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PERSON COUNTY HEALTH DEPAftTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT
1270
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �) -�n Parcel # 10 �
Zoning Township o �
Owner/Contractor t?as co� J�a �� � S Date z �:
Location/Address y9.s i/� f�.4 S S- L C N� �rv,�l �� L� ; o�✓ z�G'� j
S.R.# / /3�3
SubdivisionName ��A;���E �tALo�it Lot# ,�
SEWAGE SYSTEM SPECIFICATION3
Repair Lot Area I, oc� A� Size of Tank /� �A�
SFD Mobile Home ✓ Size of Pump Tank �1f,4
usiness # of Bedrooms_ ?_ Nitrification Line yo� ' u.�� �
Max Depth Trenches �a •'- ��''
Permits may be voided if site is altered or intended use
Well and Septic Layout by �'�,.,�Q /_'� �'�.��1��
Comments: �o "- zy�' ,�a,t T,�c �/c,y
te Ia� - 6 Installed by �. ���i5 Approved
ell Permit Paid WELL SYSTEM SPECIFICATIONS
Individual �/ Semi-Public
Public Replacement
Site Approved
Well Head Approved � � �
Grouting Approved ✓ � � �
Comments:
Date
Required Slab cC
Air Vent ! f � L
Required Well Log _��C _
Well Tag �� C L
Installed by k�. i y.d.�,�� r� Approved by
This report is based in part on informatioa provided the homeowner or his�fer
representative in the application submitted for this permi� The environmental
health specialisi is not responsible for false or misleading in%rmation
contained in the application. The 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 environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:lamipro\permi�sam O1/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: 9 Z y- y6 IlVIPROVEMENT PERNIIT #: �/Z 7�
TAX MAP #: ,�� PARCEL #: t O
OWNER/OWNER'S REPRESENTATIVE: �oSfot /tAR�J 5
LOCATION/ADDRESS:
�ys � /� �� ���.�c .�z��,�e •�1� _ . Ld%
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SUBDIVISION NAME: /��/.4 /? L� r !3 L t� � o��� LOT #:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION IS UED BY:
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AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation'must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #,g /2�0. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
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Person Requesting:
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SE P 1 1 ' 96 1 4: 33 5 1�a5�73.�b7 PAGE . uU 1 �•-`` ^`
PERSON COUNTY'ENVIRONMENTAL HEALTH
WEIiL LOG
Date: /a?- 9 - 9G '
Owner:
Location/Directions:
Subdivision N�vne:
Drilling Contractor: _
SR#
Lot # 3 -
Distance from Nearest Property Line 5�0' Distance from Source of
Pollution ICaG ' '
Total.Dep.th:� /ad Ft. Yield: o2Uv GPM . Static Water Level �5 Ft.
Water Bearing Zones: Depth ��Ft. Ft� � Ft� �t.
Casing: Depth: From��to //� Ft. Diameter: lfl /� Inches
TYPE: Steel - Galvanized Steel `-
If Steel, does owner approve: Y�s No
� Weight: 'Thickness: /� Height� Above Ground: /�/ Inches
Drive Shoe: Yes_� No .
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give r�ason:
Grout: Type: Neat SandJCement � Concrete
Annular. Space Width Inches
Water in Arulular Space: Yes No
_ .. Me.thod: Pumped . _ Pr�ssure � Poured /�- . � - - = -
Depth: From O to o2c� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 COiliJTY HEALTH DEPARTMENT.
� � 1l� �-�
ignature of Contractor � te