A32 138w � ., � =�� z
. ��r��n County Health Department �
S���rage System Improvements Permit
0 7
Date:f �� � S T� Permit Void After 5 Years�J P rmit # �
Owner! f.tl/"-,./�R�qh� � �l01'lca�/�rc'�!l ��s SR# -��
-Wrn /t{? D�� �' �� � �
Subdivision Name: a�►" s S �^^ '7 r►,c,; ll,�,Xrs �t # '"'' �
Lot Size: ype o wei�ii�[gQ" e.
Water Supp y: 'vate: —i� Public: Community: p
Bedrooms: 3 Gazbage Disposal �
Basement Basement F' wes
INFORMATION CERTIFIED BY � ��-=
Environmental Health Specialist: o ner ��T s�r�ri�
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: _����j�� gallons Size of Pwnp Tank:
Nitrification Line: /)Irl � � 3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:�2�L� Well should be 100 f� from any sewer system
BY _ Envir mental Health Specialist
Date ge y App �o�rTGJ'�1
BY � . Environmental Health Specialist
�� CATE OF COMPLETION ,.�
Contractor.—i VI� D l ���,� i �
------------------------- ��
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
nitrificadon 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 W
the site plans or intended use change this peinut is subject to revocation. �i
(G.S. 130 A-335F) �T( '
s �
Location of sewage disposal sewage system sketched on back. J
_ _. J �
(OVER) ~
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ppsaa;� �e �l�er�on Count�� Nealth Department
rdc�ns
::�r„� Well Perm��
Date:9�?y S-`�T�This Pezmit Void Aftenr 3 Y
P /1 //1 /.1Yti'1 �✓� ( / �-1 J
Own r � _ , ., �.. f..�_
��'�•'.
C ntractor
✓ S a.�
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SR# _L.�-�-
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DnllmB 0 ' W." RU r`-�"" ��jvt c!c /ir.'S�'
Distance from Nearest PropertY Line
_�1' Dystance from Source o a» /��
Pollution ��� ,� GPM Static Water Levei ,�O O F4
Total Depth: �2��- Yeld: _�-F� J,jL2_ lp.�
Water Beaiuig Zones: Depch _.Q-2..5" Ft F�Diamecerc.� Fc. Inches
Casing: Depth From .�1.— , Galvanized Steel !' -
TYPE: Steel ve: Y e s ✓ N
If Steel. owner appro Inches
w��� _ �•� ; � Hei�ht Above Crround: �_
a
�hive Shce: Yes °
Wae Problans Fs�countered in Setting che Casing? Yes No ✓
�"yes" give reason: 5���� f Concrece
Grou� Typr. Neat j�tches
pnnuiar Space Width � No �
. Watet in Aimular Space: Y�re Poured �
Method: Pamped — � � F�
�p� F� —�-� -- Wei ht of 1 ba
Materials Used: No. Bags Portland Cemenc ____�_ g 8
� �' �_
If mvcture (sar�. ga�e1. ��8s� ' Ratio: _�_ to
ID Plates: Yes ✓ No •
A. d ���t, Yes +� No�.-=-
I HEREB�c CER'TIFY THAT Ti� ABOVE INFORMATION IS CO? RECI' $ND THAT
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULA'I'IONS SET
FORTH BY THE PERSON COUN'I'Y iiE�►1-TH DEPARTI�'�NT• '
.��� �J . �"��-�'�
n nfl'rmfrne D�C
Date
$znir:+rian's SiQnature Date Completed