A28 76_. Person County i�ealth �Department .;
� Wei1 Permit �
Date:_�' ���Th Perm't Void After 3 Years �� ;..
Owner: / v r� t o�" ��C �.� ,� SR# ��
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Locatio n/D irections:
Subdivision Name: L'0
- ---- -- - ----_ �- . 91 -- �
Distance from Nearest Progerty Line Distance hom Source of
Pollurion� '
Total Dcpth: � Ye1d: �GPM Stade Water Lcvel FL
Water Bearing 7.ones: D �--� F�. FG F� t.
Casing: Depth: From ���-- F� D iamet� I nches
'TYPE: Sceel � Galvamzed Steel _
If Steel, does owner apptove: No
Weight: Thiclmess: � Height Above Ground: Inch�
Drive Shce: Yes No
Were Problems Encounteted in Setting th � ing? Yes No
�i' "yes" give reason:
Grour. Type: Neat ement � — Concrete
Annular Space Width � �ches --
Water in Aru►ular Sgace: Yes No
Method: Pumped Press e Poured/
Depth: From � i0 F�
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand. gravgl� cutur►gsi ' Ratio: �
ID Plates: Yes �� _ _____ No
d: 4 slab Yes � No
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I HEREBY CERT'ffY THAT THE ABOVE n�oRM^TjoN Is coRRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIUNS SET
FORTH BY THE PERSON COUNTY H�� �EPA��T �_' i � I,�-.�.,.
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Ske h we�tion on reverse sids.
anitarians Sign�re Date Issued
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g 'ans ignature ate Completed i
,4 NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special probiems existing on lot. VVrite in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Person County Health Department
Sewage System Improvements Permit
Date: ��� ' Permit Void After 5 Y Per�nit #
Owner: .' A�,i�._� � _ r� � �+ �1 SR#
Location/Directions: ��-
Subdivision Name: 1 G� JrG n Lot #�r�
Lot Size: Type of Dwelling: � u �
Water Supply: 'vate: Pu ic: Community:
Bedrooms: �` ii'az ge �D i sal�.��
Basement Basement Fixtures � �
INFORMA'I�Q�1 D BY �
$���: �t f � . owner or represaitative �
REPAIIt: REEVALUATION:
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Size of Septic Tank: allon� Si�e of Pump Tank:
Nitrification Line: t �
Depth of Stone: 12 inches
Max Depth of Trenches: �
Altemative System: Conv. Pump LPP Pump
Remarks: �
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Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sewage Syste Approved: �Z–Co-41
BY � ��- Sanitarian
CERTIFTCATE OF COMPLETION
Contractor. T,`.n�,►� L.z,r,.,,;s
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Sewage System location, installadon, 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
nitrification line must be inspected and approved by a member of the Person Counry
Health Department before any.portion of the installation is covered and put into use. If
the site plans or intended.use'change this pernut is subject to revocation.
(G.S. 130 A-335F)
L,ocation of sewage disposal sewage system sketched on back.
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