A29 106� z
Person County Health Department �
Sewage System Improvements Permit �
Date: �fZ `This Permit V
Owner: �a n � i ��-�*�
Location/Directions: �,-�—
1 After 5 Years
�9S' SR#
Subdivision Name: � - Lot #�
i
Lot Size: Type of Dwelling: .�
Water Supply: Private: Public: — Community:
Bedrooms: 3 Garbage Disposal �
Basement Basement Fy� ures
INFORMA D B � �� B� A� < 1� �'.�L2�.--
$�1��: oaner or representative
REPAIR: REEVALU N:
Size of Septic Tank allons Size Pump Tar�:�_
Nitrification Line:
Depth of Stone: 12 inches �
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian
Date S e ys Approv -%
BY Sanitarian
CERTI�TCATE OF COMPLETION
Contractor. �,.'� ,Nl c� v�, �� s'a � c
------------------------- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Sepuc tanlc 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 hazazd. Septic tank and't3
niuification 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 pernut is subject to revocadon.
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back. \
(OVER) �
C����' `���, � �- �Y C�
i �
�
� 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
at later date: Note location of water supplies on adjacent lots.
�� �1� (2)
• 3
Person County Health
Weli Permit
Date:�� -I-�O This Permit Void After 3 Years
Owner: '� n n r► i P i'i n�,.�,, p<
Subdivision Name:
Drilling Contractor:
Department �
�
SR# I�'7 % �
i� cn� i�� rc+��.l
�_i.1C�'''JJLOt#
WELL CONSTRUCiTON ►b
Distance from Nearest Property Line Distance hom Source of P�-'
Pollurion 20 ;�,
Total Depth: . Yield: GPM Stadc Water L,evel Ft �
Water Bearing Zones: Depcj� F��Ft Ft.�
Casing: Depth From _�_ to � F� Diarpetg�: Inches
TYPE: Steel Galvanized Steel✓
If Steel, does owner approve: No
Weight: Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: �
Grout: Type: Neat San��ent Concrete
Annular Space Width Inches
Wacer in Annular Space: Yes No
Method: Pumped_� Pr�� Poured �
Depth: From _�� to
Materials Used: No. Bags Pordand Cement Weight of 1 bag
lbs.
ff mixture (sand, gra�, cuttings) - Ratio: to _
ID Plates: Yes No ►d
4 x 4 slab Yes —T�� No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN RD CE W�ITH REGU TIONS SET
FORTH BY THE PERSON COUNTY HF� D��►R'TM]�I�T. . �
of
Sanitarians Signature
Sketch well location on reverse side.
� Date
le � u
Date Issued
Date Completed
�
� NOT'E: Make sketch of installation_ showinglN'd{� e> and
,� supplies, etc. Note special problems existing on lot. Write in
'� at later date. Note location of water supplies o ��t li
� �µr����.�
�1� ., .. � � �
I I I I I I I (�v�F U 1��'e1 r I
location of house, septic tanks, privies, water
ements in order that installations may be located
:���+��-1�I��.� ��
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s��. ��.���: �
Name �-11►�., �' �- Tax Map # �12� Parcel # ���
L133 I'�9� �12..Z. � Section/Lot# �
� ' � ' 1 i-9-vc/
Authosize tate Agent . � � Date .
` System components re�r�esent ap�iroximate�contours only. 3'he contract�r muss',�lag the systesn prior to
begrnning the i�utallation to zrrsure thatpro�liergrwcde i.r maintained .
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Applicani
Location:
Improvement Permit
Permit Valid for 1�Five Years No Ezpiration
Type of Facility: New - Addition Water Supply J�'(�,�
# of Occupants # of Bedrooms � Projected Daily Flow ��� g.p.d. �
Proposed Wastewater System: . Type:
Proposed Repair: _�y/��,��f� ���' � /r �l-�� �*•r�r-c Type: .
i -
Permit Conditions:
0
Owner or Legal Representa ' Signa Date:
Authorized. State Agent: Date: G
The issuance of this pernrit by the Health Department in oes o guarantee the issuance of other permits. It is the responsi'bility of the
applicandpropezty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage T'reatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply w�l remain
potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�. �
Proposed Wastewater System: Type — Wastewater Flow '— g.p.d.
New Repair� Exp ion Soil LTAR: �,�iD g.p.d./ ft 2
Type of Facility: c9 �,,�C. Basement _ Yes �/No
� Wastewater System Requirements
� �j
. \
�
Size: Septic Tank: � ga1 Pump Tank: --' gal Grease Trap:
field: Total Area: sq ft Total Mazimum Trench Depth _
�h Width ft um Soil Cover: in Minimum Trench Separation:
ibution: Distribution Box Serial Distribution Pressure Manifold
_ , .
