A29 145� . Person County Heatth Department
Sewage System Improvements Permit
ate: -��� This Pennit V.oid Afcer 5 Years Permit #�
�wner: /E��[�
:.ocation/Directions:
SR#
5ubdivision Name: Lot #
Lot Size: �, ����.L �� T of el '
Water Supply: Private: ��: Community:
Beclrooms: `3 Gazbage Dispo
Basement Basement Fix�es
ONTICf Of
z _ _. ____ _ __. -�_.;:_;
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REPAIR: V — — —�� REEVALUATION— — — — — — — — — — —
Size of Septic Tank: -,�� Sallons Size of Pump Tank:
Niuification Line: �//7/) � � 'Z ' �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
— — — — — — — — — — — — — — — — — — — — — — — — —
Date Well
BY
Well should be 100 f� from any sewer system
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BY�" -i/� . 1l '� • Sanitarian � ' I
, TIFICATE OF COMPLETION ,..3
Contrac[or. � �
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Sewage System location, installation, and• protection must meet state and lceal �
regulations. Septic 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 hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Deparunent 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.ocatian of sewage disposal sewage system sketched on back. /y �C �
(OVER)
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. Person County Health Department �
Well Permit � �
Date: -� I-`ll This Permit Void After 3 Y �� �/J �
Owner. G c� ,.�ti„T vPns �uY� SR# � l! �
LOC8t10I1/DIICCt10I1S:
• �
Subdivision•Name: . �" t #
Drilling ConGractor -
WELL CONSTRUCI'ION ►�
Distance from Nearest Property Line Distance from Source of �'
Pollution 1� �
Total Depth: t Yeld: 1 GPM Static Water Level F�, �
Water Bearing. Zones: Dept� � F4 ::,F� F�
Casing: Depth: From _S`� to Ft Diamety� Inches
TYPE: Steel ' Galvar►ized Steei.✓
If Steel, does owner approve: ! No
WeighG ThiClmesS: � Height Above Ground: Inches
Drive Shce: Yes No
Were Pmblems Enwimtered in Setting the Casing7 Yes No
If "yes" give reason• / ►d
Grou� Type: Neat � S Cement Concrete �
Annular Space Width Inches �
Water in Armular Space: Yes No
Method: Pnmped Press paured �
Depth Frnm � to Fc
Matecials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
� M1Xh1fC �SSiI� �'dVf.ir CIIIhT1gS� ' RaL10: [p
ID Plates: Yes � No ,.b
4 x 4 slab Yes � No cn
I NEREBY CERTIFY THAT THE: ABOVE INFORMATION IS CORREGT AND THAT
TFIIS WELL WAS CONSTRUC'I'EDI� A�CCORDANCE WTTH GULATIONS SEI'
FORTH BY THE PERSON COUNTY �I�AL,'�HIDEPAiMI'MENT_�
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Sanitarian's Signatuze
Sketch well.loca�ipn;on reverse side.
� Date
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Date Issued
Date Completed
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