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PERSON COUNTY HEALTH DEPARTMENT
WELL SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax. Map # �. � Parcel # -�
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w < 15$ Wes
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As Installed
TIONS
r Lot Area Size of Tank
Mobile Home Size of Pump Tank
ess # of Bedrooms Nitrification Line
� Max Depth Trenches
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Permit Void after 60 months. Permit id if not in compliance with zo ing regulations.
Permits may be voided if site is alt re or i n use c ged.
Well a�cptio�Layout by
Comments: -'—�-"'
Date Installed by
SYSTEM SPECIFICATIONS
by
3ividual Semi-Public Required Slab _
iblic Replacernent Air Vent
te Approved Required Well Log
ell Head Approved Well Tag
-outing Approved
Comments:
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the propecty 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 wazrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam 01/95 rev.1.0
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