A40 101z
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Person County Heaith Department �
Sewage System improvements Permit
Date:��This Permit Void After 5 Years `' %��
Owner: ��,,,rl �-I 1-� I I ° �, . - � � � ,: -�-�^ SR# `�'� _ �
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Subdivision Name: � �7 � � � � � t � .� �'�;-1'�� �� Lot # �� �
Lot Size: �`�--t-��.T— Type of Dwelling: � .
Water Supply: Private: —�Public: ommunity:
Bedrooms: Garbage Disposal �
Basement Basement Fixtures
INFORMA BY f !
Sanitarian: d � c� �'ie�en i 7,:
REPAIR: EVALUATION:
-------- ----------- �
Size of Septic Tank: __��7��`� allons� Size of Pump Tank: --
Nitrification Line: � t
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pomp � LPP Pump
Remarks:
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Date Well Approved: aWell should be 100 ft from any sewer system
BY Sanitarian
Date e. g S s ppr� - - -�
BY � � Sani 'an
ATE OF COMPLETION
`' '_..,�,,"�. _� • _ �3
----------- ----------- �,
Sewage System location, installation, and protection must meet state�and local '�
regulations. Septic tank should be pumped out every 3 to 5 years and shalt be maintained �
by owner in such manner as not to create a public health hazard. Septic tank' and'd
nitrif'ication line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put inie� use. If
the site plans or intended use change this pemut is subject to revocation. '•^
(G.5.130 A-335F) _ . �
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L.ocation of sewage disposal sewage system sketched on back. cn o
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s Person County Health Department �
Well Permit Z_�-�t I F �
Date:�" � �' �0 This Permit Void ter 3 Years � b F
Owner: r- (�Y I N� t��,����r�, sR# �.Srl 5..� �
Locauon/Du�ecuons:
Subdivision Name: �'
Drilling Contractor.
WELL CONSTRUCTION ►�
Distance from Nearest Property Line Distance from Source of
Pollution _ �� �
Total Depth: F� Yield: GPM Static Water Level Ft �
Water Bearin Zones: D FG Ft G
8 �
Casing: Depth From to Ft Diameter: Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve:� �sQ_ No
Weight Thiclrness: V V Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: ''d
Grout Type: Neat S Cement Concrete �
Annular Space Width Inches
Water in Annulaz Space: Yes No
Method: Pumped Pr� Poure�
Depth From � to �--V FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, gr �v , cuttings) - Ratio: to _
ID Plates: Yes No
4 z 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRE AND THAT
THIS WELL WAS CONSTRUCTED IN A RD CE WITH REG TIONS SET
FORTH BY THE PERSON COUNTY H D P TM . �
gn e C Date
r�M ��� � �lll��
Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
r-• NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
F at later date. Not; loca 'on of wa�k s��ies o� adjacent(z,tc�s. v� •
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