A28 83.� y
Person Count
Sewage System
Date: ��� � � Thi* ermi�t„V
Owner:
Location/Directions:
t );'!
y Health Department
Improvements Permit
5 Years /���
.�►,/ � SR# �_
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Subdivision Name: Lot #
Lot Size: �,� �� � j� �' Type of Dwelling:
Water Supply: Private: _� Public: Community:
Bedrooms: Garbage Disposal
Basement Basement �xtures .
eINF�RM/�j,' �,��D B� oµner or representa/ tive
dl ll !I
. .
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ALUATION:
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Size of Septic Tank: _�� gallons Size o�mp Tarilc:
Nitrification Line: ,��C� �,�?
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemacive System: Conv. Pump LPP Pump
Remarks:
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Date Well Ap roved:3'"�' `�a Well should be 100 f� from any sewer system
BY � Sanitarian
Date ge ys Approv • 3�-r'',� o
BY Sanitarian
CERTI CATE OF COMPLETION
C`nntractnr �. � n w,� � r -
�
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-- - — -- - — _ �
Sewage System location, installation, and protection must meet state and lceal �
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'icaaon 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 9
the site plans or intended use change this pennit is sub,ject to revocation. �
(G.S. 130 A-335F)
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L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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NOTE:'��;Make sketch of installation showing lot size and shape, location of house, septic
suppli'es, etc. Note special problems existing on lot. Write in measurements in order that insta
at later date: Note location of water supplies on adjacent lots. `'�
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��:� _..`_..- ; t ` _M �r� . � � �- ��.,,, ���jf, ��, �j��- i �S�
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privies, water
may be located
* Person County Health Department
Well Permit
DATE ISSUED: �/`� / DATE
OWNER:
ADDRESS:
DRILLZNG CONTRACTOR:
ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth• Ft. Yield:�_GPM Static Water Level Ft.
Water Bearing Zones: De th �Ft. Px./�._ Ft.
L�.7'Q-
Casing: Depth: From to Ft. Di ter:�Jr �_Inches
TYPE: Steel Galvanized Steel�
If Steel, does owner a Yes No
Weight: Thickness: � Heiqht Above Ground: Inches
Orive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes_No_
If 'yes' give reason: /
Grout: Type: Neat S Cement Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
Hethod: Pumped Pr@�y �e Poured /
Depth: From to LlJ Ft.
Materisls Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, �gr} vel, cuttings) - Ratio: to
ID Plates: Yes C/ No
4 x 4 slab Yes� No
DRILLING LOG
De th
From To Formation Descri tion
�T� ��� r�a��
�
I HEREBY CERTIFY THAT THE ABOVE INFL)RMIITION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED ZN ACCORDANCE yii�TH REGULATZONS SET �ORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PEf�tIkf1VOE� AFTHF�ITHREE/fsaxs.
of C nt ctoat 1 Date
V
I 1///,
's gn ture Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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