A29 84�J� Person Co
unty Health Department
Sewage System Improvements Permit
Date: - ' This permit V'd After 5 Years Permit #�� � D 3 y
Owner.
Location/D'uections: _ _ . w S�# %%�
Gz-o .
Subdivision Name: . ' Lot #
Lot Size: 1�`� �a � yP Type of Dwelling:
Water Supply: Private: ._� p�blic: Community:
Bedrooms: 3 Garbage Dispo _
Basement Basement F' s • �_
INF�RMATION CERTIFIED BY
Environmental Health Specialist: o or repres �t �e
�P�� REEVALUATION:
Size of SeptiC Tank; ��� g�ons Size of Pump Tank-
Nitrificadon Line: f � ' --
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pamp
Remarks�
Date Well Approved; Well should be 100 ft from any sewer system
BY Environmental Health Specialist
Date S ge y pprov _ S�/ 3-�i y
BY
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Envuonmental Health Specialist �
� C�R CATE OF COMPLETION
Contractor. __ I� „ � � �.
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Sewage Systein location, installation, and protectiom m�st meet state and local �
regulations, Septic tanlc 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 hazazd. Septic tank and
nitrificahon line must be inspected and approved by a member of the Person Counry �►
Health Department before any portion of the instai]ation is covered and put into use. If ^'�
the site plans or iiitended use change this permit is subject to revocation. �
(G.S. 130 A-335F)
Location of sewage disposa] sewage system sketched on back.
(OVER) .
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Person County Health Department
Well Permit
This Permit V,oi�i After �5 Y
Owner.
Subdivision Name: � -
Drilling Contractor:
WELL CONS UGTION
Line Discance from Source of
Distance from Nearest Property �,��s�aS ,.,. .
Pollution 6 J �s
Total Depi�� Ft. Yield:�_ GPM Static Water Level�-Z Ft
Water Beanng nes• Depth �_Ft. F�. F� ��-
Casing: Depch: From�_to�� Ft. Diameter: 6%• Inches
TYPE: Steel Galvanized Steel ��—�—
If Steel, does owner approve: Yes No
Weigh4��'��� Height Above Ground:�v Inches
Dtive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes N— o�—
If "yes" give reason:
Grout: Type: Ncat SandlCement �� Concrete
Annular Space Width 2 Inches
Water in Annulaz Space: Yes No �
Method: Pumped Pressure Poured
Depth: From b �.—.'e�` �F� '
Materials Used: No. Bags Portland Cement Weight of 1 bag�lbs.
ff mixture (sand, grav�e , cuttings) - Ratio:� to�_
ID Plales: Yes_ �/,G No
d Y d clab Yes _ No
' I HEREBY CERTIFY THAT THE ABOVE INFORMATIOAi IS CORRECT AND THAT c%
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTCH RECULATIONS SET �.
' FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �
_,����^ ���1/lc�t f' � ,'7 � ��D �l � �
Si rc f Co act r Datc A\
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anitarian s Signat e Da[e Iss ed . p�
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Sanitarian s Signature Da[e Completcd
Sketch well location on reverse side.