A40 150NOTE: 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
at later date. Note location of water supplies on adjacent lots.
(1)
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Person County Health Department
Sewage System Improve�ment� Permit
Date: ��" �'+' Th�ermit Vo' ter 5 Y ars
Owner: -���.�i��.�'��� SR# �
Location/Direcaons: �
Subdivision Name: _
Lot Size: �, �' r,
Water Supply: Private:
Bedrooms:
Basement ^
INFORMA'��N �E�t�
REPAIR:
Basement
REEVALUA
, -
� Lot#.
Community: —
Size of Septic Tank: ���;�. gall� s Size of Pump Tank:
Nitri�cation Line: Q , �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:_
BY _
Date S g s n
BY
,
Well should be 100 f� from any sewer system
� Sanitarian n , i � .
OF
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Contractor. �K '
----------- -------- -- �
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Sewage System location, installation, and protection must meet state and local '�
regulations. Seppc 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'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 into use. If
the site plans or intended use change this permit is subject to revocadon.
(G.S. 130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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Person County Health Department
Sewage System improvements Permit
Date: '��" Thi rer�►it Vo' fter 5 Y ars SR# .��H—
Owner: •���
Location/Directions: _ ,
Subdivision Name: , L.. -�� � t'� r'
Lot Size: � � ?`:-,G � •
Water Supply: Private:
Bedrooms: � G e I
Basement Basement
� Lot
Com. munity: -- �
11\1'VJu�aa.F����y� • T/— �j— _ y� '. r
�/ jj. J/ � oa�n or representat e- - �
$2111iffi1c911'i ��1��'�l� /
REPAIR'---- REEVALUA ------------
Size of Septic Tank: � gallons Size of�Piirnp�T'ank:
Nitrification Line: ��t% �� � �
Depth of Stone: 12 inches
Max Depth of Trenches:
pltemative System: Conv. Pump LPP Pump
Remazks:
Date Well Approved:_
BY
Date S g s
BY
z
�
�
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_��'�' Well should be 100 ft, from any sewer system
7.� _ Sanitarian � o /' ��
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�� TIFiCA OF CO LETION �
Contractor. �'�'
------------ -------- -- �
Sewage System location, installation, 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 portion of the installation is covered and put into use. If
the site pians or intended use change this pemiit is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
� ` .
Person County Heaith Oepartment
Existing Sewage System Report For:
i�
Requestee: �Oe-
Location/Oirections:
� �� � �
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Ho ile Home keplacement
�ition
Home Phone#(3���- y��9
Business�
�i y� P� r y9 �
'iax Mapx �.5�p
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o riginal Permit Located
Septic System Uesigned For: ��% v�n %�p�� � T""' 3�� �D�^
itesidential � E3usiness Other (specifyj
# Sedrooms J # Employees Other
llate '1'nstalled (9 � Wa er supply w
�r �
Type ot System �nl�P�� �4
Nitrification Line �� f iC � /
Tank 5ize (- ���
Certified Operator Required ! �/� _ �
On site wastewater disposal syste� sliowes no visuaily apparent
malfunction on �
�ermission is granted to:
� �
b�, � , .
`0 _ .��� � x �o ' �
According t the attached site p1.an.
Comments: u.� `�P �
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Environmental Health g�C..
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NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES E1ND COMMUNITY DEVELOPMENi
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
P.O. BOX 27887 - RALEIGH,N.C.-2781-1,;PHONE (919)733-3227
/�� 12���P.. =. %' * � .S :`'I'/ . --- _,
C�`�� _ _
WELL CONSTRUCTION RECORD
FOR OFFICE USE OIJLY
Quad. No. Serial No. _
Lat. Long. Pc
Minor Basin
Basin Code
Header Ent. GW-1 Ent._
DRILUNG CONTRACTOR i�� / L-G�iG � �/"� ��G
ST�i'E WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER -3 FERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location belowJ
Nearest Town: �JO/�O County: �' �-�5��
(Road, Community, or Subdivision and Lot No.)
2. OWNER G-Pf�%�/i��P� �l��T/%/1I
A D DR E SS . 7L9� %I�PG� �� /Y 4 L'VCL�`1� ��
'_ I (St et or R��� �.) �,���
ff%.� a,ve , .
City or Town State Zip Code
3. DATE DRILLED ,.� -� �. 9� USE .OF WELL ���e
4. TOTAL DEPTH �" CUTTINGS COLLECTED ❑ Yes � No
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes � No
6. STATIC WATER LEVEL: ��_ FT. ❑ above TOP OF CASING,
� be�ow
TOP OF CASING IS � FT. ABOVE LAND SURFACE.
7. YIELD (gPm): •.� METHOD OF TEST ���W
q /
8. WATER ZONES ;depthJ: ,/3
9. CHLORINATION: Type ����k Amaunt �� �°� ��!��tN�
10. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From � To �� Ft.�1�// '��� C�` ��
From To Ft.
From To Ft.
11. GROUT:
Depth Material , Mettiod
Frcm �� Tn •.�� Fr. .�r��� _,�`�.�ic�—
From To Ft.
12. SCREEN:
From
From
From
13. GRAVEL PACK:
From
From
14. REMARKS:
Depth Diameter Siot Size Material
_ To Ft. in. in.
To Ft. in. in.
_ To Ft. in. in.
Depth Size Material
_To Ft.
_To Ft.
Depth
From To
DRILLING LOG
Formation Description
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If additional space is needed use back of form.
LOCATION SKETCH
(Show direction and distance from at Ieast two State Roads,
or other map reference points) /`
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I DO HEREBY CERTIFY THAT THIS WELL 4VAS CONS'CRUCT,C�O IN ACC Q'�CN ��TH 15 NC�C 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD N��'8 -N PROVIDE ��HE L,OW ., // 4 ��%
-� ` � � __ �— t) _ �
, SIGNA7UFE OF CONTRA(,'TOR AGENT DATE
,,... .,� . .' " p,.�....0 ..,.�..�I �� flivicinn n'r Fnvirnnmentol AA�nnnomni�t �n�i rflnv f�l WP.�� owner.
� • � , AppltcaUon �i: .
� Tax Map 8: lT� ye� •
Parcel #: _L��Lx'
Person County Hoalth Departrnont , �
Envfronmental Health Sectlon `
� ' �31TE 8KETCH..
� Jp f � �r o �s� /� °Co � oC
IlcanYa Name Subdi oN3ectioniLot# �
• � `d Q
uthorized State Apent Date . ' '
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