A27 178. ��� Person County Health Department
�'
Owner.
System Improvements P�rrr�it
s Permit Void After 3 Years � u f
�—P�h � �r sR# j3�::�
. . ,. _ � . �_ _ _
Subdivision Name: �� �,� [a!
Lot Size: _ 1=- �����- Type of Dwelling:
Water Supply�.�Private L� p�blic:
Semi Private: If not Private Tax Map#
Parcel # of Water Supply or Name of
Supplier#
Bedrooms: _ s Garbage Disposal
Basement Basement Fixtures
INFORMA�i��'I�IEk) BY -- - A
Lo[ #
JaI11i8I13I1: �� owner or representative `
�P�� REEVALUATION:
Size of Sepdc Tank• ons
g ���� / -
Nitrification Line: �
Depth of Stone: 12 mches
Max Depth of Trenches:
OPERATIONAL PERMIT: . yes no
Remarks:
Date Well Approved:�� �yel l should be 100 ft, from any sewer system
BY ,2,,.., SaniTarian
System Approxed:�
Contractor. `� � � ;
OF COMPLETION
.
Sewage System location, installadon, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such manner as not to create a public health hazard.
Septic tank and nitrification line must be inspected and approved by a member of
the Person County Health Department before any porcion of the installation is
covered and put into use.
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
z
�2
�
�
.�-?
�
�e
�o
.�
_ _ /�
���NOTE: Make sketch of installation showing lot size and shape, lceation of house, septic tanks, privies, water
��supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
:� at later date. Note location of water supplies on adjacent lots.
(1) (2) :'-
■■■■■■.■■■■■■. .■■■■■■■■..■
■■■.■.■■�■■■■■ ■■■■■S■■.■■■■
■■■■■■.�■■■■■. ■.■■■■■■■■■.■
■■■■■■■■■■■■�■ ■.■■�■■■■■■■.
■■.■■����■�l�� �■ ■■■■�■■■■.■■.
■�■��r!���������■ ■■�������■■�■
■���t�+��!�������■ ■���■e�������
■��������`�►���■ ■�����������■
■���■ . •�����.�.��� ■■�■���■�■��■
■ �.�■■■���r�,��J.■■■■■■■■■■■.
t �iil�■�������l�L�1 ■��■■����n�■
■����■����■�'."�"i� !�'�i�i���■■����■
vlv��������� �a'
���
� � mg/�k ��'��Ocn�'i�tj
� DA7� i;iSUED� •
OWNER�
JIDDRESSi
DRZLLINC CON?R1►C'�'pR�
unty riealfh Depert�nent
Nell Permit
DRILLEDr��--�-L� COVNTYt C
_ R011D/STR86T� . lj U
�a,.;.. r� .�
— ._� .� - -
Dlatance from Neerest Property Lin�TRUCTION
Pollutlon�(f ��,,5 �i+tanc• lrom Sourc� ot
Total Depth� Ft. 7ield,
Fater Beering Zone�, p�?«;� Q GPM Static Natar L�rel � Ft.
Caain i Ft F�• ' p�,
4 Depth� Fran�_to� t. Dianeter� � Ft.
TYPE: Steel Gelvanized Stnel Z� Inchas
If Steel, does owner epprover Yea
Neightt Thicknnsar�'� N�
Height Above Groundr Inches
Drive Shoe� Yea�_ No
Mere Problem� Encountezed in Satti— e Ca�in9? 7es�pp �
If �Yes• give zeason�
Croute Typee Neat_� _Sand/Cement
Annuler Space Nidth_�_ Concr�t ��
Mater !n Mnuler Spac�e y�s Inchas
MethoAr No t�
Pumpad Preasur�
Depthe Frqe Poured L.�
Materials Us�d� N— o, gaqs po=ti� C�a—tt'
1 �aq q t� lb�, �Meight ot
It eixtu'z�sand, gravel, cuttin i
ID Platea: Yas V Nfl 9 I-�tio��_to�
� x 9 �leN Y� L/ "�'-'�--- .
aw
I tIEREBY CBRTIFY ?t(A2 TNE ABOVB INi'ORFIATIpN ZS CpRRE� Apb �T YHIS
NELL N11S CpNSTRUCTED IN ACCOADANCE WJTH itEG�L�pIpKg Sg�, �� gY �8
PERSON CQtr�y gp�RD OF HFALTIt. pERMIT VOID AFTER 'tyqyrE YEJ►�g�
.�.�� �i a.a-f�'7
�ynacure oF ContzacRor �to
Senitarian's Siyaature Dats 2asu�d
Sketch well location on reverae aidatarian'a Siqnatura Dats Completed
,�puiicaticn Date: � � ��
Amount Paid•
ii�c�9pt #•
Tax l�aA �: ��
Parcai �: � � .
