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A28 121 & 1224 � , !� � �. , ra �32, 3r 3 , GoAtjj�n( d 3 p-�-- S � / A �Z f � 0. � �-. PER�ON COUNTY HEALTH DEPARTMENT SEWAGE DISPOSAL IMPROVEMENTS PERMIT NO. Issue Date: � Owner: �n � � C7SP'+ Locatio : . G 4' Septic Tank Contractor: _ �Aa�+� Building Contractor: Water Supply: Private Public ! All wells should be 100 ft. from sewer system. � �'� G�tr�s Lot Size: Sewage Disposal Facilities: N. bedrooms ` / Size of tank:� Nitrification line: � Other disposal facili . ,- ' ,�/ � . Water supply and sewage disposal facilities location, installation and protectiion 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 a 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 CO. HEALTH DEPARTMENT STAFF BEFORE ANY PORTZON OF THE INSTALLATION IS COVERED AND�PU T� USE. THZS PERMIT VOID AFTER 3 YEARS. Date Well Approved:�_s _ Signe By: Sanitarian � Date Sewage Dis osal A proved: Counter- By: � signed (Owner is representative) Certificate of Completion Date Approved: �� ( � B : anitarian (Over) Location of well and sewage disposal facilities sketched on back. 0 � � � �� a. i ` .� • .ii► - �'' �. � . f Person County Health Department �', �� � Well Permit DATE ISSIIED:O-��^ DATE DRILLED: . �: COUNTY: Y p. OWNER: �tOAD%STREET: � . ADDRESS: .. ;- ' DRILLING CONTRACT = : � I� y� r��� �. �� �"r. _ , • .V, ADDRESS -�r WELL CONSTRUCTION Distance from Near�st Property Line /�� /u,�Distance from Source of Pollution /D d n �isS Tota1 Depth:��Ft. Yie1d:���GPM Static Water Level Ft. Water Bearing Zones: Depth /03 Ft Ft. Ft. Ft. Casing: Depth: From�_to Ft. Diameter: Inches TYPE: Steel Galvanized Steel �� ZP Steel, does owner approve: Yes No Weight:�_Thickness: /k�Height Above Ground:�Inches Drive Shoe: Yes p ` �lo Were Problems Encoun�n Setting the Casing? Yes No �/ If 'yes' give reason: Grout: Type: Neat L� Sand/Cement Concrete Annular Space Width � Inche� Water in Annular Space: Yes No Method: Pumped—}-- Pressulre Poured L� Depth: From [� to Ft. Materials Used: No. Bags Portlan Ce�ent�Weight of 1 bag��lbs. If mixture (sand, gravel, cuttings) - Ratio:_a`to� ID Plates: Yes �� No 4 x 4 slab Yes�— No � DRILLING LOG De th From To Formation Descri tion .Q— �.�,1-- l �— a, G�n,�� ,,� ✓� p v� , -f c� I HEREBY CERTZFY THAT THE ABOVE INEVRMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY BOARD OF HEALTH. PERMIT VOID AFTER THREE YEARS. �a� Zt1 vl�� `�7 - �`I��', Siqnature of Contractor Date ��� �= 23-d'� 's Signature Date Issued Sanitarian's Signature Date Sketch well location on reverse side. r7 t _ ` j � ! �..,,, /�� j` � C� �. f.f' � l p{ �,..T .ti ...w+....-.�.�-'. . . . _. _ . .... . .. _ . .. � , :�'� . . ;�� ., � �, _ �- �b l � - y .� l�' �J .. . � . ... ' . ✓^ re :' / � � . �' �' «f �.bi .�:' \'� . 7 . ' . . . . } ...,�f' 1 ��� � . . � e � c r� �,.'� , �l �:� � � � ���� ��_ �ti __� a�l Y> Q��� � °O� � � a��i'� ..•�n��' � • The District Health Departrnent ���� CASW�LL - CHATHAM - LEE - PERSON COUNTIES � 3� � • Water Supply and Sewoge Disposal IMPROVEMENTS PERMIT No. , � .. D q- / . � v,;d-' ' j�'�� � �, Owner: � - � Contractor. ��" Water Supplp: Piiv`ate Public Sewage Disposal Faeilities: No. bedrooms ��� Dishwasher, Disposal, washing machine, ther automatic appliances Size of tank: �}�' � Nitrification line: Other disposal facility: ,y�. Water supply and sewage disposal facilities location, �nstallation and protection must meet state an� local regulations. Septic tank should be pumped out every 3 to 5 years an3 shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTEB AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE I ALLATIO IS ' COV- ERED AND PUT INTO USE. Date approved: _�igned� � Sanitazian Well: Sewage Disposal: By:. I �Certiiicafe ot Comple2ion Date Approved: Counter- � l.