Specifications:
Authorized State Agent: �
Permit Expiration Date:
The type of system permitted is � Conventional
the permit.
Owner/Legal Representative:
g�
in
Date: /� d
�
0
�— Innovative ---Alternative. I accept the specifications of
Date:
PCHD7/30/2002
11-03-2004 09:51A� FRO�-BD BIOSCIENCE
+9196206201 T-i35 P.002/002 F-0T5
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D PROPH�TY L1I�1E9 At�1D C� YL3ST BE CLF,ARLY MARl�. •.
➢► THE PRC� �.00�7fON O� ALI. �1'R�I�TURF3 lIM1JST BE S'f'�►i�! I� Fl.�►C�• .
�'THB 8t1'E I�I,IS'T 8� RFA�LL.Y ACt�3S18l.E �Fi Jl1i Lsi1/AI.UATt�M BY'TH@ HEALTH DEPARTI�i�1T
ST1�F'f. . "
! he�ahy r� �� to it� Person CauntY He�lth Qeperlrn�rt i+or a sife �ort far tha ar� sew�ge d�
syst�n i�cr tri� �ov�-�� WnP�Y ��� �'�e �tts ot #�S aQp%iian a�a trus� atid repr+e�t tt�e m�x�urn
� tio !� ptac�t ort the proQ�ctY- i unde�tand �f th+e s�e ��ted �x the �ended t�se dtiange�, i�� P�t �
be�rq� inv�f- ��
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ow� ar l�ai R�rtie�tive
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ziz AnaC[85i6S 4f1�OFI I�zuawuoi�wug �c� uoa�od
SE�iiC �'}�Ad� 1N�P��'TI�N t����S'd' (T� !I - fV�
Tax Arlap-# Parc� # � � System Type (Table Va) .
Owne�IAQQ�icant Sui�division
AddresslLocation � SeclPt�ase � Lot # ' � , ,
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pcf�d rev. 3I13/01
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'�' �rn�a�r-�ms�.ir�rn.a��n�.�.� �'���za.v.��a
Applicant:
-Location:
Tax Map : i ` P�rcel # � —
Suibciivision
Ph�se S�ct:ioniLot #
# of Bedroorns
Operatio� Perr�it
System Type (ln Accordance With Table Va): —
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA� GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE 1MPROVEMENT PERMIT AND CONSTRUCTION.
AUTHORIZATION.
� 1�2.G -d�'
Aut orize State Agent Date
Installed By:_ �iY�g �DJ��� Date: _ ���s ' O�""'
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PCHD, rev. 07/29/04
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Applicani
Location:
T��x M�,� .i[/ � P�;rcel # / •
S�uhc1!ivi�s�ioia
F�h��•s_etSectioi1�1Lpjt r
Improvement Permit
Permit Valid for t� F've Years No Ezpiration
Type of Facility: v� New _ Addition � Water Supply _�_
# of Occupants --� # of Bedrooms _2 Projected Daily Flow � g.p.d.
Proposed Wastewater System:
Proposed Repair: I � nC�f'�-� �
Permit
Owner or Legal Representative Si
Authorized State A�en��
F�a�, if.���fi7�
�I��I�fC-l:
Type:
Type:
Date: � . �b � �
Date: / — � � d 5
The issuance of this permit by the Health Department in d�s not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement P,ermit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Const�uct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: /'�� �/iL�?t�� Type �r Wastewater Flow �.p.d.
New Repair � Exp ion _ Soil L� •`� g.p.d./ ft 2
Type of Facility: . vst Basement � Yes _ No
Wastewater System Requirements
' �c� : -t�Ci
Tank Size: 5eptic Tank: �� gal Pump Tank: -�` gal Grease Trap: -- gal
Drainfield: Total Area: DD sq ft Total Length �OO ft Mazimum Trench Depth r�,��
Trench Width � ft Minimum Soil Cover: ('o in
Distribution: Distribution Box �_ Serial Distribution
Specifications: / G��� ��p .! Go��3
Minimum Trench Separation: ft
Pressure Manifold
Authorized State Agent: a�.�G�� ��',GG'�y- Date: /— 7�5�'6 �
Permit Expiration Date: � � U /— �s ' /lU
The type of system permitted is Conventional Innovative Alternative. I accept the specifications of
the permit. ,
Owner/Legal Representative: Date: � �b °��
PCHD7/30 002
.
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Tag lYtap # b? Pa=cel # /6G�
�. Section/Lot#
/-� -oS'
� Date .
� System c�mponen�r represent a�broximate�contours onl�r. The arntractor must, fiag the system prior to
beginning ilie instaAatwn to insure thatpropergrade is »zaintained :
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