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A28 191z �'erson County Health Department � ` Sewage System Improvements Permit Date:��-��This Permit Void After 5 Years Permit #�� ��'3 g Owner: ��—� �P.=L'1T,— A �—,�� Lb� � Location/Directions: �? l r,�-�� „�--,-r�� Subdivision N e: W� Lot #_�— Lot Size: ' /�'sType of Dwel ing: Water Supply: Private: ___L� Public: Community: Bedrooms: � Garbage Disposal Basement Basement Fixture ` INFORMATION CERTI�TTED BY C� � � Environmental Health Specialist• o er or rep r�u�e REpAIR: REE UATTON: Size of Septic Tank: �n� gallons Size of Pump Tank: Nitrification Line: �� �� � � Z � Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: ---------�--------------- _ � . Date Well Approved: BY Date S � e ��; r�; BY � Contractor. Well should be 100 f� from any sewer system � Env� n�en�t�l I��yth Specialist � Environmental Health Specialist ;ATE OF COMPLETION ------------------------- 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 ni!rification line must be inspected and approved by a member of the Person County Health Depaztment before any portion of the installation is covered and put into use. If the site plans or intended use change this pennit is subject to revocation. (G.S. 130 A-335F) L.ocation of sewage disposal sewage system sketched on back. (OVER) �e � � b ��rson County Health Department �Sewage System Improvements Permit Date: � Owner: Void Afte 5 Years Permit #— � J�v � ; ,� sv v SR# Subdivision`Name: Lot # .s'� 'o�' Lot Size: c Type of Dwelling: %�%�+� �� r,b^'�c Water Supply: Private: Public: � Community: Bedrooms: Z Garbage Disposal U Basement /�o Basement Fix s N� � / INFORMATION CERTIFIED BY i�` � !�y -` � o r or resentative Environmental Health Specialist: � "'P�, �....... REPAIR: REEVALUATION: Size of Septic Tank: 1 C�Uc� �allons Size of Pump Tank: 1 CX�� Nitrification Line: 3CX� � x 3 Depth of Stone: 12 inches 12" Max Depth of Trenches: tR,= 2t.1 �� Alternative �stem: CQnv. Pump i�� S� LPP P}im,p , . ,, �a■�, — — — — — — — — — — — — — — — — — — — — — — — — — Date Well Approved: Well should be 100 ft, from any sewer system BY Environmental Health Specialist Date S a S s Approv • � 2- 7 �%? BY ^ Environmental Health Specialist ,�ERTIFTCATE OF COMPLETION Contractor. � � M .g��' Sewage System location, installation, and protection must meet state and local regulations. Septic 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 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 irso 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) �rson County Health Department � � Well Permit � Date:/U-Z7_`�Z'I'his Permit Void After 3 Years Owner: ,��vd� k� �/� 6%^�-;o�v SR# G i-' '� L� ., /S'� : " a.� Subdivision Name: �t # � �S, Drilling Contracwr. � � s � -� WELL CONSTR Ci'ION � Distance from Nearest Pmperty Line /��,. c Distance from Source of Pollution _/ � � .�0 �u-s �. Tatal Depth�(��Ft Yield: � GPM Static Water I.evel `� Ft � Water Bearing Zones: Depth �FG�{� Ft. F� FG Casing: Depth: From �_ to�� FG Diameter: �� Inches TYPE: Steel Galvanized Steel v Grout If Steel, d owner approve: Yes No Weight �� Thiclrness: Height Above Ground: ��Inches Drive Shce: Yes `�� No Weze Problems Encountered in Setting the Casing? Yes ' No i------ If "yes" give reason: � Type: Neat Sand/Cement ' Concrete Annulaz Space Width .� Inches Water in Amtular Space: Yes No��_ Method: Pumped Pressure Poured �� Depth: From � to FG Mat Used: No. Bags Portland Cement � Weight of 1 bag _;� Ibs. If mixture (sand, r�avel, cuttings) - Ratio: `1— to �_ ID Plates: Yes No 'TJ 4 z 4 slab Yes �— No �. .� I HEREBY CERTTFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPART �. �� W Q�, s' !'{E;?P LclSt-1 I ]CX� � �rorh Q,.� P �'1 . Signat�se of Contractor Date �ca�,� 13 _ o''""` �o -z7-y; Sanitarians Signature Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. . �NOT'E: Make sketch of installation showing lot size and shape, location of house, seotic tanks, privies, water � supplies, etc.,Note special problems existing on lot. Write in measurements in order that i;istallations may be located � at later date. Note location of water supplies on adjacent lots. (1) � (2) , I ' .I I ,r , . �' � � � a� U �, c� a � �J � -P� i'����� A 17 5 9 PER ON COUN"I`Y HEAL'l,H DEPA.RTMEN"T . WELL � SEWAGE SITE, LOCATION ��RLO� MENT PERMIT Tax Map # 'L� Parcel # Zoning � Township _ � � � Owner/Contractor C� / Date —.�- `� Location/Address �-(��_ ` Subdivision Name Lot# SFD SEWAGE SYSTEM SPECIFICATIONS Lot Area o ile Home # of �edrooms . r -----� Size of Tank Size of Pump Tank^ N�i rificat� n Line � D�ntlh Trefiches Pe �t V id after �i0 onths. �r�nnit V�id if not in cor�i pli�nce �ith zo P �ts ay be voided if site is altered or intended use changed. ell d Septic Layout by omments: Date _ Installed by Approved by. WELL SYSTEM SPECIFICATIONS Semi-Public Required Slab Replacement Air Vent Site Approved Required Well LQ� 5'(8- Well Head Approved_ __ Well Tag Grouting Approved -�"�- Date by. � Approved by. This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pemut. The environmental health specialist is not responsible for false or misleading infonnation contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wattants that the septic tanlc system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam O1/95 rev.1.0 ORIGINAL � _... ,._. -. ..._.. ,, ... . _. _ . � , PERSON COUNTY ENVIRONMEHTAL HEALTH WELL LOG i � • � .. � ' Date: 9 ' � Owner:_ �'—�r �a �I�I lv�'� ��`r� - SR# � Location/Duections: « �►� Tl�h � a'��-a� � ��, -��-�.,, , .� Subdivision N'Zrne: Drilling Contractor: � Lot WELL CONSTRUCTION � Distance from Nearest Properry Line (G Distance from Source of Pollution_ . ��C� ' Total Dep.th:�_ Ft. Yie�d: �______ GPM Static Water Level 2�_Ft. Water $earing Zones: Depth�b �,yrt.__ F� F� Ft. Casing: Depth: From�_to�Ft. 'Diameter: ` Inch�s TYPE: Steel � GalvaniZed Sceel_/ If Steel, does owner approve: Yes No � Weighc: Thicicness:�_ Height�Above Ground: l�( Inches Drive Shoe: Yes ��No Were Problems Encountered in Setting the Casing? Yes No � If "yes" give r�ason: Grout: Type: Neat Sand/Cemenc -� Concrete Annular. Space Width Inches Water in Annular Space: Yes No _ . Method: Pumped . ..- Pressure � Poured �. . . , _ Depth: Fr�m C� to Z� Ft. . . Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixture (sand, gravel; cuttings) - Ratio: to �ID Plates: Yes � No � � -� � . �� 4 x 4 slab Yes—��No � %s "rj � .. :� I HEREBY CER'TIFY THAT THE ABOVE 1NFORMATION IS CORRECT AND TH AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY-THE PERSO�t C�ui�ITY HEALTH DEPARTMENT. i naturc of Contractor atc� g ►..