� )t,�,�d�e signed (Owner or his representative) By: _ Sanitarian . (OVER) Location of well and sewage disposal facilities sketched on back. NOTE: = sketch of installation showing lot size shape, location of house, septic tanks, �es, 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. 5'�-'� � `S�d ...____•__._.._..._.�.':4'.. . . . . . . . . . _ . t +maun t '� iieceipt � paid 1QQr�0 �i ' l _ _ . _ _„�, '7-�3 i� Date � w � a 1. Permit requested by: . owner/prospective owne � gent• Address: � � � n��T�-� s'��n' �'��?�S 2 iome Phone #: 3usiness Phone #: ��� �.C� �� /S�! 0 W � 7. Dimensions or Proposed Structure: Width: y��Q — �TlPnth• c-U 8. What type (if any, additions, expansions, or replacement is anticipated to t�e structure or facility that this sewage disposal system is intended to serve? 2!r�GAC�f ��B�C.Lr ��L� I�tfoB�LCI H�Gr �ri1�L �Cf /�CjA�td ��� I�Iame and addre5s of current owner. 9. Water su ly t} pe: S� �rG �os� � private (� public ❑ community ❑ sprin�g.�,❑� 8�1 D LqyLA'K �iA�/��/ R��' Are any wells on adjoining property?Yest� noU. lZv X�,t0, ��C If so, identify location: Property Description: Lot size: .S2 � � - e/f '1' • Pro sed• xisting: Q Tax Map#: . � � i�SZ Parcel#: � � � 3 ��' Township: � �� � v-e- � � Directions to property: State Road #& Road ames,�tc. /1/. C . � : 2 .tifr� ��S o wA���S �R� i� i O�t/ c � �R�/ /�v�) SR ��S O�+/ L ��'FT I0. Type of structur aci ity. po • Type of dw�ell' � House: L� Mobile Homg : CI Business: ❑ '�jrpe of businesr. �Y/g Number of Employees: - Number of bedrooms: 3 Garbage Disposal? Yes ❑ N �� Basement? Yes ❑ No f so, # of basement fixtures: ,,. Number of occupants or people to be secved: Z _ CLEARLY STAKE ALL CORNERS OF TT3E PROPERTY AND THE CORNERS 4F ALL PROPOSED STRUCTURES• . �I hereby make application to the PersOn COunty T:�eslth Department for a site evaluation for the on-sit� sewage disposal system for the above described propercy. I agree that the concents of this application are true and represent the maximum �'acilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can t issued, I must present a survey pla[ of the property to the Health Dept. I unders[and that in the event I have no delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. �%�J � ..�(.��C �. - � - - • - • • — • t. �,��,�,, • M , , \ Ll ` �,':;:, . 'y0-y� B,N 7� � f ,i , � . � T . � \ . , i. 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'� ;�,.. � � ��.,: � . _ _ 3-6+•ra-�s•s � 1 ���.,. -� . -- - _ �� �:,.�. -_ ,t�tt :,. ,,,,',: l' �� �•,i•...o�•:� •. /A. ♦ • e Person Coun�y Health Department Existing Sewage Syste� Report For: Requestee: V Mobile Home Replacement ;��' Addition � Home Phone# Business# 'Pax Map# -' �v� Location/Directions: —1 1`-� � � � Dl,c �-e._ � �� _ Original Yermit Located Septic System Uesigned For: kesidential Business _ # 13edrooms � # Emp7.oyees Other (specify) Other _ n���„►_ Uate rttstalled ' — Water supply 'Pype of System ' ' '- � � Nitritication Line Tank 5ize r� Certified Operator Required On site wasL-ewat r disposal system showes no visually apparent malfunction on � � !� � Yermission is granted to: �� �+��� According to the attached site plan.. Comments: Environmen�al Health � DATE I � . � �t ,., � . : � �.. y�� . v w�, ,�s �d 3,e� � . ti ;,i �Y � ; � . rl i l•y, . « 5 X` -. � f." � r t l� C :, J �'�. .� 5 k �. ,;u.� ' � t � . - . - yf ,:.M � . e �4 . �7 at -� � ,t : � �, ."' . . . r ,.s ° � .� s , � t�.� is Lj�t A. � {,� .A�es ' � ' � . . . . . i •7 � : � { �1��� �, +t•• ' ti V ��: �. 1`1 . " . . . . ' y r ^ . 3..,'w} r`F.J� � �.`� i i�t W ' . . ,. � .. !' .� � ��f�!'�� ;:/'��CB�� 7 `' �1� , � AN . . , . :" , - ;�. � ; ` : e , , � . � � � � ;`c ' t; . � 3; ._. ti � I. fR i.� -- LL � t� .�,' - . . . ' ,� G. . I��$B } -`•v i,r .y, L+L� r . , �,ht �i �`�, � 9, ,a � • � ; • � . . . .r i . - r � �, Y,r � k � t '� i± 4 ,•�' � � 1 � . . . 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