���`7.�� ���� ��
�.' -,- � � �T1��' �L" �Y�
7�..���ir��a3^--- .a�s�.11 ��aoio.71.�71z
APP�ICAT101V FOR S�R1fICFS
tF THE IPIFORMATION 1M THE APPl.1CAT10N F�R AN IMPROVE3VIENT PERMIT IS IiNCORRECT. FALSIFiED.
C6iAPIGED �R T�IE SITE IS ALTERED THE1V TIiE IMPROVEMEAIT PE9�MtT AWD AUTHORIZA'PIOPI TO
CONSTRIlCT SHALL BECOME 1NVALID. . - . ''
1) Permit requested by: {Qwnerlagerttlprospective owner): II f�L e r� A n'eW
Hame Phone; 3 3O - 0 6 0? . Address: C�o? Sc h u L L e r s t� P��
8usiness Phone: -- . . R� X h�rn nlc � 225� S�
2j iVame and acldress of.current awner. - .
3� Prap�rty Descriptioea: Lot size: Tawnship: Subdivision: Lot #�
Directions to the �property (Including road names and numbers): � -
4)
�)
Proposed Use and Stru�ure Descriptian: answer each of the foilowing questions:
a) Proposed . Existing 1/ , ype of Strucfure: Width: ' Depth:
b) Number of Bedrooms: :� . N�u� ber of occupants or people�to be served: .
c) Basemen� Yes , No U Will th� be plumbing in the basement?
d) Garbage Disposai: Yes , o�/ �
� ew ar e�tistin �/ Public Commun' S rin -
Vlfater SuPP�Y �!�fPe: Private ._ (n _ 9�, �l • P 9—
� Are any weits on adjoining propert� Yes No _ Ifi yes,�pleasa indicate approximate location on the
� site plan. � . ..
6j I�oes yaur property c�ntain previmusly identifiec# jurisdictional wetlands? Yes_ [do_
PLEASE. PIaT'E'TNE FaL�aWING:
➢� A PtAT OF THE PR�PERTlf OR 51i'E PLAIV MUST BE SUBMITTED 1NITH THIS A►PPt.lCATION.
➢� PROPERTY LdNES ANt� CORNERS MUST BE CLF_A42LY All�►RICED..
➢ THE PROPaSED LOCATI�N OF ALL STRUCTURES MUST BE_ STA�D OR FLAGGEI3.
A'i'F!E SRE MUST BE READILY ACCESSIBLE EQi� AM E'' _llATI�N �Y THE !-tEALI'!-I DEPARTMENT
STAFF. � �
_�
I herehy make appiicatio� to the Person County Heaith Departmeni for a siie evaluation for the on-site sewage disposal
system for.the above-described property. 1 agres that the cantents'of this appiication are true and represent the maximum
facilities to be plac�ci on the property. i understand ifi the siie is altered or the intendecf use changes, ttie per►nit st�ail
became invalid. �
7i a�.�i� C , � /�'�� / a - ,� - o -3
Owr�er or Legal Regrasentative Date
PCND, rev. 06l27/OZ
�� ( ��� �.Ll.LI �� ��
� � � ����
I�a.a�ns�cn nan�.� rcn.tE.rn.)I. 7H� m,tn.l�lElla.
i c, h.c. c.J
s.�utr- C'�t-ce.K
Authorized State Agent
SITE SKETCH
Tax Map #��1 Paxcel # i 18
Section/Lot#���
� -► �--�,3
Date
System co�nportents represent a�iproximate contours only. The contractor tnust, flag the system ptzor, to '
beginning the iristallation to insure that propergrade is maintained '
-...�__ �.._ ._.
_..._ _.. ...
� _.._ .._.. __....
