A32 139�
Person Count
S�einra�� System
Date: 2-� ���T iis Permit oid,,
Owner:
Location/Directions: _
y Health Department
Improvements Permit
5 Years P�rmit #
Subdivision Name: � � t
Lot Size: ��' Type of we hng:—.
Water Supply: Private: Public: Community:
Bedrooms: � Garbage Disposal Q
Basement A��_ Basement Fixture ,/�
INFORMATION CERTIFIED BY
Environmental Health Specialist: o er or �e
REpAIR: REEV UATION:
Size of Septic Tank: ������L�-- gall�ns Si�e of Pump Tank: ----
Nitrification Linc: � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternative System: Conv. Pump LPP Pump
Remarks:
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Date Well Appro ed: r ell sh d be 100 f� from any sewer system
gy ���/9 S Environmental Health Specialist
Date ge y m pprov : -�
By Environmental Health Specialist
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�ER'TIFICATE OF COMPLETTON ,..�
Contractor. � .J-�� � �� s �e
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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 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nisri�cation 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 �-�►
the site plans or intended use change this perrtut is subject to revocation. �
(G.S.130 A-335F) �
L.ocation of sewage disposal sewage system sketched on back. �'`i
(OVER)
NOTE: 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 }ater date. Note location of water supplies on adjacent lots�
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Person County Health Department
Weli Permit
Date: ��� ��? �Fhis Permit Voi After 5 Years -a.
Owner. ri..' "; .� l/��.� �rs: L,�;x, " r t rq S� SR# �
Location irectiof�s: r� �-�� ^
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Subdivision Name: Lot #
Drilling Contractor:
WELL CONSTRUCI'ION
Distance from Nearest Pmperty Line Distance from Source of
Pollution
Total Depth: Ft Yield: GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. Ft. Ft Ft.
Casing: Depth: From to Ft. Diameter: Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve: Yes No
Weight: Thickness: Height 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
Annulaz Space Width Inches
Water in Annulaz Space: Yes No
Method: Pumped Pressure Poured
Depth: Fmm to Ft.
Materials Used: No. Bags Portland Cement Weight of 1 bag ]bs.
If mixture (sand, gravel, cuttings) - Ratio: to
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 WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
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� j� �v i nsfztll Ssff. L�rn��� � Date
�J�� i �5 �'e�edt � e�.�('�v �I .�yGt,'��1 Is��1 � �.--�
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-Fo� �e G� �� �� �6/ayl9s �'�� an'" Srgna e Date Issued`
y�s.�-a,{��d bY kn �s,� u�`,rl;aK /a .S
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��ro�ed b� /�� � " anitarian's Signature Date Completed
Sketch well location on reverse side.
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' NOTE: 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
, locatoti at later date. Note location of water supplies on adjacent lots.
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Person County Health
Well Permit
2�� ��'his Permit Voici After 5 Years j
Owner.
Department
�Y SR#
Subdivision Name: � �#��
Drilling Contractor: ��+�-�
WELL CONSTRUCTTON
Distance from Nearest Property Line Distance from Source of
Pollution
Total Dep� FG Yield:�� GPM Static Water Level F4
Water Bearing Zones: Dep F FL FL Ft.
Casing: Depth: Fmm to Ft. Diameter Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner approve: �1'�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 Cement Concrete
Annulaz Space Width Inches
Water in Annulaz Space: Yes No
Method: Pumped sure Poured�
Depth: Fmm �to Ft.
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
ff mixture (sand, grayel, cuttings) - Ratio: to
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 WTTH EGULATIONS SET
FORTH BY THE PERSON COUNTY H T EP ME
� 11 Q,5
'g e Co trac or Date
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Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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" NOTE: Make sketch of installadon 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 of water supplies on adjacent lots.
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