A25 77The District Health Departmenf
._.;
CASWELL - CHATHAM - LEE.'- P6RSON COUNTIES
'�; Water $upply and Sewage �Disposal
IMFAOVEMENTS PERM�T No. � ' `
` • ' � Date '� - r
'�.
Owner: � `
O �
pq Location: 0.AA C $
. �S �-� :
�{j�//�f Contractor: 1 G..r,� �-^
{� �.� .� ..
� �� Water Supply: Private -j, �'a�ht_�
Sewage"Disposal Facilities: No. bedrooms _-,-? Dishwasher, Disposal,•.
washing machine, ther automatic appliances �
Size of tank: '�' Nrtrifica�ion lin� & s�
r.,� , . i , . . .. . _ ..
��s.. „"
!�' � (ithar. Aicnn��l f��
0
, wa�r 3upp y and se ge sal 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 main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line .MUST BE.. INSPECTED AND AP-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. �
/� ' �
Date appioved: Signe `
�jell� ✓ ''Sanitarian
Sewage Disposal:
By:
Counter-
signed
(Owner or his.representative)
Certificate of Co leti n
Date A �/
pproved:' � g ;
anitarian �
(OVER)
Location of well •and sewage disposal facilities sketched on back:
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Tax Map #_�'� Parcel # �
Existing Sewage System Report For: V Mobile Home Replacement
Addition Type:
Requester: �[K ! l,tr'�h t°.� tbs' ��`� ��h �� Home Phone#
�7 �,��/��/S %�7� )) �(. Business # ��.3 -D �1D
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Original Permit Located: �_ Water Supply: � � i1aQ�.
Septic System Designed For: esidential Business Other
# Bedrooms .� # Employees Other
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System Type:��i ��� � Tank Size: Nitrification Line: , zDT' k3 (
Date Installed: � ��� � � Certified Operator Required: / " ��
On-site wastewater disposal system shows no visual signs of malfuncrion on 3` ��0 Z,
Permission is granted
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Environmental Health Specialist � ` �L�' Date:
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Diractions to ttfe P�i��l itndudir� r�d.rwmoa ar�d
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Propo��ad I,� and �tru�ture ga�.ivn: ar�nrec' es� af tite ffotk�wing qu�na:
✓ T�o vt struc�,re: Dou3t.E !„/�4� _ 1Mdth:.,�;8 , Depltt: 6 6'
a% Pt�P�aed _ � F�t�t9 _,
h) Nwnb�c ot Bed�am� Num�� of oacupattta ar paaple tn be served: _� '
c) Baaen�an� Yee _, No�WBI th be pt�nbiny In the ba�n�tt7 • .'
d) Gerbage Otsp�aak Ya4 ^, No �%
W�r 3uPF� �Y[� Prtv�e �tusw ,_,_ o� godei�sg ✓. �, Carrmu�ttY _, sP� _
, Ar+��mny vw� on �al.f�ining P�onY7 Y�„ No lyes„ pieasa ir�be approocirtw� �tr.� cn the s►te pten.
Doa ttt� ptaperty contalit previciu�iy ju�diaial w�!lo�ei�? Yaa' No �
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'➢ A PLA7 OF'Tl�E PROPEi�TY OR SiTE F'UIN YUBT 6� �U�T1EL) WRi� TNtB APPi.�C11T1�lN:
➢ f�tiOP�R!'Y L1NES AND C�R� �l�i` � C�1RLY MAR�.
� T� P�'OSF� LOCA710N OF AU. S'iRiICTURL°8 A�T B� �fAKEO OR rRA�. �
➢ mE srrs �u�n- e� �wu.Y Ac�ss�� Fa� �w tvN..un� e�r n�� t�►�.ni u��rrro�ar sr�.
�• here�y m�ae tlon tio the Person Cow�tbj i�aW� O�cp��etrt hu �� e�rai�on far tha �ite sawa�e dfsQos�!
�rn far trio ed property. I agnee �tfd it�e cort�d�� of thi� apptication are t�ue and r�pt�t the rrmoc�num
�ftks ta t�a p ttt ropetty. t undets�nd i� the� site 1a �imced ar ttw IRbdtded �so ct�ange�, tt�s pesmit strall
becorYr� in - . � . ! � , o �
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D.B, 205-110 "
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Carolina Fower
and Llght Co,
This Is a survey of lots 5&6 of
Mrs. Carrle Shore Est, as -
shown tn P,B, 21-168
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Tax Map #_�� Parcel # �
Existing Sewage System Report For: V Mobile Home Replacement
Addition Type:
• - . - �� /. / �� 1.. � � � �
� I/ _-r- �/ �-.
y� � .