� „�� __._... . .....__._ ._.., �
_. . . __ . ._,__.,.. _ _.__.. .__ ,
i � ' ,� � „",�•
� /g,l t
.� ``� ``�� 3• �r.��° �' �./�
� �c, o � , -z��� �I � / ��"
rn a ry '�
�Oo,.
o�,o�o
,, ^� � . �
�• �� w o
'�' g. `C� 0� '4ti
o �
�
t,��t�afi )
�
�o:�o
z� . (p�� � �� .
,.� . ,�,Vq T . j��
\ z� ''"�fe.��'�Ta�1s �'R�a��'
� a �-�Q
�.��. �,�„� � ��e••�„��NG�
�iS-r� ra � D��/ '��'`��Ta�' ;
�y�.l��.,, �' ��z - /$o,��i,�/�
���;���,� ( 5�-�� �����r� .
� �� � ��
� �� ```—�.: _
G \`� ��v'S�.
•o�,
O '
� . �
� /g.i \
t� �,r�n/��t� �. � � nT�{ssY�'/�' $�
o��� �:.% `>'�'�,a�vn/
'e f'
� 8le" T/��4✓G��/ �,� '
/�oT� s, .
.r—....
� ��-r��'�//�i.a�/ CdM��/���✓�� .
��Qa�i�('�-�
/
� �'N���`,��°.� T�.� �,a��'{� J"s�.�,�„ '
� �'��.G'��: /�G r��l�iG9�iit/ y�a.f� ,�,
�
����
t;r✓ .��✓r �L?��4?���'��-" �'".�f..f�°'
O -�G�/1�� �'��� ���� ���� �,
�
� � K,ce� 5��tc-�-► tX.�.-E c:�F �°� -1 y� n�
e
Qr Cr 1 n i"�.ctr
� � �= � I
Scale: �
��.�a
� /� F ��o��,
` 1 �,�,�, SYs,�.rn, ou.t o
K,CG,p �+fSk.(,M �00• P��`S r'r�m WC I)
� �
�I -
- 23 - 55 -'�1 2�9.94' {#otal
zoo.00
PCHD, rev. 09/12/01
,.--�--�
z.��' �,,jp 1'/���.� ��'oo��/ , � ��i *,,�' �+�",�Q,�,c3 � � _ ,�j( �
�'�l-�'�i+sl� ��'� ,y�r� ���1/ �k'�C��cs/�� ,6/o�C � 4�'
t �I�. ,���
�
�`���� 1 ���� ��
�� .y� i � �
— `� � � ����
IE��-aa-��.���¢�.1L �3C��.Il¢11�
� f
Applicant: a� C r'I L� hc �
Location: �1 �J L 4�n�,'S c5 �� R� ��
��t�e , 2.n.1 ho�,-,c_ on (L f�X -�# .;
T�x M�� j - P�rcel # �
S�uihcllivi�s�ion ir •
Ph•as�e Sect�ioia Lot #
nt
� �, � P � � � � Improvement Permit
Permit Valid for Five Years No Ezpiration
Type ofFacility: E�Xi�in� New Addition Water Supply�X�StI� .
# of Occupants (.Q maX. # f Bedrooms � Projected Daily Flow 3(0o g.p.d. �
Proposed Wastewater System: � . Type:
Proposed Repair: �nnOVC1-�i Vt (o"tSSo r'c�-u-c.�'�� ) Type: �]'G
Conditions: Zr1 S�al( SjLS-C-trr, a.b �S�.at,.�n On �'ftc. SKc.-Cz[�, m�ric�a�-�o�-
—L' z�n ;4E.Ti��.t'�`an i'An Ferr /tcc, I�r ��D f1P t,� ��Sff n� i�1�5-� 1[a-h'On (nc7�mi,
Owner or Legal Represe
Authorized Sta.te Agent:
C.
Date: I-1 -0-3
Date: — -
The issuance of this permit by the I�ealth Deparhment in does not guarantee the issuance of other permib. It is the responsibility of the
applicant/property owner to in sure �I�at all Person County Planning and Zoning and Building Inspections requirements are me� This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater Sy tem: �..nnova-�i u�, �asy� r�u.c,f���ipe �G Wastewater Flow ��;.p.d.
