A40 126''� �
Person Count� Health Department
Se��:age System Imp'rovements Permit
Date:��� P�rmit Void After 5 Yeacs Pennit #
Owner: ��'.,J.�d, �LL.. -�- -�-��.�—
Location/Directions: _��,��P��,,:�,�—�/ �,�, D�t
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Subdivision Name: ��0� u-l� S//.� Loc # - �°
Lot Size: —�/, �2r 6•r�,c__ Type of Dwelling: .�
Water Supply: Private: � Public: Community: "
Bedrooms: �_ Garbage Disposal
Basement Basement Fixt�es � ,
INFORMA D BY ;-�� �. -
5���: owner a pre�'aitative �
REPAIR: REEVALUATION: �
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Size of Septic Tank: gallons Size of Pump Tank:
Nitrification Line: ZQl'x 3� -
Depth of Stone: 12 inches
Max Depth of Trenches: �
Altemadve System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:7
BY�,M�
Date w e S�sterr�, A
BY �'
Well should be 100 ft from any sewer system
CER�TTFTCATE OF COMPLETTON . , ,.,3
Contractor. Ep� j� �-GeC �
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to S years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tardc and
niuification 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 into use. If O
the site plans or interded use change this permit is subject to revocation. �
(G.S. 130 A-335F)
Location ofsewage disposal sewage system sketched on back.
(OVER)
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Person County Health Departrraent
Weil Permit .
Date: -►q -9 2 This Permit Void After 5 Y c�F
Owner..-�" !�_ [ P �e y� � r
r ,,,..,.:,...m._,.,...__ �� � a : r--S SR# �S
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Subdiv sion Name• Lot #
Drilling Contractor.
WELL C NS`I'RUCTION
Distance Near t Property Line�� Distance from Source of
Pollution � d u S �
Total Depth: .L F� Yield �S GPM Static Water Level p�.
Water Bearu►g Zones: Depth O a p�,�_FG Ft Ft
Casing: Depth: From_�to��Ft. Diameter: d" Inches
T'YPE: Steci Galvanized Steel �--�—
If Steel, does owner approve: Yes No
Weight� Thic� f� S�Height Above Grotmd: / a.. Inches
Drive Shoe: Yes No
Were Problerns Encountaed in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sand/Cement '� Concrete
Annular Space Width_ � Inches
Water in Aimular Space: Yes No -�
Method: Pumped Pressure Poured -✓
Depth: Fmm�_ ��F�;
Mz:eri� Us�: No. F.a�; Fc,rtla�id �erncnt� Weight of 1 Uag_ 9'�:�;,
If mixture (sand, gravel, cuttings) - Ratio: �- co�_
ID Plat,s: Yes -� No
4 x 4 slab Yes �-No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �'
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET ��
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. ...
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Si e of Con� U����—� a�
Date�7 ` -
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Sanitazian' Signature Date Issued
Sazutanan's Signature Date Completed
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, wate:
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.
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