A30 90s .. - ..
Person County Neal�h Department
Sewage System Improvements Permit �
Date: -' �� is Permit Void After 5 Years -
Owner: ��� � P n SR# �'� �
Location/Directions:
:� ►t O . ?� ►.!1 Y ! �v�
Subdivision Name: Lot #
Lot Sizc: 3� S3 =� t-v os Type of Dwelling: �� � .
Water Supply: Private: 1� Public: Community:
Bedrooms: Z— Garbage Disposal �
Basement Basement Fixtures
INFORMAT�� R D BY -
$aIlll�iilc971:
� %, �� oa�ncr or repre tativ
REPAIR: � � REEVALUAT'ION:
Size of Septic Tank: _.���� gallons Size of Pump Tank: ----
Nitrification Line: � F� � X3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:
Well should 6e 100 f� from any sewer system
------- ---- ----------- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Sepdc tank 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 hazard. Septic tank and'd
nitrif'ication line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pennit is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
' (OVER)
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�
�' NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
. at la�,er date. Note location of water supplies on adjacent lots.
� (�) �r' ►�1��'� 1 �� � � ��� � �%�` (2> �
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Person County Health Department
� Well �errt�it
Permit Void After 3
Owner:
m
SR# � �-�d
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�
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Subdivision Name: Lot #
Drilling Contrac[or: ��L�-J1s— �c.-� t
WELL CONSTRUCi'ION 'd
Distance from Nearest Property Line � c� S Distance from Source of �'
Pollution �- t ;�
Total Depth:� Ft Yield: �_GPM Static Water L.evel `�_Ft �
Water Bearing Zones: Depth � FG��FG FG FG
Casing: Depth: From _Q_ co ��. FG Diameter: � Inches
TYPE: Steel ' Galvanized Steel t�
If Steel, does owner approve: Yes No
Weight: ..1�_ Thiclmess: �� Height Above Ground: �� Inches
Drive Shce: Yes �� No -
Were Problems Encountered in Setting the Casing? Yes No L,.�
If "yes" give reason: �
Grout Type: Neat Sand/Cement Concrete
Annular Space Width � Inches
Water in Armular Space: Yes No t�-
Method: Pumped Pressure Poured_j�
Depth Fmm /� to � Ft
Materials Use�: No. Bags Portland Cement _� Weight of 1 bag
�� lbs.
If mixture (sand, gravel, cuttings) - Ratio: �- to �_
ID Plates: Yes t/ No
4 z 4 slab Yes � No
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THI3"�ELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FQRTH BY THE PERSON COUNTY HEALTH DEPAR'TMENT.
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:,LL Si e o o r
�;` ���, /z �/
�t �./ tarians S' nature Date Issued
�, r ��/�"
��I�''J D "�'! '
/ Sanitarians Signature Date Completed
Sketch well location on reverse side.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots. ,
(1)
(2)
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B 2717
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 6een issued.
Tax Map # � .�� Parcel # �
Zoning Township /� , ��
Owner/Contractor �� ,� .�' �o �c�� � Date a� ' �� —
Location/Address .y'' eS. Lc�' o.� �d.ssc/ /�����
' d 6 v /���.#
s 6t/ i1 i-�� ou ���.1 i`..� L'U�uG �7�i.,�., i��•p/aec �
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,3. � r4c Size of Tank se� n�ew %a,v� %OGD qcs�
SFD a vs� Mobile Home Size of Pump Tank
Business #ofBedrooms�_ NitrificationLine J.�O' v� � ���
Max Depth Trenches �y `�
w � /%� .�%�.S v L �
V Permits may be voided if site is
� Well and Septic Layout by �
a COmments: SEe Sk.�.�
Date �9- i9 Installed by��
Wel mit Paid� WE�L SYS
�c��� ���5�� %/�,;�f s .f�cr+ , /
or intended use changed. y �
� /
� �/`'i Ur' Gt7�c�i iv.'vS a� ,�/'/h/�T,
��,n Approved by
EM SPECIFICATIONS �xiS�i �✓ y l✓-t lI
q 'red Slab
'r nt
equi ed W 1 L g
ell ag
Drate stal d by pro e�d 1 y ,
This report is based in part on info ation provided the homeowner 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:\amipro\permit.sam O1/95 rev.l.l
► .
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G
AUrHORLZATIOI�i FOR WASTEWATER SYSTEM CONSTRUCTIOI�I
(Void si:cty (60) monchs irom date of issuance)
DATE: �-�3"�9 IMPROVEMENT PE�'4�T K: � �7��
TAX M�p K: � 3� : PARCEL �: %O
OWNE�lOWNER'S REPRESENTATIVE: 1,e� d.�,'II G�vl��a,�
LOCATION/ADDRESS:
�95. .���'� o,� -�-l�ss�ll �-lo��a�, ��. ,�o �. o� ,��'�
i� CU�ve,
SUBDI�rSIONNAME: LOT �:
SECTIO,F ORBLOCK:
AUTHORZATION FOR CONSTRUCTION ISSiJED BY:
�,�
AUTHORLZATION CONDITIONS
� I'���.-�- �. �-(.5 , oN I� �- b� �« ,�si �.,U,�,�� �,.,o� �. .
1. The Wastewater system construction and instaIlation must meet aII of the conditions of the
attacE�ed site plan and specifications as set forth in Improvements Pernut ��27�7 . The
construc:.ioa and installation must also rneet aII applicab[e rules and laws.
2. No por`son of the Wastewater system shall be cavered or placed into use until inspected ane
approved by the Person County Health Department
3. Any alterations in site or soil conditions �inctuding structure Iocations) or modification in use
design wastewater IIow, or wastewatet characteristics as specified in the associated improveme:
permit and appiication, may void this aut[�orization and associated petmits.
s� �sx�.��� � .
4. Conditions:
_ .��� `���.=.� :
:! !�SL+ t �+C �' � ^�t'�{r`i'r'� - .�:� .
��r
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�st',�� S,eD�`ic �.c,vk, C���.s� Q�e' �Xectve�� �X�Sfi
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7"aN�. J� �" NPw T�s�� pg� S��c7`c�. %'S t�ar IJQSC�C
�7CG Q�Qi�T/ON� / �JL/ r p � G'(lai.v�NC �O�' Q�Ci,7'/O✓c � ���%�.
h. 1 � ' lTN�
SC `1 Q fJi aC v.vdG / Qn � uc s✓as/ R.,. c� D�/ I�l IIa r,� D� ��i°.et
o ve/ dar�S, /�L°j.�ai`� l�l,c � Sf�d�` 4� eNc/ o,� d�,i�,C;i.L�.
Pecson Requesting:_ . .__ _ _ _�__ Y.._ • .-----
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