A32 137,�3�.-137 z
- P�rson County Health Department �
�ewage System Improvements Permit
Date:� This Permit Void After 5 Years Permit #
Owner: 1 A 1�►I r� w� L�o���P✓� �� SR# � �
I.ocation/Directions: �.�r�.i- �._ r'—�!l �#' �/r��' ;' a �#-
Subdivision Name: � ` ' � � - � � t #
Lot Size: Type of Dwelling:
Water Supply: Private: �`�" Public: Community:
Bedrooms: Garbage Disposal
Basement Basement F' tur
INFORMATION CERTIFTED•BY �
Environmental Health Specialisr ° �°f��,re�'�"°e
REPAIIt: REEVALUATION:
-------------------------
Size of Septic Tank: /Q(Z� gallo� Size of Pump Tank:
Nitrification Line: !S�D D' X 3 �,� -3 R.
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System; Conv. Pump LPP P�mp
Remarks: � ��e—� lloc./ , � � u
r, � � � � GA � • � s�, o �-
-------------------------
Date Well Approved:
BY
Date e ag te
BY
- Well should be 100 ft, from any sewer system
— Environmental Health Specialist
'7 /2-�Z
Environmental Health Specialist
v � 1 ir1CATE OF COMPLETION ,�
Contractor. � � �...P�-1� �e
------------------------- �
b
Sewage System location, installation, and protection must meet state and local �p
regulations. Septic 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 hazard. Septic tank and �
nitrification line must be inspected and approved by a member of the Person Counry
Health Department before any portion oF the installation is covered and put into use. If c
the site plans or intended use change this pernrit is subject to revocation
(G.S.130 A-335F) �
L.ocadon of sewage disposal sewage system sketched on back. W
�
(OVER) W
�
�NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
sup�}lies, 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.
N '�
_ Pe.rson County Health Department �
Well Permit �
Date:S 3"� This Permit Void After 1►'Years
Owner: jJ. � iJ���Ci r+� �,�7dnn� pi�i � SR# 1(�C� %
Location/Directions:
f� ✓1 _ o� ! 0 U l_ a:P S/? I//
Subdivision Name:
Drilling Contractor.
Lo[ #
Distance from Neares�Properry Iane,��� Distance from Source of
Polludon d
Total Depth: _ G Yield: � GPM Static Water L.evel Ft.
Water Bearing Zones: Depth � Ft f� Ft. FG Ft.
Casing: Depch: From �_ to �' -�Ft Diameter: ___(� L Inches
TYPE: Steel Galvanized Steel f
If Steel,_ owner approve: Yes No
Weight: � Thi�jmess: Height Above Ground: � Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No ;�
If "yes" give reasan:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Armulaz Space: Yes No�.--- '-�
Method: P�mped Pressure Poured �_ �
' Depth From �_ to FG
Materials Used: No. Bags Pottland Cement � Weight of 1 bag „d
� lbs. �
If mix e(sand. gravel, cuttings) - Ratio: � to �__
ID Plates: Yes �_ No
4 z 4 slab Yes No
De th
m To F adon Descri don
,�
Q r
-/ t
�
. , CD .
I HEREBY CER'I�Y THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET ,�
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �
�On�l�"
' ` ct�.'.�.�� ' ���.
1
�V lf�� o�,.
Sketch well location on reverse side.
of
� ��
Date Issued
Sanitarian's Signature Date Completed
NOT'E: 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 oi wafer supplies on adjacent lots. .
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