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PERSON COUNTY HEALTH DEPARTMENT �
WELL AND SEWAGE SITE, LOCATION IIv�ROVEMENT PERNIIT
Not for waste water system constructeon. 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 # 9 �
Zoning Tawnship v �
Owner/Contractor ,� , �,,,,� c , ��,g _5 � � Date �
Location/Address /s'7 5 T11� v� ��,viv.v �iZv✓� c:-�. RD
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� ,�-,.�� �� c�,� S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area /3, I S a� Size of Tank /vvD �� L
SFD Mobile Home ✓ Size ofPump Tank ,�//�
Business # of Bedrooms ,� Nitrification Line S'�i' x 3'
Max Depth Trenches �r> "
Permits may be voided if site is ered or intended use chan d.
Well and Septic Layout by o l
Comments: ,�ir" .�.a x �.� u� v =- /
i��+r�t� �i�'c� T%lI� v v.�,u v.z�..,.taC�.,� D:�
Date �-�'�'1 Installed by ��, ,,_, i s Approved by
Well Permit Paid C� WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab
Public Replacement Air Vent
Site Approved /� Required Well Log
Well Head Approved � Well Tag
Grouting Approved +�
Comments:
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. 7Che 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
H 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 01/95 rev.l. i
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance) '
DATE: �� IMPROVEMENT PERNIIT #: ,z3 i� i/
TAX MAP #: ,q _�/ PARCEL #: � g
OWNER/OWNER'S REPRESENTATIVE: 1�/c>i c� ���_Sr,n!
LOCATION/ADDRESS:
l J�1 ,c.r an! L c�F r.
SUBDIVISION NAME: - LOT #:
. SECTION OR BLOCK:
. AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
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TION CONDITIONS
�vZ. ca�l. �s�
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 #_,�3/Gt/ . 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:
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Person Requesting:
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Date:
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Location/Directions:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
SR#
Subdi�����on Name: Lut �
Drilling Contractor: f�►JK�N W�1 u.1 �m Sau.� T.N �
� WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.th:
Water Bearing Zones: D
Casing: Dept�i: From_
Ft. Yield: � GPM Static Water Level Ft.
l�i ameter:
TYPE: Steel � Galvanized Steel �
If Steel, does owncr approve: Yes No
� Weight: �� Thickness: • � Height Above Ground: Inches
Drive Shoe: Yes No . � �
Were Problems Encountered in Setting the Casing? Yes No
If "ycs" give rcason:
Grout: Type: Neat Sand/Cement Coricrete
Annular.Space Width �2 Inches
Water in Annular Space: Yes No
_ Method: Pumped � Pressure Poured �vr �
Depth: From � to 2� 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 INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
,
' -36-q7
SignaYure of Contract � Datc