New Repairy� Expansion _ Soil LTAR: �� g.p.d./ ft 2
Type of Facility: � i��i Basement Yes _ No
�'X►St�„ Wastewater System Requirements
�" • � . _
Tank Size: Septic Tank:,��ai Pump Tank: gal Grease Trap: N� gal sc�
Drainfield: Tota1 Area: � O sq ft Total Length �O ft Mazimum Trench Depth ��in �� �
Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Sepazation: �_ ft
Distributiton: V Distribution Box Serial Distribution � Pressure Manifold
Specifications:
mt
Authorized State Agent: _
Permit Expi
F 7Z���W, �FP�d
Date: r�—l1��3
The type of system permitted is u Conventional � Innovative Alternative. I accept the specifications of
the permit. .
Owner/Legal Representative: Date: � ( `' � � '� -�
� PCHD7/30/2002
���:sf. I�I��.���
- �c�����
IC.a.awnsanaana�n.�rcn.deo.Jl. �HIQ�.�n,ILdlln
e UA, (C ri t, �hCt�
iv�isi�n �c�-vu- �c.c.K
Authorized State Agent
SITE SKETCH
Tax Map # Aa 1 Parcel # I�18
Section/Lot#s��
_J (-►�-�3
Date
Systesn components represent approximate contours only. The contnactor tnust flag the system pt-ior to
beginning the installation to insure that propergrade is maintained :
''� ny-.-__-__._..._..__�_�.,...._._.....,.___..___. .
� J` �.__�._._._.--------,.._�__.__ ___.._._. . _,_...___,._
--___. _..�.. ..� . __ . _.___ � - - _.
_. __._.__._ .__
7 �n �� �
. �+ ��
.� ``� ',`�. 3 �sr� ��I
� �a p _ , '�� �I s ���
�
�
�n p ory ,� z� , �A�� v� � .
. , � �
o ,'� o' � �o ��" 1 '�'T�.,�T � �
�
,, 0� . � � ���d�ts �R.o��1�
�• �� m o � a �-�
o ��� .
� � Q � � \ ���5 � ~ h�d ,.T.��+✓G�yt
�
�ISTt►J � D�/ �OY G�'Li✓r'
�'1��� � � �Z ` ��onfG��/�
,� �<�q��;��� � 5��� ���'���✓�
m
�
O � � `�� �Qvs
O �.
�,
O
_� �
ti.. �
� /g.�
. � ?���%l��/Y / � nT���'•"�TyC G�,�
� .. �v�s �,�.._� ���wN
O
�t
` a�" TQ��✓G�,� �.,.�,�
�
w
,
d�
�
0
�
�
O
�
2
Narf.S: � ��_rN��'�/��a�/ ��l f2��✓G�
----- �Qf�vi�'�-t� �
.�
� o'ti!�a�r � T�� ha,� r-4� fi��r �,.
`„�`�-' G'j't��'�' /�L f'-�G!>.c�,�i�t/C� Fo'�
.G���'S
� �y �U����,✓� �,�.��-
fl -��� z�f�T �.�9� i-�9a `.
� � K,CC 5 S�t-F►-. Ou--� OF I o� "�Y �"
�, �P Y �
.
CirC.w 1/� f Lt�r
((� ) �trn Ol.�-,� OF �•���.
v Kecp S y5t�
K� S yS�.�M t� o' P�� s���,�. W C„
� `�
�i-89-23-55-'�
t,��ta1) �
�3Q:0�' Ca�3.90
I , ,_ 5a.
Scale:
2C 9. 90' �#ofial
200.0{3�
PCHD, rev. 09/12J01
C�j�� !.� ` ►2'
��=--.
���� �� ���� `L.1� �
`l�. o ~ � �/ � � � � �
,..,
��wn.�-��a�����.� �'��.tn.���n.
� .. - r , , �.��� -� :��=�
._.
. �_
t � 1
:�. .,, .�. ; , • � •�,
T�x Map � Parcel # `
Su�bcilivis�ion ,� /
Ph�s�e Sect�i�on Lot #
# of Bediroom�s
System Type (In Accordance With Table Va): 7 �'
THIS SYSTEM HAS BEEN INSTALLED IN COMPL.IANCE WITH APPLICABLE NORTH
Gi4ROL1iVA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMEiVT PERMIT AND COi�1STRUCTION
AUTHORIZATION.
