A32 68� �
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Person County Heaith Department
Sewage System Improvements Permit
Date: ���ZThis Permit Void After 5 Years
Owncr: Ta��S' d- GcJ�%r�Q/e��• /Qio►�M�� SR# //03
Location/Directions: �C iSi S � l�l�r�/G /''I�`I/s ,�'
Subdivision Name• /v�'�` Lot # �"'�
Lot Size: Type of Dwelling: D�u64 GJ,�
Water Supply: Privatc: Public: Community:
Bedrooms: � Garbage Disposal /V�
Basement Nn Basement F� yr� ,
INFORMATION CERTIFIED�Y � � � -� _
$�1��: � �� �� �,` ow�ner or representative
REPAIR: REEVALUATION: •
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Size of Septic Tank: �Q� gallons Size of Pump Tank: /�
Nitrification Line: y!�'J � X 3�
Depth of Stone: 12 inches /Z'�
Max Depth of Trenches: A�,o�ax �y ��
Altemative System: Conv. P mp LPP Pomp
� . ,, - - - --� - � , � � � _ _� �- -- �
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Date Well Approved: � Well should be l00 fG from any sewer system
BY Sanitarian
Date Sewage Syste Approved: �-ZS-�2
BY � � . Sanitarian
CERTIFICATE OF COMPLETION
Contractor. T�i�,�v ���s
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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 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrif'ication line must be inspected and approved by a member of the Person County �
Health Depaztment 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)
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Location of sewage disposal sewage system sketched on back. �
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(OVER) �
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' �CWE �dO�,C �'����
` Person County Health Department �
Well Permit �
Date: ��'"�2This Permit Void After 3 Years . �
Owner:.r,�a/+�..�s cr- /,e�i'/rh/�v.� ��n/�!' SR# %f U-3
Location/Directions: Ne i.s`7 S�o iS/�x�J4 /'�.'!/s
SR //03 L�•1 a�.+ .fe..� bt.L6 � s!7 !I/_S'
Subdivision Name: . ' t #_ ,�� J�
Drilling Contractor: _ __
WELL CONSTRUCTION ►�
Distance from Nearest Property Line Distance from Source of �'
Polludon � �
Total Depth. _ FG Yeld: GPM Static Water Level Ft �
Water Bearing Zones: Dept�,q � FG FG `�
Casing: Depch: Fmm _�_ to ' FG Diameter: Inches
TYPE: Steel ' Galvanized Steel
If Steel, does owner approve: � No
Weighr. Thiclrness: � Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Settin the Casing? Yes No
g / ''�
If "yes" give reason: '
GrouC Type: Neat $aadlCetnent Concrete �
Annular Space Width 1 G. Inches
Water in Atmular Space: Yes No
Method: Pumped Pres e Po�sed `�
Depth: From � co Ft
Materials Used: No. Bags Pordand Cement Weight of 1 bag
lbs.
If mixture (sand �avel cuttings) - Ratio: W
ID Plates: Yes � No ►�
4 x 4 slab Yes �� No �
I HEREBY CERT'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED CO DANC WITH GULATIONS SET
FORTH BY THE PERSON COUNTY PAR IyT
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Signature of Conuactor Date
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Sanitarians Signa Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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 later date. Note location of water supplies on adjacent lots.
(1) .
(2)
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