A34 84�$3�""g�' z
`�Per�on County Heaith De artment �
Sewa e S stem Im roveme�its Permit
9 Y P , j
D�; - - Z' Pem►it Void After 5 Years Permit #�(b
Owner: ' SR#
Locaaon/Direcaons: � ' - �
�� ►.� a^ '..�
Subdivision Name: Lot #
Lot Size: �-f" ���— Type of Dwelling: .
Water Supply: Private: —l� Public: Community: �
Bedrooms: � GarbaBe Disposal
,
Basement Basement Fixtures
iNFnR R�[FiIED BY Jyi ��
REPAIIt: V••' - -��• •- REEVALUATION:
Size of Septic Tank: __1��� 8�� s S'� of Pump Tank:
Nitrification Line:
Depth of Stone: 12 inches
Max Depth of Trenches: -
Alcemative Svstem: Conv. Pump �P �mP
-------------------------
Date Well Approveti:�-�.�Well should be 100 ft from any sewer system
BY Sanitarian
Date Se Sy te A ved:
gy Sanitarian
(/ `�" `- TIFI�ATE OF CUMY1.��11Viv ,,.�
Contractor. � �;.�o��•A S' — �
------------------------- �
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic tanlc should be pumped out every 3 to 5 yeus and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrificarion line must be inspected and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If �`
the site plans ar intended use change this permit is subject to revocation. 1t�
(G:S. 130 A-335F) �
�
L.ocation of sewage disposal sewage system sketched on back. �
, (OVER) `
Person County Health
` � ' Well Permit
Date: �.3� �1Z This ermit Void After 3 Y�ea�s
Owner: � � ,[�i1
Locadon/Direcdons: � , _
Department
SR# �/3� ��
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Subdivision Name: T ' , � U �
Drilling Contractor�,
WELL CONSTRUCi'ION
]�stance from Nearest Praperty L'u►e Distsnce from Source of
Pollurion '
Total Depth: FG Yeld: GPM Static Water Level ' F�
Water Bearing Zones: Depth Fy� Ft. F� Ft.�
Casing: Depth: From � C� l Ft Diameter: � Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner approve: � No
Weight: Thiclatess: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered ir► Setting the Ca,ting? Yes No
If "yes�� give reason: �
Grout: Type: Neat S ement Concrete
Annular Space Width .� Inches �]
Water in Armular S ace: Yes No
Method: Pumped p �� Poure� �
Depth: Fram $— � S�_ Ft
Materials Used No. Bags Portland Cement Weight of 1 bag ,b
lbs. �
If mixturc (sand �a� � cuttings) - Rado: co _
ID Plates: Yes No
4 z 4 slab Yes �— No
De th
From To Fo ation Descri don
'd
c�
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN�C CORDANCE W1TH REG LATIONS SET ,.;
FnRTH BY THE PERSON COUNTY HF.NULTH t%�rP�'1'A4�Nr• �
ian s'signanue
Sanitarians Signature
Sketch well location on reverse side.
4 zZ 4 ►�
� Date �
7/�/�5a a
Date Issued .�
�
Date Completed