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- Person County Health �Department: -:-�
:� Sewage System'J�ipro�.e� e.nts `Per-m:it
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�?a�C�r.r— jJ ��Ge„�, : • � f..r: '
Date: -" �s Permit V.o�d Af n 5. Y' s i, ,r._. ...,,�.
Owner: . -''�' R#_:.��,�,�,,,.
I.00SLIOII/Dt1'8C[10I1S: — f _ . ;! 1 .
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Subdivision Name• `� Lot #��
Lot�Size: ta y`� �� -��^ ype af Dwelling: �
Water Supply: Private: �Public: Community �
Bedrooms: Garbage Disposal
Ba`sement Basement Fixt �res � '
INFORMATIOI�E y , ' , ` -' �
$�j��: ! � % -t . owner ar represeptauve � .
REPAIR: REEVALUATION:
Size of Septic Tank: ��.�� gallons Size.of Pump Tank: -��c�
Nitrification Line: ' � � -�
Depth of Stone: 12 inches ' � t���n �_Y � �' (;���, �
,��—,�
Max Depth of'Tr.enches: . - .
Altemative System: Conv. Pump _ �"" LPP Pamp .- �.��.....
Remazks: .
-------------------------
Date Well Approved: Well should be l00 ft, from any sewer system
BY $8I11t8I1ai1 _
:Date e age y v �i- U— Z,,,
.
BY S.1i11Tc1i18II
- _ `PE OF COMPLETION
...�����._=. .�� ...��.�������� ����o ��� � �
•Sewage System. location, installation,..and protection must meet. state and loqal ''�
regulations. Sepdc.tank should be pumped out every 3 to 5 years and shall be maintairied �
'by:�owner in such manner as not to creaie a, blic health hazard: Septic_ta�;,�nd'O
nitrif'icatian line must be inspected and appz ; ed by a member of the; P.:eF3� County �
Health Departinent before any portion of th ' tallation is covered; aa� put irito use. If
' the site plans or intended use change this 't is subject to revoEafior►. �,�Y �
',(G;S. 130 A-335� ��
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':Localion of sewage disposal sewage system. sketched on back. ��
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��a�n�rona�nca����.Il IHI��o,Il�lla
Date: I / 7' / t �
Name: '��� i�� �— Tax Map:�� Parcel: / Z��
Address• 7!P o�� �, �� i 2.�;.�,
�� M���s. . r.IC. Z73 �}-�
Re: Bacteriological Test Results
Dear WellOwner:
Your weil water was sampled on i/:3 / ti? , and iested for both total and fecal coliform bacteria.
Your water sample test results are noted below:
X 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 6acteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
lota! c�l�orm bacteria are naturally found in the soil. Fecc�l coliforrra bacter�a a.*e as�ociated :v:th
anim.nat a.nd/or human waste. The presence of either total o: fecal coliforrn bacteria in well watzr 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 ind:viduals with compromised immune
systems are especially vulnerati[e and their physacians should be noti, fied of the test results.
A well that tests positive for total �r fecal coli%rm b�cteYia should 3e p;�er: disinfected afzd retested
prior to resuming normal use. The well may be disinfected using the enclosed disinfection procedwe. A
well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly
flushed out of the system, please cuntact fhe Healih 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,
— Y' �
���%�
Environmental Health Specialist
Perscn County Health Departme�t
(rev. 4/20/16)
Persen Ccunty En riror.men!al Health, 325 S. Psorga�� St., Suite C, Roxhoro, NC 2i573, Fhone: 3;6-5; 9-1 i90, Fax 336-597-7ROfi
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� �ersor'�'�un,, ealth. De ;artment � .- ,_,
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, u� .�_ eI.I�Permit �
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Date .. is Permit V'oid Aftet 3 Years , � a,f'f' .
.Owner. ' - �"SR# 1322 �
Locadon/Duec��
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subdivision Nam�: " : y . Loc #
Dtilling Con�astor'
. _. . vv�LL rnrrsrRucriorr �
D1S1911CC �f11 N29iPS��pI0n2liS►'LVIe.�S' DiSi9[10E f!'Ofl1 $tltlfCC O�
-Popution� /e � � Ia.:�c . �
Tatal Depth��.F� Yeld: f S GPM Stadc Water Level l� Ft
� Watet Bearing: Zones:, Depti►f 2,� Ft�pQ Ft; F� Ft.
Casing: Depth From _[J to ,,,���. Diameter. � � Inches j
'` T�CPE: .SteEl �. . � G�lven�zed`Sieel . ''�—�`� i
If. Steel, does owner approve: Yes No � !
WeighG�L� .. T�uclmess• Height Above Groia►d: ��inches
Diive Shce: Yes ��� No
Were'Problems Encoimt�ered 'm Setdng the Casing? Yes No �_
„ ��: . •. •
If yes, give zeasan: l�' l �
Grouti Type .Neac : Sand/�einent '!�'— .C.oncrete '
� . Annyler; Space Width Z Iaches `%
` Water m A�mulefr. Spacx: Yes ° No �—" H;
� ':. Method.; ;,P�umped, Pmssurc� Potaed : t �'
�epttz�I�to�[' �'t�- ' ; : w' : " _ .�:_Ft..- ." .`. ' ..:_ _ ... _. . � _ ' . .
4� Maun ..Uaed. No Bags Pordand-Cement �_ - Welght of l bag .,,_
__. _ ,
-�,y;,: ,..,_ .1� , :.
� IIIIXWLC �SBi�; gfBV� Q11i111gS� � RShp ', i , '� � i
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' `�.ID PIB�ESI Y&S" :: �� � ` .
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�c^4�alab Yes � lso ' , �
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� Fmm .. .To Pom�atian-Descfi 'on �. �' ,
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I HEREBY CER'T�YTHAT THE ABOVE WFORMATtON IS CORRECT:AND THAT �.
THIS,WELL V11AS-CONSTRUCI'ED 1N ACCORD`ANCE WTTIi �REGULATIONS. SET ,.:,;:
FORTfi:BY.THE-PERSON COUNTY HBALTH DEPARTMENP. � .
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_ Sketci��well'locatian on reverse side. � I
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