A24A 12�
PERSON CO�UNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant
Address
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Collected By
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Date Collected l� C S—� � Time Collected 1���
Source: �Vell ❑ Spring ❑ Other
Location: ❑ House Tap pWell Tap �-Other �s
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�No Charge�harge
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Total Coliform
FecaUE. Coli
Results
Present bsent
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?'he Dis�rac� Heai�h �epar��ae�a�
Orange, Person, Caswell, Chathasn, Lee Counties
Water Supply and Sewage Disposa)
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owner: -
Location• �
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Water Suppiy: Private Public "
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing mactu-�� suto atic appliances —
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Size oi tank: ��� Nitriflcation line• ���,� br�--_ -.
Other disposal f8cility: -- -- ----
Water supply and sewage disposal facilities location, installation and ,' _.
protection must meet stHte 8nd local re�ulations. -
Aliove recommendations based on mformation receined and observed
soil condition. Septic tank and nitrification�e_MUST BE INSPECTED
AND APPROVED BY A MEMBER: OF'THE D�S�tIGT.HE2iLTH DE-
PAR.TMENT STAFF before any poition of ,the. installation is covered
and put into use. "`'�- ` �
: � W..«— � '�1�
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' ' Date approved• ,
. Well• �
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Countersigned
MPLETIf�
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j Th�"d►sinc� Nez'th �ep�.r:n��nt
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(OVER) _
Location of well and sewage disposal facilities sketched on back.