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Home Phone#
Business # ��.3 -D'i��
o n � � � `7� r� - � ,
Original Permit Located: �_ Water Supply:� � i 1�
Septic System Designed For: esidential Business Other
# Bedrooms 3 # Employees Other
System Type: ��� ���t� o� Tank Size: l� Nitrification Line: �� �s 1
Date Installed: ���' 1� Certified Operator Required: /"/�
On-site wastewater disposal system shows no visual signs of malfunction on �` ��0 Z. .
Permission is granted
Comments:
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Environmental Health S ecialist C.x "L� Date: �
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and Ltght Co,
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Th�s is a survey of lots S&6 of
Mrs, Carr►e Shore Est, as
shown tn P,B, 21-168 �
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�s' na�n�ro�ranvra��a��.� ���an,Il��a
Date: Y /�L/�
Name: L./yr,rj�,�/� �� Tax Map: �¢LS Parcel: 77
Address: G t ,
.�.�� �'- ���'3
Re: Bacteriological Test Results
Dear Well Owner: �
Your well water was sampled on `if /�/�, and tested for boti� total and fecal coliform bacteria.
Your water samplz test results are notzd 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 only.
Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
7otal colif'orm b�cteria are n�turally found in the soil: Fec�l colifor..m ba�teria �re asse�ia�ed wit'��.
animr_al and/er human waste. The presence of either total or feca: co:ifo,�m 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 with compromised immune
systems are especially vulnerable and their physicians should be notified of the test results.
A we11 th.at lests p�si!ive or total or fecal colifor .m bacteria should be proper;v disirfected ard -retested
prior to resumin� 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
flus�ied 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,
���
-. . � . .
�nv�ronmental Health Speciahst
Person Coun�y Hcalth Dcpartmer�t
(rev. 4i20/16)
Person Cour.ry Envi:or.mer.tzl Health, 325 S. It4crgan St., Suitc C, P.oxSoro, �C 27573, Phcie: 33b-579-I i90, Fax 336-597-7808
S� 1 � ��eg
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant ���� �tit
Address '� �O �;�G� �� .� County
�f '
Collected By -�-I-�t-�-�P/�
Date Collected ��'i Time Collected Z��?J'
Source: 0'Well ❑ Spring ❑ Other.
Location: dHouse Tap ❑ Well Tap o Other
❑ No Charge [�Charge
......................�r5 ..� ............................................,
*,�,�******************�******************************************************
Total Coliform
Fecal/E. Coli
Resuits
Present
❑
❑
Reported By
Date Reported ��3 � � �
Report Called
Calied To
❑ YES ❑ NO
Absent
f- .
\� �
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��. � � � ����
��n�n�-on-anvra�natE�.Il IHI��.Il�lin
Date: -,S / i % . /�
Name: _ •'� Tax Map: J� Parcel: ?'%
Address: � /�.G� J.�� � l �,� �
s � t=-'���t►�iG Z2?i��
Re: Bacteriological Test Results
Dear Well Owner:.
`,�our well water was sa�npled on �S' i�/_l(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 bacterio[ogical results only.
X 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 co�iform hacteria �.re assoc:ated �Nith
aaiimria! aitd/or human was�e. Tne gresence of ei�her total or fecal co:ifcrm bacteria in well watEr n�ay
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 samp[e, the water
may not be safe for use. Young children, the elderly, and the individuals with compromised immune
systems are especia�ly vulnerable and their pfiysicians should be no#ified of the test results. �
A well th,at tests positive for t�tal or fe�al coliform bacteria should 3e dreperlv disinf2cted 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, piease contact the Health Department to request a re-sample.
For additionai 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,
���
�G���o�'
Environmental Health Specialist
Person Ccunr,� H�a:t� Department
(rev. 4/2U/16)
Persnn Ceur.ry En:�ironment2l Health, 325 S. Margan St., S�ite C, Roxbcro, NC 27573, Phonc: 33b-S79-1790, Fax 330-597-7R08
� �.
v
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �.-�. �.col-c.n.
Address �� LL-.c f���� �(,1 �' ; County
Collected By � �=Liaf
Date Coilected TT� 4v Time Collected �=�[�
Source: [�Well ❑ Spring ❑ Other
Location: C�'House Tap o Well Tap o Other
❑ No Charge C�harge
..............................................................................�
***�****************************�***********,�****************�*�************
Results
Present
Totai Coliform
Fecal/E. Coli ❑
Reported
Date Reported �l � ��
Report Called �YES ❑ NO
Called To ��in � ( (��
Absent
C