A32 125�3�-1�
6Person County Heaith Department
Sewage System Improvements Permit
a�r
Date: ���.A is Permit Void After 5 Y s yr �
Owner: �.���� � ���� ¢��!-P� SR# ��
Location/Directions: .
1 _�,.- , _ � � r" �+ /e� �L.,.�
Subdivision Name• ✓ Lot #
Lot Size: Type of Dwelling:
Water Supply: vate: � Public: Community:
Bedrooms � Garbage Disposal
Basement Basement Fixtures
.,; ,�
INFORMAT�Q� R�7� D BY . i,,;;:•,�`'� �%�'��'—;d<C�`
^- - -----__/i/n _1!�! ►! Jl .. �_�� ownero�reoresentauve
REpAIR: �/"� "�"I �`�ZEEVAL[JATION:
-------------------------
Size of Septic Tank: � gallons Size of Pump Tank:
Nitrificauon Line: � -
Depth of Stone: 12 inches
Max Depth of Trcnches: ` � �
Altemative System: Conv. Pump Pump �
Remarks:
-------------------------
Date Well Approved:
•BY
Date Se� te
BY
Well should be 100 ft� from any sewer system
Sanitarian
� OF COMPLETION
z
�
�
Contractor. � J � �/►'l a ��i H _ �
------------------------ �
Sewage System location, installation, and protection must meet state and local ''�
regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazazd. Septic tank and`d
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposai sewage system sketched on back.
(OVER)
. c��-�.�- ����� i�� �f� �� �. .� =
� �
P�'rson County Heaith Department �
�' ���� Well Permit . r �
Date:=L-1!L' L� This Permit Void After 3 Yea�s p o T� '�
Owner:_�j �rA. GG � � IS ��r�lu1 P� � SR# 1 1 I� I
SubdivisionName: � � Lot#�� ''n�t
Drilling Contracwr: � �ei___(�� le)
W LL CONS RU ON
Distance from Neare t Property Line u-.S Distance from Source of
Pollution d � u.- 5
Total Dep :/ FG Yield: GPM Static V�ater Level �4 Ft
Water Bearing Zones: Depth �Ft � Ft. Ft. t�. —
Casing: Depth: From ,..�Q__ to �c. Diameter: � Inches
TYPE: Steel � G varuzed Steel _�
If Steel, does owner approve: Yes No
Weight: �ry_ Thi lmess: Height Above Gound: ,� Y Inches
Drive Shce: Y� No
Were Problems Encountered in Setting the Casing? Yes �� No
If "yes" give reason:
Gmut: Type: Neat � San ement Concrete
Annular Space Width Inches �
Water in Armular Space: Yes No
Method: Aunped Pressure Poised '�
Depth: Fmm � to 1./ Y�Fc.
Materials Used: No. Bags Portland Cement _� Weight of 1 bag
�_ lbs.
If mixture (sand�avel, cuttings) - Ratio: 'S co .�_
ID Plates: Yes No
4 x 4 slab Yes �� No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPAR'TMENT. ,
Due
Sani[ ians Signahlrel Date �'ssued
�'� _�//-5Y
Sanitarians Si nature Date Completed
Sketch well location on reverse side.
��
r
.. f
NOTE: Make sketch of installation showing lot size and shape, location of house, sQptic 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, r� � � v� w�
.o �--