A29 109.., '
. � SEWAGE DISPOSAL RECORD
_______�.(�197�_________________County Health Department
� �
�- �'�`y
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,� . T :_T___T______ _______ ;
Name.of Occupant_______�%(___�4�1�4¢W___�________Location of Building__���________ _____ �1.��'c'0
. �/
Name of Owner-----------------------------------------------W--------C-------- Date of Installation-----------------------�'----------------------------
Type of Privy Constructed---------------------------------- umber------------------------------ ,.�,� ,...���Nw==��---
--------�------------------
,/j � �- .
Septic Tan�____ ___- ��_ ______ Date Inspected______'/�_�__ �________ Permit No.______________ Capacity__� S_ �____
(c crete, metal,�etc.)
Number of Users_______________'_/___________________,__ Type Secondary Treatment __________________ ,-___ ___
Source of Water Supply______ _ _________________�e''�'
- --------------------------------- Address ----------------- -- -------------------------------------��
Contractor or Plumber___________ �-_! _ • � –
Approved by ------�.���'� ----------------------------- ---
-- -----------------------------------------------------------------------------------------
Remarks---------------------------------------------------------------------------------------------------------------- (Over) ---
N. C. STATE BOARD OF HEALTH 10M 8-40 FORM NO. 207
NOTE: Make sketch of installation showing location of hoizse, septic tanks, privies, water supplies on adja-
cent property, etc. Write in measurements in order that installations may be located at later date.
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W�� ���-�`� ��- A 0 01 1 9 8
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�- ' � PERSON COUNTY HIJALTH DEPARTMENT
WELL E1ND SEWAGE SITE, LOI;ATION IlV�ROVEMENT PERNIIT
Tax Map # �� o� �f Parrel # ( O�j
Owner
Location/Address
ovvnsmp
/Contractor �,l ,�P✓� �'► Date
Subdivision Name
l � � SEWAGE SYSTEM SPECIFICATIO �
[�epair Lot Area t S Size of Tank
SFD Mobile Home Size of Pump T
Business # of Bedrooms Nitrification Lin
Max Depth Trenches
Pernut Void after 60 months.
Permits may be voided if s:
Well Layout by
Gomments:
Permit Void if nat in compliance with zoning regulations.
Date Installed by Approved by
�
WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public , Required Slab _
Public Replacement Air Vent
Site Approved � Required Well Lo�
Well Head t�pproved Well Tag
Grouting Approv,e� l� .,�� I l�/7 98 � _� ,
�
�- ' - ' ' ' �'��pp y
Date . Installed by �N •u , roved
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pecmi� The
environmental health specialist is not responsibie for false or misleading infoanation contained in the applicatioa The environmental health specialist
is also not responsible for concealed conditions on the property or for stai.ements in this repoR that may have resulted from fatse or misleading
statements provided to him in the applicatioa Neither Pecson County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily n� the firture or that the water supply N711 remain potable: c:4vnipto�permitsam Ol/95 rev.1.0
r� .
P�RSON COUNTY ENVIRONMENTAL H�ALTH
WELL LOG
Date:.� �_-�� -I�JJ�I .
Owne:: �� ���2Y�' � 2 � �
Location/Directions: Q O 6 .
Subdivision Namc: ,a
C � ntractor•
�
L�t �
Drill�g ° � � WELL CONSTRUCI'ION
Distancc from Ncarest Properry Linc _ Distancc from Source of
Pollution
Total.�ep.th: � Ft. Yield: 2� GPM Static Water Level FL•
Wat�; Bea::ng Zo�es: �JeFth _ Ft. Ft. F�_ �t.
� Diameter: � Inches
Casing: Depth: Fr�m � to �
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes NO------- Inches
Weight: __ Thickness: • � 'Height Above Ground:______
Drive Shoe: Yes No . -----
Were Problems Encountered in Setting the Casing? Y�S - No_______.
;, "ycs" givc rcasor�:
Grout: Type: Neat __ Sand%Cement Concrete
Annular.Space Width 1�.—�ches
Water in Annular Space: Yes _ No_
, Method: Pumped � Pres2O Poured �=
Depth: From � to Ft.
Materials Used: No. Bags Portland Cement_______ Weight of .1 bag__._..,_.lbs.
If mixture (sand, gravel; cuttings) - Rauv: to _ .
TD Platcs: Ycs � — No _
4 x 4 slab Yes ✓ No _
I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SE'I'
FORTH BY•THE PERSON COUN'I'Y HEALTH DEPARTMENT.
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Signat��re of Contract � atc