A24A 34The Dis�r�ct Heali�h pepartment�
CASWEi.L - CHA7HAM - LEE - PERSON COUNTIES
Wa�er Supply and Sewage Disposal
IMPROVEMENTS PERMIT No. R �
Owner: _
Locatiot'�:
Contractor:
Pubiic
-- -- �
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposai,
washing machine, other autom tic appliances ��
Size of tank: Nitriflcation iine: n Yce �c'
,. u
' �
Other disposal facility: . . � "
.�� . �
d �ii•. �
Water sugply and sewage disposal facllities location, instaliation �nd`"
protectian must meet state and local regulations.
Septic tank should be purnped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitriftcation line MUST BE lNSPECTEA AND AP-
PROV�D BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
ERED AND PUT NTO USE�ION OF THE INST�ILLATION [S COV-
/ j i�
Date approved• -
wen:
Sewage Disposal:
Hy: ' - - —
; (.. ^ v v�J. . :f i •i � .i ;.��� ,
Signe
' Sanitarisn ,_ ,l
.�;, f, � .. .
Counter- � ' • � l
sfgnecL � �� � '
(Qwner or his regresentative}
CestiBeate of Compleiioa / 1
` . r•
Date Appraved: r , By:
San tarian "
(OVER)
Lacation of well and sewage disposal faciiities sketched on baek.
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Date: Z /�/�2
.., � . ,
•�� - l�%�i�. .,_ ��. 1.
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Re: Bacteriological Test Results
Dear Well Owner:
Tax Map:'�Parcel:�
Your well water was sampled on 2/�/�, and tested for both total and fecal coliform bacteria.
Your water sample test resulis 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 bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are naturally found in the soil. Fecal coliform ba�teria are associated 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. IJcoliform bacteria are present in your water sample, the water
may not be safe for use. Young childrer., the elderly, and the individuals with compromised immune
systems are especially vulnerable and their physicians should be no#ified of the test results.
A well that tests positive or total or fecal coliform bacteria should be properlv disinfected and retested
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 office
hours are 8:30 to 5:00, Monday through Friday.
Sincerely,
��
�����
Environmental Health Specialist
Person County Health Department
(rev. 4/20/16)
Person Counry Environmental Health, 325 S. Morgan St., Suite C, Roxbom, NC 27573, Phone: 3i6-579-1790, Fa�c 336-597-7808
l
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �`'-� ��'v��?���
Address ' �-�� �., � - County
'�� .
Collected By �
Date �Coll�cted ��� � Time Collected � � '•OG
Source: ' ell o Spring o Other
Location: 1�'House Tap ❑ Well Tap ❑ Other
❑ No Charge o � arge
..............................................................................�
******�*********************************************************************
Total Coliform
Fecai/E. Coli
�tesul#s
Present
❑
❑
Reported By
Date Reported �.�.� n � (�
Report Called
Called To
❑ YES o NO
Absent