A28 127�3�
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PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISP�SAL
IMPROVEMENTS PERMIT NO.
Issue Date:�� -- /�
Owner: `.:. � �NN L--. e. +1v l5
Locat`ion:
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Septic Tank Contractor: ��
Building Contractor: �
'Water Supply: Private /_��Public
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� t All wells should be 100 ft. from sewer system.
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Lot Size: C� �,� r� ~�
Sewage Disposal Facilities: N � bedrooms
Size of tank: �n%,�� G�`�/ Nitrification line:
-r��',�� T _
Other disposal facility:
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 5 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 SE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON C0. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS. �'
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Date Well Approved: Signe /���
gy; Sanitarian
Date Sewage Dis os 1 Approved:_
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gp; � �( signed
(Owner or his representative)
Certificate of Completion /���
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Date Approved: � " ' � u BY=
Sanitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
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Person County Health Department
` Well Permit
DATE ISSU O� /� DATE DRILLED: COUNTY: �%� �s�.�,
OWNER: . ROAD� ST�R�EET:
ADDRESS: ,a1��n_
DRILLING CONTRACTOR: �w (�.l�l„S
NAME ADDRES
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution - -
Tota1 Depth: t. Yield: �� GPM Static Water Level Ft.
Water Bearing Zones: De h Ft. F��Ft.
Casing: Depth: From � to ., Ft. Dia er: inches
TYPE: Steel Galvanized Steel
If Steel, does owner app�y� Yes No
Weight: Thickness: �t��Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes_No_
If 'yes' give reason:
Grout: .Type: Neat San�ement Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
Method: Pumped P�'% �ure Poure�
Depth: From �to G-Y+ Ft.
Haterials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand,�p vel, cuttings) - Ratioz to
ID Plates: Yes / l No
4 x 4 slab Yes � No
DRILLING LOG
De th
From To Formation Descri tion
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND T THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WIT��( TION6 SET FO H BY THE
PERSON COUNTY BOARD OF HEALTH. PERMITlVOI1��TER A'I�tEE RS,
of o ractor v Date
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�' i_ a ura Date Is ed
Sanitarian's Signature Date Completed
Sketch well location on reversa side.
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Anplication Date: �
Amount Paid:
Receipt #:
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Tax Ma #:
Parcel #: � .1��
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�^ aavaa-�s�.-�-�--�• .oaa��.A �E-���.IL�Iia
�►PPtICATION FOR SERVICES
IF THE INFORMATION 1N THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED�
CHANGED OR THE SITE IS ALTERED THEIV THE IMPi20VEMENT PERMIT AND AUTHORIZ.�►TION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownerlagent/prospective owner): . s• ��U �
Home Phone: � � ,f,L� Address:
Business Phone: 5 .-R� . . �.
2) Name and address of.current owner: S Aty1 �
3) Property Description: Lotsize: l►� Tawnship: D��Yc��l� � Subdivision:I��;a� LN[J Lot#�
Directions to the property (Including road names and numbers): � �
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed 3 g� Existing �,2Type of Structure: .DI I,J Width: Z r"� _ Depth:�
b) Number of Bedrooms: '' Number of occupants or people to be served: �
c) Basement: Yes_, No , 7�, Wiil there be plumbing in the basement? Ma
d) Garbage Disposal: Yes J No �
5) Water Supply Type: Private �(new _ or existing�, Public , Community , Spring _
. Are any wells on adjoining properly? Yes� No _ If yes, please indicate a�proximate location on the
site plan.
6) Does your property contain previvusly identified jurisc9ictional wetlands? Yes_ Mo�
PLEASE FIOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLIC�►TIOfd.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢'�HE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE S1TE MUST BE READtLY ACCESSIBLE FOR AiV EVALU�4TlON BY THE HEALTH DEPARTMEfiIT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for. the above-described property. I agree that the contents�of this applicaiion are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become inval id.
or Legal Representative
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PCHD, rev. 06/27/02
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Tax Map #-�L '��- Parcel #
Existing Sewage System Report For: ✓ Mobile Home Replacement
Addition Type•
Requester: � �J'l� Home Phone# �! 7'
Business # � T'/ — �a
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Original Pernut Located: Water Supply:�.����
Septic System Designed For: �idential Business Other
# Bedrooms � # Employees Other
S stem T�7}�e: �(1'Q'ank Size: Nitrification Line� �3 �
Y .7I� �v
Date Installed: �b"� O,�_ - Certified Operator Required: N(�
On-site wastewater clisposal system shows no visual signs of malfunction on " I'�J.
Permission is granted to:
Environmental Health Specialist
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Dr�infieid
Eas�err�er�t an
Lernris land
Qair�fand R�d.
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9 Q' Ea��ement
�, �—to Drainfield �
. Pro�ert�+
Lines
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