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PERSON COUNTY-HEALTH DEPARTMENT
WELL SEWAGE SITE, LOCATION Il�IPROVEMENT PERMIT
Tax Map # � Parcel # a � -
Zoning Township
Owner/Contractor ' Date
catio,�/Address - {��t�- G��
�
, Y�r �r�'� �_ G� �' � S.R#
iihriivici � ., � � _ ...ii. � . .nt� .
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� SEWAGE SYSTEM SPECIFICATIONS
Repair �, Lot Area Size of Tank
SFD °�-�`-' Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line '
Max Depth Trenches ,�,
Pemut Void after 60 months.; Permit Vo'd if not in compliance with zoning regulations.
Permits t��y be voided if site is altere q i n d u changed
Well and Septic Layout by ��
Comments:
Date � Installed by Approved by
� " WELL SYSTEM SI�ECIFICATIONS
Individual Semi-Public Required Slab -
Public Replacement Air Vent �.
Site Approved Required Well Lo ;
Well Head Approved Well Tag
Grouting Approved
- Comments:
Date - Installed by -- Approved by
7ius report is based in part on inforcnation provided the fiomeowner or hisJher representaGve in the application submitted for this pennit 'Ihe
rnvironmental health specialist is not responsible for faise or misleading information contained in the application 'Ihe environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the environmrntal health specialist warrants that the septic tank system will
continue to function satisfactorily in the future or that the wata supply will remain potable. c:�amipro�pertnitsam O1/95 rov.1.0
OWNER
S7e�'►ti
�
i'1?It:;ON COUN'I'Y r;NV.LKUNMLN'1'�il., III:AI:I'll
WI�,LL LOC
Date:.�����'
�
Owner: —�.�. _, � � � � d�' L SR# � .
Location/Directions: - � � _ __
�;;�,_':visioi1 N�u»c:
Drilling Contractor:
Lot ��
WELL CONSTRUC'�'ION
Distance from Nearest Propc:rty Linc 1_,- �h..� List.�nce from Source of
Pollution_,,%D �
Total.Dep.th: �'� Ft. Yield: d GPM Static Water Level Ft.
Water Bearing Zones: Depth T°`/� .Ft. Ft. Ft. �t.
Casing: Depth: From �_to_��Ft. Diameter: �� Inches
TYP�.; Stecl � Galvanized Ste�.:l
If S teel, does owncr approve: Yes I`� o�
' Weight: /� Thickness: 1 R'�.Hcight Above Ground: � z Inches
Drivc Shoc: Ycs No • �
i
Wcrc Problcros Encountcrcci in Sctting the Casing? Ycs No � �
T /`
at 'ycs' give rcason:
Grout: Type: Neat Sand/Cement � Concrete � �
Annular Space Width 3 Inches
Water in Annular Space: Yes No �
Method: Pumped__ Prc;ssure Poureci ✓
Depth: From �_ to �-o rt.
Materials Used: N�.�. Bags Portland Cement_ � Weight of .l ba� 9"� lbs.
If mixture (sand, gr<ivel, cuttin�s) - Ratio: �_ to �
ID Plates: Yes ✓ No � � � .�
4 x 4 slab Xcs�_ No
I HEREBY CERTIFlr THAT THE A,BOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTEll IN ACCORD�INCE WITH REGULATIONS �SET
FORTH �3Y-T�-IE PEI�SON COUN'T'X I�IE.�LTH DEPARTMENT.
, �
���-- � `-�'�— _-__ . ---- � ' �� ��
Si�naturc <�f C'c>ntr�ctor Datc .
�
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The Dis�trict Health Department
Oraage, Persoa, Caswell, Chatham, Lee Counties
SEPTIC Tee►NK PERMIT
DatP ,, -"- .1,.'� '�' ►:, � �' � �
�� �
Name of owner: ,��.��� � ��' ��� �?'6 � � �'7 �
�`+
Name of contractor: �� � i
Address and Directions "x" �`'d�- p ==� ���`�,
�; R� ry � �� .+�� �'1� ��.U; l f � � �'"
�
Person or firm doing installation:
Address � '�'
No. of persons to be servecL Bedrooms 1,� 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine � �� � P.
. �/
Recommended• Septic tank °� �� 4�� f �
p�� � i � � �
Nitrification line: �„ �'��• �.�-� r � a �+ ,
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the Disirict Health Depaztment s3aff before
any portion of the installation is covered.
Da proved: �-,;��'—� �
Signe�
� Sanitarian
By'
O. David Garvin, M.D., M.P.H.
District Heaith Officer
Couatersigaed
(Over)