A28 131. l�erson `County Heaith Department
Sewa e System improvements Perr�it �
Date• �" �' ' Permit V i�, After 3 Years a f'
Owner: SR# --��
T riratinn/ilirPrtinn •
Subdivision Name: � � s'� S'�fti n,_ � �
Lot Size: � F TyFe of Dweling:
Water Supply: Private: Public:
Semi Private: If not Private Tax Map# _
Parcel # of Water Supply or Name of
Supplier#
Bedrooms: Gazbage Disposal
Basement Basement F'
INFORMA D BY
Sanitarian: own�r S
REPAIR: REEV U�,TI4N: _ �
Lot #
Size of Septic Tank: _����'�— �� l� — — — — — — — — — — —
�Nitrification Line: g ��� l?(� � /
Depth of Stone: 12 inches
Ma�c Depth, of Trenches:
OPERATIONAT: PERMTT: yes , - _ .. _ . no
Remarlcs: _ �
Date Well Approved: - l�
BY
Date Sewag � �
Wel! should be 100 fG from any sewer system
�
BZ' Sanitarian �
CATE OF COMPLETION �
Contractor. " � �
------------------------ �
_�
Sewage System location, installation, and protecdon must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shail be
maintained by owner in such manner as not to create a public health hazard.
Septic tank and ni�ification 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. �
Location of sewage disposal sewage system sketched on back.
��/'� '1 %'(, -f� � Lt (OVEI� � � iJ 1
V �(/�, (� +���� fj�j �� �, v
�� t� �i � h-�{� 1�.�� � d A� • l, �J G Y y',-.'t � G- � O�
l/ f �
Peraon County HeelEh Department
t � , - • f+ell Permit
DATE ISSV De • f�9L"S_L+P,:LL�Dt/d-�,/ p%COVNTYt �G /-�i d i�.
ONNERi �"�� �?pJ►D/STRE6T�
ADDRESS� �
DRILLING CONTRI►C1'ORr „) (�h, � Jdf�/I ,�h�,�l�iy
i �
nnr7E JIDDRES- S �'
NELL CONSTRUCTION
Distance from Nearaat Property Line DSstance traa Sourc� ot
Pollution D �
Total Depthr Ft. Yielde� d GPM Static Mater L�v�l.� Ft.
Mater Beazing ones: Depthy[�� Pt Ft. Ft. Ft.
Caaing� Depthr From�to „Z_Z Ft. Diameter� di IncAes
TYPE! Steel Galvanised Steel_ L--�—��
If Steel does owner approve: Yea No
F►aight��_Thickneaa ��IeigAt Above Ground� Z Inches
Drivn Shoar Yea � No
Were Pzoblems Encountesed in Sattiny th� CasinqT Y�s pp
If 'yes' giva raesoni — —
Groute Type� Neat ✓ Sand/Cement Concr�t•
1lnnular Space Nidth � Inchas
Mater in Annular Spec�� Y�s No�� �
Methodi pump�d Pzass � Poured
Depth� lrom 7� to Ft.
Materiels Us�dr No. Sag• Portland Cem�nt�_N�ight ot
1 baq�_lbs.
I! �nixtur� (sand, qr�v�i, cuttinqi) - Ratloi_�3_to�_
ID Plateai Yea �� hp
� x � slab Yu�— No
I HEREBY CSRTIFY THAT 2'HE 1180VS INFaRlU►TION IS CORRECT 11liD tNAT Tl1IS
NELL MAS CONSTRUCTED IN 11CCORD)1IiCE N7TH REq1LATI0l13 S6T FORTH BY TNE
PERSON COUNTY 80ARD OF NEALTH. QERNIT VOIO AFTER TNREE Y6J1RS.
Si�.�.�.--• ' �(� • ��
r� ot Co�tia� or T—Date
Sanitarian's Siynatur� Dat• Isaued
Saniterian's Signature Dat� Coepleted
Sketch wall location on reverss sids.
�� �
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�:�.�����.�.��.�.�.�. �-��,��.nt��.
�uilding Additions/ M[obile I�ome Re�lac�ments
TaY Map #:, . OZ Parcel#: i3 ( Address: ��( ��.i►:, t��Lv � L,d�c�
Approval Requested for:
Applicant Name:
Address:
Phone #'s: 3 3G - .�0+-1� -
Mobile Home Replacement
—� Building Addition
o1�,�N� �e_l� .�
i ✓i , i
7.
� .
Permit Located: �� Yes No
Installation Date: Design flow: �� (apd)
Cunent Contract with Certified Operator on file (if required): �_
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: p (date)
(Applicant's signature if site visit is not required)
Adtiition/Replacement ApQroved
�
� Environmental e th S cialist
�/�/��
Da—te �----
Person Counry Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-�97-1790/ Fax: 336-�97-7808 �vw�v.�ersoncountv.net
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