A31 142�
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f.-�' Person County Health Department �
Sewage System Improvements Permit
Date: � �ifiis Permi� oid After 5 Years Permit # �'� � �
Owner: SR#
Location/Directions: �
Subdivision Name: �'� t # �-�
Lot Size: � Type of Dwelli g: ��.-n
Water Supply: Private: � Poblic: Community:
Bedrooms: � Garbage Disposal
Basement Basement Fi s ? .. �
INFORMATION CERTIFIED Y ,�_�
Environmental Health Specialist: e r�e"c�ti°e
REPAIR: REEV A ON:
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Size of Septic Tank: �� �gallons Size of Pump Tank:
Nitrification Line: T � `E,�3
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: e ,
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Date Well Approved: �`� Well should be 100 R fmm any sewer system
BY �� Environmental Health Specialist
Date a S ste App �- � 2� �`'{
BY ` Environmental Health Specialist
CATE�COMPLETION ,.�
Contractor: '� �
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic 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
nisification 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)
I.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
�}.�;upplies, 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.
-Person County Health Department
' Well Permit
�s ���"W 2 is Permit Void Aft r 5 Years
, �vner. �'� r � � SR# �%Z
Location/D'uecdons:
Subdivision Name:
Drilling Contractor:
Lot #
�� W bLL l.lJ1VJ 1 KUl.11V1V
Distance from Nearest Property Line /,�[�Distance from Source of
Pollution,� b� 3
Total Depth:�� FG Yield: a a GPM Static Water Level Ft
Water Beazing Zones: Depth �o �) Ft.��Ft FG Ft. _'
Casing: Depth: From�_to�� Ft. Diametet � Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve: Yes No
Weight:_�_ Thickness• eight Above Ground:_��—inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Annular Space: Yes No �
Method: Pumped Pressure Poured �--
Depth: Fmm [7 to F�
MateriaLs Used: No. Bags Portland Cement t Weight of 1 ba�9 y ibs.
If mixture (sand, gravel, cuttings) - Ratio: ,� to�_
ID Plates: Yes ✓ No
4 x 4 slab Yes t/l�o
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET �
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. ;�
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S' a e of on actor Date
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anitarian's i nature Date Issued
Sanitazian's Signature Date Completed
Sketch well location on reverse side.
r
E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
lies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
1Gc�ted at later date. Note location of water supplies on adjacent lots. �
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Site Evaluation Application
y Fee Collected Y�S V Y�0
Uate: �-- /D ' ��
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��b� `� APPLICATIUN FOR I1�iPR0YF�iEfI'TS PEI�i�IT •
1. Permit requested by: owner/prospective owner:
� , agent:
Ad d r e s s: y�,.',f/J �.Y � r..��-�� G�-�-e_ �� -
Home Phone ��: , �,'- 9 ;� - . , =�SL�9 Business Phone ��:
2. Name anci address of current owner:
J •
4.
5.
Property Description: Lot size: l(j �C f a��""'�'�s �
/ �.. -c-a� �
"Tax map �t`: 3 % Totanshi : � P
Subdzvision Name: c�s Lot �t: o� D
Directions to property: State Road �# & Road Names, etc. `
.� � . 1 ! I � /1 .J. � ,. � ' _ � ,__ _ `r� ,. c �1
+�. Perrait requested for: ._New Installation: ✓ Repair:
Additi�nal Renovation re-using present system: -
7. Number of oceupants or people to be served: ��{-}�Noc.J� � �
���v�� �
E3. Dimens ions of I'roposed Structure : i,lidth : Nu'� Ki�o t� �1 Depth: 1� A,L ,��) ��,vn(
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9. ��Ihat type (if any) additions, expunsioc7s, or replacement is ariticipat�d to the stru�c- �
ture ar facility that this sewage disposal system is intended to �ervs?
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10. Watex supply private? �� public? community? __ spring? �
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Qther source? (Speci�y):
Are there any wells on adjoining property?
• .. _�_ . . •
�- If so, identify location:
i'ype of structure or facility: Proposed: ✓ Existing:
`Type o� dwelling: F�ouse: _� Mobile Home: Business: _
'iype of business: Ivumber of Employees:
Number of bedrooms: �t.�r�- d/au% Garbage Disposal? Yes No
Ba�ement? Yes No If so, number of basement £ixtures:
12. Clearly stake all coriiers of the property and the corners of all proposed structures.
I hereby make agplication to the ,erson County�Health Departnent for a site
evaluation or existing system evalua�ion for the on-site sewage disposal systern for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the praperty. I understand i€
•th� site i.s altered or the intended use changes, the permit shall.become invalid.
Permits are valid for 60 manths from d�ate of issue. Permission is hereby granted to
enter the property fnr the evaluation. G.S. 13UA-3'S(�) '
Signe Ocaner r thorized A�ent
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_'ermit Issued
; :GOI��fI'r:rIDATIO�IS/COMMEt�i2S:
;rTE..CLASSiF�C��TICiN �DI�.��'u�t (��c' �.Sc��.l az�as, property lines, roads, s�re�ms, gu�l�e�, -�
•o?C� 8g�8".3 s .f ��� ��'(1FS S s �r3�'.7.:: � ..: °? i uCil3.�R'. :' r ;al Ti3 �3Y C �(:i'Lla o L'tC. �