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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 # ��� Parcel #_
Zoning Township
Owner/Contractor _ F'�
Location/Address �-4 R S
' " ' S.R.#
Subdivision Name W; I�p � L4 �� Lot# 1�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �, Lr 7,q C Size of Tank ���C�-QQ
SFD �� Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �(� `�3 �
Max Depth Trenches �' �
Permits may be voided
Well and Septic Layout 1
Comments: ��,��
Date �]-7.� -�j$ Installed by,
is altered o� i�t�nded use changed.
Approved
� Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual_�S emi-Public
Public Replacement
Site Approved ✓
Well Head Approved ��
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Grouting Approved �
Comments:
.•
Required Slab ��G
Air Vent �J
Required Wel Log �
Well Tag C�
�vdl/9�o�� � B--
Date 7�-�j�Ej� Installed by1� r np-��P Approved by.
This report is based in part on information provided the h�meowner or his/her
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 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:\amiprolpermit.sam O1/95 rev.l.l
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AUTHORiZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: 'i -� O-�� IlviPROVEMENT PERMIT #: a Z
TAX MAP #: : PARCEL #: � 'S
OWNER/OWNER�S REPRESENTATIVE• � Q,("�e s �,U � �
LOCATION/ADDRESS:
SUBDIVISION NAME: � � ) ` � � �� �Q. � � LOT #: c
SECTION ORBLOCK:
. AUTHORLZATION FOR COI�ISTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and instal[ation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #�a��Z The
construction and instaltation must also meet all applicable ruies and laws.
2. No portion of the Wastewater system shali 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 st�ucture 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 pecmits.
4. Conditions:
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PERSON COUNTY ENVIROtIMEHTAL HEALTH '�
WELL LOG
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Date: ' � �
Owner: .C' �(a�F s �a�lTs � SR#
Location/Directions: �"�_��. � s ►n-r A�o�� � y�
.. �� .... � L-.-..-- �---" — • — ---- — .
Subdivision Narrie: __(�--, , � c�c t>
Drilling Contractor: ���E��,
Lo t # ----
WELL CONSTRUC"I'ION `
Distance from Nearest Properry Line �p Distance from Source of
Pollution_�pcS '�
Total Depth: 7oa _ Ft. Yield:_�p______ GPM Static Water I.,evel�_r_�^�_Ft.
Water Bearing Zones: Dep[h� �o �{ F� Ft. �r,
Casin De th: From � to`�� + i ---
g� p ��_Ft. Diameter:_�� Inches
TYPE: S�eel - Galvanized Steel ,/'
If Steel, does owner approve: Yes No
Weight: Thic�:ness: l�8 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 Sand/Cement �'' Concre[e
Annular Space Width Inches
Water in Annular Space: Yes No
_ . Method: Pumped . .. Pressure � Poureel /� - �. � � �. � : .
Depth: From c� co Ze� 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 �
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT ArID TH AT
T�S WELL WAS CONSTRUCTED lN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Vi1T'Y HEALTH DEPARTMENT.
ignaturc of Contractor Datc
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