A30 1091
�
B 1264
� PERSON COUNTY HEALTH DEPARTMEN'T
�, WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT
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 # � 3 v Parcel # S
Zoning Township �3v r �a Y F� +� K
Owner/Contractor e�� �4 i�, ► � �/a � � c. � B�.A L o C.1� Date y/�� J_y �,
Locatio n/ A d dress 49 5 i,(1 l�A S S� L L HG �Z i a N � n �� �r � s
��.� �z ��- �-� -� s.x.# 113 8
Subdivision Name c N�► �Z ��i i�-�►Loc.� Lot# S�
SEWAGE SY3TEM SPECIFICATIONS
Repair Lot Area /, o€; ,+� c Size of Tank ic�`- �' �a c.
SFD Mobile Home +� Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line r,�c� ` x 3'
Max Depth Trenches 2�''
Permits may be voided if site is altered or intended use
Well and Septic Layout by /�� ���i�
Comments: 2�" . n�w x T,e�n► ���- D � i
���Tou � F! - o �� �
Date � � Installed by �'r MM �/ CF✓f
by
� t� FT. Gc>� N�
o � i — c.
Well Permit Paid �� WE L SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab ✓
Public Ijeplacement Air Vent v� _
Site Approved t/ r�P Required We11 Log
Well Head Approved w�� Well Tag ✓ r�-�P
Comments:
Date i l-27-� {� Installed by �,c ne�tf? Approved by
This report is based in part on information provided the homeowner or his!'6er
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
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 misleadiag 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:\amipro\permi�sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void si�cty (60) months from date of issuance) ,
DATE: ,S" �,�7�9 6 IlVIPROVEMENT PERMIT #: �/� y
> >
TAX MAP #: �J36 PARCEL #: �
OWNER/OWNER'S REPRESENTATIVE: �i-� A/z�� ���L� cE ��� Lo G<
�
LOCATION/ADDRESS:
�9s T/G. ciV s1�t sf Ecc. f�orzTd.�/ 2 a
,�
� Lo T /s o� ��G��
SUBDIVISION NAME: Gl�li.�R c � c-: 8�''¢ �-� 4� LOT #: s
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
�� � � __�
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 #—�4�� , y 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 permits.
4. Conditions:
�• rvl�!- Y TiZc � L' l3 T'�-P ✓J �� � ��b L f� L-! s.1 c�
�,� ��� ��z . �� � �� w.4- y � �S �
Ga.� e. i.v .4 c�,J c,�— �� �.�f �1�4.v� �o �
Person Requesting:
Nov-26-96 08:55A Barnette �ell Co. 910 599 0015 P.O1
' • PERSON COUNTY ENVIRONHENTAi. HEALTH • �
WELL LQG
Date: �/ -as-�'G '
Qwner. r �+ �-
LocationJDirections:
SR# J/3� ' � -
� _ �. r- . -
Subdivision �Name: ._ �, ��1�.___ Lo[ # cs'
Drilling Contractc�r: ���nY�� • � ��' ,t.�/I..�. �rG4j� ~�
���
--�.
Distance from Nearest Praperty Line /o' Discance from Source of
Pollution /oo � '
Total.Dep.th:- / o Ft Yield: /�.c.f GPM Static'�iater Level a.s^' �t�
Water Bearing Zanes: Depth ��r Ft. /�3 F�. � F� �t.
Casing: Degth: From�_to ���Ft. I3iameter: C�� _ Tnches
TYPE; Steel - Galvanized Stee� �
If Steel, does awner approve: Yes No
� VJeight: Thickness: f�f Height�Above Ground: l5� Inch�s
Drive Sho�: Xes �-- No � .
Were Problems Encauntered in Setting the Casing? Yes No .r
XF "yes" give re�son:
Gr�u� Type: Neat SandJCernent i Concrete
Aru�tular Space VYidth Tnches
l�ater ir� Aimular Spa�e: Xes No
_ .. Method: Pumped - Pressure F�urad ,i- . . -
Depth: From � �o �,� �t�
IVlaterials Used: No. $ags Portland Cement Weight of 1 bag�lbs,
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plaies: Yes -� No � =
� 4 x 4 slab Yes i �to
I HEREBY CERTIFY THATTHE ABOVEII�lFORMrITIt�N IS CQRRECT AND THA`T'
THTS WEI..,I.,1�AS CONSTRUCTEll �i ACCORDA.NCE V�T�T'H REGULATIO�S S�7'
FC�RTH BY THE PER50�1 C�'Ji�ITY HEALTH DEPARTMENT.
9�� - -� -�4�� �
Sig aturc of Contractor �;�
Whitfield
3-328
-o -
o. , 9
� G• �
.
C�' i
— — —�
�pNTROL
CpRNER
. <
. „e:
N-79_ 5- 5_—
,
C 7. Blo�ock Est.
.. n r ` . � . ' . .
�''_ /
- 10d
vi� �,
, ?�► �.
� ��
� '1 1�' -/'� F� � w a