3SSA SOU7H MADISON BLVD
ROXBOR�, N4RTH CA�tGLINA 27573
BACTERIOLI�GICA�. WA7ER SAMPLE ANALYSIS
Name of Owner or Tenani ��S �r��o,��{�� �
Qddress�'7 �1 (���x.l��`�� ?►1� t l.� �ounty
��
Collecied By �.- �s'"7_c_�•,/ —
Qate IColleated t� �Time Collecteal �`_ t�
Source: r�wel[ ❑ Spring ❑ �ther
.L{ra ��
Location: O House Tap �d WelilTap o Qther _
❑ No Charge �arge
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Re�ults
Present
Tatal Coliforrn
Feca1/E. Coli ❑
Reported By
Date RepartQd /.,D � ��
Report Called S ❑ NO
C�Iled 7o Oy��
Ab�ent
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