A27 115LJ� �7 �`. �C�cL�S
PERS�N COUNTY HEALTH DEPARTMENT
SEWAGE DISPOSAL
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IMPROVE!lENTS PERMIT NO
Issue Date: �. 3 � �
er: • �� � - '^SrP. i7w �� �v
0`� Septic Tank Contractor: �'� `
Buildiag Contzactor:
a Water Supply: Private � Public
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. All wells should be 100 ft. Prom sewer system.
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Lot Size: .� �1�t P
Sewage Disposal Facilities• No. bedrooms
Size of tank: Nitrification line:
Water supply and sewage disposal facilities location, installation and
protectiion must meet_state and local regulations.
Septic tank should,b'e�.pumped out every 3 to 5 years and shall be
maiaiained by�own'ei-in'�such a.manner as not to create a public health
hazard.�.S�ptic;,tank and nitrification line HUST BE-INSPECTED AND'
APPRUVED.�B'Y-'A'MEMBER OF THE PERSON'CO. HEALT,Ei DSPARTMENT STAFF BEFORE
AN7G�P�RTZON OF THE INSTALL'ATION'•IS COVERED AND PUT TO USE. T S
PERMIT"VOID AFTER„3 YEARS.
Date Well Approved: ' Sig ed
By: anitar'
Date Sewage D'spos 1 proved: ' r
• Counter-
By: signed �
(Owne or hi representative)
Certi£icate of Completion
Date Approved:� � y:
T an' rian
(Over)
Location of well aad sewage disposal facilities sketched on back.
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WELL PERMZT
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I DA DRI :�`���+ r COUNTY: .. Sl�+
DATE ISSOEDs _ � ROAD/ST :
aF1NER: VO ONE EAR
ADORESS
DRILLING C NT TORs. �uc �p S . �_
WELL CONSTRUCTZON
Lyne Distance irom Souree of
Distanee from tiearest P�P�y � 5 �
pollution nield:��� Statie Water Levels �-
lbtal Depths - pt� Fy,/�'—Ft. .
iiater Baarinq� Zo�es: P�=�Pt. Diam}tes t'� Iaches
�E_ ��ths Froe to
l Galva:suad Stsal ��
It Stan . doas ov^ez app� Yef�,� No
Waights �� T��tift Height Lba�►e Grouad: Inehes
Drive Shoe: Yesi N°i
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iieye p=oblems Eneount°red ia Sattis�4 tA�
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11poa3,a= Space Nidth �d' n s �
watnr ia 1►aanlar Space: Y�� �O—��urad
Methodz PusP�d Pt.
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Z�SY �IFY T81►S T!!E A80VE ZNFORliJ1?IOtt IS CORRELT
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Siqaature oi Ccnt=actor Date
REASON Fd8 !10
= SaaiLa=iaa's Sigaatnre Date
Sketeh vn2l loeatiaa oa•reverse side. Use established refereace
points• '
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October 28, 2011
Prudential Pointer & Associates
Attn: Linda Vann
216 S. Main Street
Roxboro, NC 27573
Re: Bacteriological Water Sample at 103 Miranda Lane
Tax Map: A27 Parcel: 115
Dear Ms. Vann:
nsuring a healthy environment
The well water was sampled at 103 Miranda Lane on October 26, 2011, and tested by the Person County Health
Department for biological contaminants (total coliform and fecal coliform bacteria).
The results of your water sample are as follows:
X No coliform bacteria were found in your well water and therefore your water can safely be used for
drinking, cooking, washing dishes, bathing and showering.
If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays
from 8:30 am to 5:00 pm.
Sincerely,
�^���s. ����,� fi�`�S
Bonnie Holt, REHS
Environmental Health Specialist
Person County Health Department
Revised (11/13/08)
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant
Address �o?� ��,���_ �,r12
Collected By`��
County Per��
Date Collected ���aL�1�� Time CollectedJO'�c�nti
Source: C�'Well ❑ Spring ❑ Other
Location: D House Tap
❑ No Charge �Charge
❑ Well Tap �Other �is�cle �i�-
........................................................................�
*********************************:�*�************************************
Results
Total Coliform
FecaUE. Coli
Present
❑
J
-. ,
Reported By � �"
Date Reported � � ( ri-� � �
Ab ent
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