A40 165. � z
Person County Health Department �
Sewage System Improvements Permit
Date: - �� This ermit Void Af er 5 Years t
Owner: c, ��r ��� G f � SR# � 1�%1 '
Location/Directions:
SubdivisionName: �--ovn r. ;1� T �itt� Lot#
Lot Size: �'� -�,� G � Y� t Type of Dwelling: �
Water Supply: Private: —�� Public: :
Bedrooms: 3 Garbage Disposal �'"'"'
Basement Basement Fixtures� �
f�i� � 4' a.�
INFORMA y�- •� BY � � `" � [ �9 ,
�__:._�.._ 1 . /i li�... ��o3�nerorrepresentative
. .. .
s
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Size of Septic Tank: _,�� gallons Size of Pump Tank:
Nitrificauon Line: �)h � �C 3 �
Depth of Stone: 12 inches
� Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:�Z-� '�v Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sewage System Approved: I Z � G-`� d
BY /./l � �"�..Sanitarian
f CERTIFIC TE OF COMPLETION
Contractor��
--------� ---------------- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Sepdc 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'd
nitrification line must be inspected and approved by a member of the Person Counry �
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 revocation.
(G.S. 130 A-335F)
L,ocation of sewage disposal sewage system sketched on back.
(OVER)
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
at later date. Note location of water supplies on adjacent lots.
1��'I
,.
• �k���L'�G
' � Person County Health Departm
Well Permit
Date: -.�' � This Permit Void^After 3 Years
Location/Directions:
Subdivision Namer
Drilling Contracwr.
ent �
�
II�/ �
�—
;�
WELL CONSTRUCtION �U
Distance from Nearest Property Line Distance from Source of �'
Pollution ;r
Total Depth: � Yield: �GPM Static Water I.evel FG �
Water Bearing nes: Depth Ft. F� Ft.
Casing: Depth: From _� to Ft Diame� �� Inches
TYPE: Steel ' Galvanized Steel
ff Steel, does owner approve:� No
Weight: Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
1 E tered ' S nin ch C' � Y N
Were Prob ems ncoun m e g e asmg. es o
If "yes" give reason: � �
Grout Type: Neat S�ement Concrete
Annular Space Width �_ Inches
Water in Armular Space: Yes No
Method: Pumped Pres Poiued �
Depth: From �— to F�
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, gr vel cuttings) - Ratio: to
ID Plates: Yes ` No
4 x 4 slab Yes � No
I HEREBY CER'I�Y THAT THE ABOVE INFORMATION IS
THIS WELL WAS CONSTRUCTED IN OR C� WIT
FORTH BY THE PERSON COUNTY HE� ��tT�
AND THAT
TIONS SET
Date
Sanitarians Signature Date Completed
Sketch well location on reverse side.
� 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
� at later date. Note location of water supplies on adjacent lots.
(1) (2)