A29 139, z
`� • Per�on County He�lth Department �
Sewage System Improvements Permit
Date:� �-I�-�Z�T"hi_s �P r"mit Void After 5 Years Permit #�1'�' ��� �
Owner: W�+�- �'-��1G/ (� W Aa � SR# _.l I1,!/
Location/Directions: ��
Subdivision Name: Lot # _
Lot Size: �.,�-f� G!'�'--r Type of Dwelling: �� �� -
Water Supply: Private: � Public: Community:
Bedrooms:.�— Gazbage Disposal �
' Basement Basement Fixtures �
INFORMATION CERTIFTTED BY arnG�—ZZ—
Environmental Health Specialist: � �* ��tacive
REpAIR; REEV UATION:
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Size of Septic Ttanlc: �� gallons Size of Pump Tank:
Nitrif'ication Line: N QD f X 3'
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
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Date Well Approved:
BY
BY��
Well should be 100 f� from any sewer system
Environmental Health Specialist
Environmental Health Specialist
"` " - ` ' ,�ERTiFic;A'fE OF COMPLETION ,.�
Contractor. � : r"� ° � � c �
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�
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank azid
nitrification line must be inspected and approved by a member of the Person Counry
Health Deparunent before any portion of the installation is covered and put into use. If �j
the site plans or intended use change this petmit is subject to revocation „�
(G.S.130 A-335F) �
L.ocation of sewage disposal sewage system sketched on back. �
(OVER)
` � _, �; - ,
�''. �erson Coun�ty Health Department �
Well Permit �
�Date: - � 2 This Permit Void After 3 Y
Owner. � Cti � (�_Q+� SR# �
Locadon/Directions:
Subdivision Name: Lot #
Drilling Contractor. !�i! ,� r, s i,�) ��
WELL CONSTRUCi'ION
Distance from Neares Propaty Line��c Distance from Source of
Pollution s
Total Depth: �(ZFG Yield: �GPM Static Water I.evel �Ft
Water Bearing Zones: Depth $�_ Ft � Ft. Ft. Ft.
Casing: Depth: From � to �'� FG Diameter: � Inches
T'YPE: Steel Galvsnized Steel ✓
If Steel, does owner approve: Yes No
Weight: ��_ Thiclrness: �[$C Height Above Crround: �_�--inches
Drive Shce: Yes / No
Were Problems Encoimtered in Setting the Casing? Yes No.�`
If "yes" give reason:
GrouG Type: Neat Sand/Cement � Concrete
Annular Space Width .3 Inches
Water in Armular Spacc: Yes No�-
Method: Aunped Pressure Poiaed ��
Depth: From n to ___�_�__ Ft
Materials Used: No. Bags Pordand Cement �_ Weight of 1 bag
_ ���lbs.
If m' (sand. gravel. cuuings) - Ratio: a— to �_—
ID Plates: Yes � No
4 z 4 slab Yes �� No
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
_ FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
,�.n, . , . �, �,
l�� i� ��I:�,,..:��►.►
�. , .
Sanitarians Signature Date Completed
Sketch well locadon on reverse side.