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+ `� � � :� The Distr�ct Health Departme , .
� Orange,- Person. Caswell, Chatham, Lee Couniies
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Water Supply a�.� S�va:ge?Disposa
IMFROVENlENTS�RMI -N ` : �
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• Owner: ,
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� Location• " `;;, -
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Contractor: "'
Waler Supply: Private �.�blic ,
Di� acili3ies: ,No. bedrooms � lDisnt�vasn�.�uisPosa�
chin other sutom , tic appliances
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t�; � � � � � � ' Nitrification line:
Other disposal..fac ity:- � ' `• ' "
,
Water supply and sewage disposal facilities location, installation and
protection must meet. state and local regulations.
Septic tank should.be pumped out every 3 to 5 years and shall be m� J`
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTET3 AND AP-
PR,OVEI} BY A MEMBER OF THE DISTRICT fiEALTH DEPAR.TMENT
STAFF BEFORE ANY POR.TION OF THE.:FNS�ALLATION IS COV-�
ERF,D AND PUT INTO USE. � , .�
1 � ,/ j / !i. � _.
. f /./� jf, ��'/���ti �'' �
Date approved• Signe��/T� %x � c ?
Sanitarian
Well: � �
Sewage Disposal• Counter-
signe
By: (Own�r or his representative)
a
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Certificate of Comple3ion
Date Approved: � ' � �
�:F` (OVER)
�' LOC1t10ri Of W@ll arid SeWage disposal facilities sketched on back.
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant K� �K �.t f�S�
T ' "�
Address �%�{b �n�QS �('I� R�.
Collected By �5
County o
Date Collected �—/2 �( Time Collected Z�' 3 d
Source: Ca'Well ❑ Spring ❑ Other
Location: L� use Tap
❑ No Charge B'Charge
0 Well Tap ❑ Other
�— �c�
........................................................................�
**************************�*********************************************
Total Coliform
FecaVE. Coli
Reported By
Date Reported °�. � � � I
Present
❑
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Results
A sent
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