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:� ihe . Dis���ct� Heali�h Departme�t:
CASWELt - CHATHAM = LEE - PERSON.COUNTIES', , '
Water Supply �nd Sewage� Disposat
IMPROVEMENTS PERMIT_ No
-• Date _—�,'_t� ='2'---i"—
7.
OWIlE'T: 'A_J ;�: .. C
Location:
._ - ` � '-�i._-� t . -ti . �
- ti
� . .
Contractor: � f�" `� =��- y �
Watez Supplp: Priyate r� Public
5ewaqe Disposal Facililies: No. bedrooms -� Dishwasher, Disposal,
washingmmachine.�;other automatic appliances
. _ _ �^� � ,- % '� '�'
_ ._.._.__.... ,
Size of tank: ' '� '� "' - Nitrification line: , � +�'� � '
Other disposal facility:
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 an3 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 INSPECTFI? AND AP-
PROVEI} BY A MEMBER OF TIiE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE IN5TALLATION IS COV-
ERED AND PUT INTO USE.
� T � ;! ';�_. _ q�itF`ti�
Date approved• Signed '� � �' %�'.,�?t_<:'' �-:��`_ '•�'��{:;�.
Sanitarian `
Well• '
Sewage Disposal:
By:.
Counter-
9igne�
(Owner or his representative) .
' '_ .
/
, .. . , ' r • c (' +
CertiScaie of Com letion ` t /��. � j� � �
% �? /��, 1 }�i - 1%:' ; l�� ( ` , ��
. Date Approved: � � , � By;. /� "; ' , , `- `
'" , _ ,'' Saiii#aiian � t i �f �'+' � „ .,
t
(OVER) .
Location of well and sewage disposal facilities sketched on back.
PERSON COUNTY H�ALTH DEPARTMENT
3�SA SOUTH NTADISON BLVD.
ROYBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant•� r(,c�, ��'t
Address �%t�/� Me�h��'s �l � I �� County �Pa'C� _
Collected By��n� i e 1-1��i-
Date Collected � � ►'� ��
Time Collected / �o'�%
Source: �Well ❑ Spring ❑ Other
Location: �House Tap OWell Tap ❑ Other
��SQ rr���.�
�A1�o Charge �Charge
��****�******��*�***�*��****�***�*�**�*��**���***�*��*�***���**��*���**�*�x**�
�*****�****�***�*�**�***x*******���*�t**�*:�*���***��****��********�**�x***�r*�**
Total Coliform
FecaUE. Coli
Present
❑
0
Results
Absent
�
�
Reported By ��'�'`�� m�
N�� �
� � 13 �t�la
bactreport
A2s-g-)
• PERSON COUNTY I�EAL'T� DEPARTIV�NT
325 SOUTH MORGAN STREET . .
ROXBORO, NORTH CARO�INA 27573 . .
��
� . � � . , � .� ��1 �.
. BACTERIOLOGICAL WATER SAMPLEANALYSIS - .I � �fl.
.�,g3 _� �r
. -.-1�Fame� of Owner or �enant �'l� �°ti�� •�-� i-'��n � " -
_ i ;1�1 �d � connty �����a1 .
. Address LI��� �c�-'thee 5 M . . .
Collected B��'�� �
Date Collected l9 �� �� T'une �ollected _ 1 c� = 5S
Source: [� We11 ❑ Spring O Other � �
Location: � Souse Tap ❑W� Tap � �tb�' � �
�
O�Na Charge Charge . , � � . . �
�*���*���********�**�**�*�**:*�**����.*�********:*****�********�*�*�*��***��*��
�*�****�**�***�*******��:**�**�*��������*********�****�****�*::******��*�����
Total Coliform
FecaUE. Coli
R'esutts
P�� esent Absent -
� . : D .
i�. . . �.
Reported By
� ���� �� � L-' 1 �
r���•�
� �1r_Q� � I i � I�
}ia rtrPnnTt
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� �l°5
,
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���� .�� ���� �.+i\\�
\_._.--. � • < --� � � � � J�. Jl
��.�a� � ��,-m„ ����.IL ZL-� � � IL -��
Tax Map # �ZS Parcel # � 1
Existing Sewage System Report For: Mobile Home Replacement !
�Addition Type: ('�4R��-1— 3Z�aC 2�L �
Requester: � L��R�� f�,� � _ Home Phone# 7�D�S�
Business #
Location• � � �����D -
��� � � n�l� y7�� r�� _
Original Pernut Located: Water Supply: �f /.�,
Septic System Designed For: 1/ Residential Business Other
# Bedrooms_� # Employees Other
System Type: �,d,/1� Tank Size: �ho D Nitrification Line: .�o D
Date Installed: �� Z7- �G Certified Operator Required: /I��
On-site wastewater disposal system shows no visual signs of malfunction on /��
Pemussion is granted to: C�6is��/li>G� �� .�027"
Comments: � .�_'�� ,��1...�f��3 ��. �T �'•�/�.o%�;�'-�L a�/
4 lJTiG ��5 ��-tA� � G'��'�
Environmental Health Specialist Date: ��� ' D?