� � ��
Authorized Stat Age t � Date
Installed By: �- u�' Date: `7 � 6�
�, �5 �� �,
9 �,��
30 � f
��
�
c?`�(�j�
z
7�,,
� ,
f
� � �����
i �
7 . � �a,�
ii /z,, �
� '
.��a
�� !��
.� . �AN,� �,��
�� �
G$iL�.
oo.
J
7��- `�'S�
�� .
.
.�o G.�/ �r:
.�
��
PCHD, rev. 07/29/Q4
, y
;��
�
. ���-r�c ��v� g�s���-�����co-����:�sz (�'vpe u - ev�
Tax Map # Parce! # System Type (Table Va)
Owner/Applicant Subdivision
Address/Location SeclPhase Lot #
� Sep�ic Tank ni4iaU ate itr� �cat�on ines Initca ate
State ID/date Trench �dth � ft. ly
Ca aci al. � � Trench De th - in.
Tee and Filter T,rench Le� th ft.
Baffle Trench Grade � �
Sealant Trench S acin
Riser if a licable � � Rock De th and Quali
Tank Outlet Sea! Dams/Ste downs etc.
Permanent Marker Pressure Laterals � �
Pump Tank Hole Spacing
State ate o e ize
Ca ac� al. Pi e. Sleeve �
Wate roof /Sealant Tum-u s/P.rotectors
Riser Required� SetbacDcs
Water Ti ht From Wells �
Pump From Property lines �
Check Valve/Gate Valve StructuresBasements
Ant�-s� on o e i c es raina e a s
Fioats/Swiiches � Surface Waters
�11arm visable and audible Public Water Su lies .' �
Electrical Com onents � Vertical Cuts >2 ft. P� - �
Rate m � Water Lines
A roved Pum Mode! Vehicle Traffic �
Blocic Under Pum Ad'acent S stems�
Pum Removal Ro e/Chain � Easemenfs/Ri hf.of Wa s
��Distribution. System Other _
Serial Distribution Easements Recorded
ressure ani o ert e erator ontrac
Low Pressure Pi e Tri-Partate A reement
A r. Pi e Material. and Grade �
Valves
Comments . .
pct�d rev. 3/13/01
�!�
��S
ne dapa►tment
of 6ealth and
human services
��������� �g���� � ���� ������
�� � �,� � �� � `m �� � , � � .
��� � �� � �.�� �� ������:�� ������������`��
� �'! t✓ _I
Sample ID #: �
Fo� lnorganic Chemicai Contaminants
�%�rl��+� .
TEST RESULTS AND USE RECOMMENDATIONS
I. 0 Your well water meets federal drinking water standards for inorganic cltemicals. Your water can be used for
drinking, cooking, washing, cleaning, bathing, and showering based on the inoreanic chemica[results onlv. You may
have other water sampling results that are not taken into account in this report.
2. 0 The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health
levels. The North Carolina Division of Public Health recommends that your weli water not be used for drinking and
cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for
washing, cleaning, bathing and showering based on the inorFanic chemical results onlv.
Arsenic � � Barium � Cadmium � Chromium 1 Copper Fluoride Lead Iron
Ma�iganese � Mercury � NitrateMitrite Selenium Silver Ma�nesium Zinc nH
3. ❑ a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of
20 mg/I. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted
diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on
the ii:nrpanic cl:emical results onlv.
❑ b. Levels over 30 mg/I may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc.
4. ❑ Re-sampling is recommended in months.
5. ❑ Re-sample for lead and /or copper. Take a first draw, 5 minute, and IS minute sample inside the house (preferably
the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the
lead and/or copper.
6. [�The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking,
cooking, washing, cleaning, bathing, and showering based on the inoreanic che►nica! resu[ts on[v, but aesthetic problems
such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system
to address aesthetic problems.
Barium Cadmium � Chromium � Fluoride Klron Magnesium
Man�anese Selenium Silver pH � I
For ntore informatior: regnrdingyour we!/ wRler results, please ca!! t/re Nor!/� Carolinn Division of Public Heq/th ai 919-707-5900.
