A28 71Person County Heaith Department
Sewage System Improvements Permit
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Subdivision e: Lot # i
Lot Size: Type of Dwelling: . ,
Water Supply: Privatc: —�.� Public: Community:
Bedrooms:._._.�— Garbage Disposal --�
Basement ' �"�— Basement Fi "
INFORMA �ERTIFIED BY' �
$�t11C�lan: � � �j owner or resentative
REpAIR: REEVALUATION:
Size of Septic Tank: �aZ) gallons Size of Pump Tank: �-----
Nitrification Line: _� r � �3 �
Depth of Stone: 12 inches
Max Depth of Trenches: _'2 t� 3� +-r+ •
Altemative System: Conv. Pump LPP Pump
Remarks:
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Date Well Appmved: Well should be 100 ft� from any sewer system .
BY Sanitarian
Date S w e st ppmve • — —
By Sanitarian
�ERTIFICAI'E OF COMPLETION
Contractor. _ _ _,��o.,�_z!_f _ _ _
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'd
nitrif'ication 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 permit is subject to revocation.
(G.S.130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
P�rson County Health Department �
Well Permit �
Date' – Q�This Permit Void Aft�r ears
Owner:
Location/Direc ons:
Subdivision Name: � '
Drilling Contractor:
WELL CONSTRUCITON
Distance from Nearest Property Line Distance from
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s�'/�.�—
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Source of
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Pollution t""� . - cP
Total Depth: G Yield: � GPM Static Water Level ' FG �
Watet Bearing Zones: Depth �r�_ FG F�
Casing: Depth: From �_ to .7L. FG Diameter: Inches
TYPE: Steel Galvanized Steel
ff Steel, does owner approve: Y� No
Weight Thiclrness: � Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: ''d
Grout Type: Neat S ement Concrete �
Annular Space Width �_ Inches
Water in Annular Space: Yes No
Method Pumped Pres Poured v
Depth: From � to F�
Materials Used: No. Bags Portland Cement Weight of 1 bag
Ibs.
If mizture (sand, gravrel,� cuttings) - Ratio: to _
ID Piates: Yes V No
4 x 4 slab Yes �— No
I HEREBY CER'TIFY THAT THE ABOVE INFORM{�TION IS CORRECT AND THAT I
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY H�H (J$PAR7�714Fs?i'T. /j
Signanue of Contractor
Date
Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
'ATOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, 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. '
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