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- Person County Health Department
�� �}ewage System improvements Permit
Date:�_ This Per�it Voi After 5- Y
Owner: JI/I Ct �' ✓ 1✓1 1�, PG ✓
Permit # �
SR#
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Subdivision Name: Lot # �
Lot Size: -� %� �' r�/'-� Type of Dwelling: -
Water Supply: Private: Public: Community:
Bedrooms: � Garbage Disposal
Basement Basemen�i ures
INFORMATION CERTIFIED BY '
Environmen[al Health Specialis[: o er or repre e uve
REPAIR: REEVALUATIO : ���' . �'
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Size of Septic Tank: (/
Nitrification Line: � �
Depth of Stone: 12 inches
Max Depth of Trenches:
AltemaUve System: Conv. Pump
Date Well Approved:
BY
Date S� e yst m
BY
Size of
LPP Pump -��
—.L'ti.4� �„ 1QJ�---�'—=—
_ Well should be 100 f� from any sewer system
— Environmen[al Health. Specialist
7- �� - �1_y
� Environmental Health Specialist
��t�ri�ri�A'I� OF COMP�,�TION ,�
Contractor. �• �!� lS/� V �� .� ��O �
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Sewage Sys[em location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped•out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nisification line must be inspected and approved by a member of the Pcrson County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intende.d use change this permit is subjecf to revocation. �
(G.S. 130 A-335F) ,.[
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
, . .��C171� �� R�S ETTE . Cc�wTi'��Tc� (Z
y, �erson County Health Department
Well Permit
Date: �-�7 is Permit Vol Af r 5 Y
Owner� ►� �/ f� /'�' �� ��� SR# � _
Locauon/Duect�ons: /���
Subdivision Name: ` #
Drilling Contractor:
WELL CONSTRUCI'ION
Distance from Nearest Property Line Distance from Source of
Pollution�� �h
Total D th: Ft. Yield: v GPM Static Water Level Ft
Water Bearing Zones: D,4Pth �t-�_Ft. Ft Ft.
Casing: Depth: From�_to �-•• Ft. Diameter: Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner approve�No
Weight: Thickness: Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat �d/Cement Concrete
Annular Space Width Inches
Water in Annulaz Space: Yes No
Method: Pumped� Press►yr�_ Poured `�
Depth: From to LtJ pG
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixriue (sand, gravgl, cuttings) - Ratio: to
ID Plates: Yes � No
4 x 4 slab Yes��No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH R�rGULATIONS SET
FORTH BY THE PERSON COUNTY HB?ci.Ti-PDEPA�TMENT. A
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C�{� ��
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Sketch weil cation on reverse side.
Sanitarian's Signature Date Completed
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N TE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
' su plies, etc. Nofe special problems existing on lot. Write in measurements in order that installations may be
lo�ated at later date. Note location of water supplies on adjacent lots.
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