North Carolina State Laboratory of Public Health 3012 D�st?ct�Drve
Environmental Sciences Raleigh, NC 27611-8047
htto://sloh.ncpublichealth.com
Inorganic Chemistry Phone: 919-733-7308
Fax: 919-715-8611
Certificate of Analysis
Report To: H. KELLY
PERSON CO ENVIRONMENTAL HEALTH
k��'�i'd�]:irl_L`E�1:7��_�
Name of System:
JOY PICKERAL
92 SCHULLERS PT DR
ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574
EIN: 566000331 EH
StarLiMS ID: ES052317-0006001 Date Collected: 05/22/17
Date Received: 05/23/17
Sample Type: Raw Sampling Point: Outside tap
Sample Source: Well Temp. at Receipt:
Time Collected: 3:30 PM
Collected By: H Kelly
Well Permit #: A27-178
GPS #:
Sample Description:
Comment:
Inorganic Chemical + Metals I (Profile)
Analyte Result Allowable Limit Unit Qualifier(s)
um
Cadmium
<
< 0.1
< 0.001
0.010
250
Chromium < 0.01 0.10
Copper < 0.05 1.3 mg/L
Fluoride < 0.20 4.00 mg/L
Iron 1.40 0.30 mg/L
Lead < 0.005 0.015 mg/L
Magnesium < 1.0 mg/L
Manganese < 0.03 0.05 mg/L
Selenium
um
< 0.0005
5.9
< 0.005
< 0.05
10.00
0.002
0.10
Sulfate < 5.00 250 mg/L
Total Alkalinity 13 mg/L
Total Hardness 8 mg/L
0.10
Report Date:06/06/2017
Page 1 of 1
5.0o m
Reported By: Deddie .�ivncol
�
�� �
� ��i �
v� � �'^� �/ � �L.J � V � �
'�' �n.�nson�n.naca�an.��o.�. ���Il��a
Date: �/ ?�/�
Name: / 1 Tax Map:� Par�el. /��
Address: ,V� � .
�
Re: Bacteriological Test Results
Dear Well Owner:
Your well water was sampled or� �/ ZZ-� l7 , and tested for both totaI and fecal coliform bacteria.
, Your water sample test t�esults 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 bacteriological resu[ts onlv.,
� Total coliform bacteria were detected in the sample.
Fecal coliform bacteria were detected in the sample.
Total coliform bacteria are nat�ually found in t}?e soil. Fecal col form b�cteria are associated with
animnal a�id/er huma*� v��aste. Th� presence of either t�tal or fecal colifo:rn bacteria ia well water niay
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 sa»r�le, the water
may not be safe for use. Young children, the elderly, and the individuals with compromised immune
systems are especially vulnerable and their physicicrfas should be notified of the test results.
A_ well that tests positive for total or fecal coliferm bacteri� should �ve p;�erl • disinfected u;zd 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�ed �ut of the svstem, nlease coniact the Health �enartment to reauest a re-samnle_
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,
S� /'��'���
Environmental Health Specialist
Persor. County H�alth Department
(rev. 4/20i 16)
Person �o�n,ry Envi:or.mental Health, ?25 S. ^�;ergan St., Suite C, R�xboro, NC 27573, Phone: ]36-574-1i9G, Fax 336-59i-7R08
MAY-24-201T 14:09 FROM-HEALTH DEPT
�� .
3363226098 T-953 . P.001/001 F-690
J'� �
PERSON CQUNTY HEALTH d�PAFrTMENT
35SA SQUTH MADISpN BLVD
ROXBQRO, NORTt� GAROLINA 27573
BACT�f�101IOGICAl. WATER SAMPLE ANALYSlS
Name of Owner or Tenant °F" E
Address � ' _ �County � �
Collected,By � • �. .
Date Collected � � Time Cotl�cted � = ��
Source: �eli ❑ Spring ❑ Other
Locatian: t�}/House Tap o 1Ne!! tap ❑ tither
❑ No Charge �' Ch�rge
■a���r����r�ar�����������:a����������������������������������ai�rr�r���rr■�r��si
i1rYeYe�F�###*7t;t*ttrtYY�kWft�t�t7YritYfYeMtkf�ie*7kfYatifltYe4fkYe7FWBrtt**7ttiNW7YYewflt7YfYfk7t4fMettfeYeMrirfk4ta4#�MflrsMeF*$drir�k*
TQta! Coliform
�eca1/E. Coli
iESId��S
Present
`� �
r
�
Reported B �
date Reported �' b� �- / � �
Report Calied �YES ❑ NO
Calted To _ �`� ;l� �c�� �
�—, - - -
Absent