A35 93� �, y , •
The Districf 1-lealth Departmenf
Orange, Person, Caswell, Chatham, Lee Couniies
SEPTIC TANK PERMIT
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Name of owner: �
Name of contractor:
Address and Directions K,� �+' � YYC�C��1��
� 1 � �(� �i I��� � W �i �_�1
1 �
Person or firm doin installation: �
Address
No. of persons to be served Bedrooms 1,�2 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine �� b � �
Recommended• Septic ta
Nitrification line: �% �T '� ,%� -..� •
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspecled and
approved by a member of the Districi Health Department staif before
any portion of the installation is covered.
Date Approved:.��—���(��
sy:
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Iiealth Officer
(Over)
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�NO2'E: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
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Person County Health Department
Weil Permit
Date:3 - 8-R3 This Perm�t Void filfcer 3 Years
^------ ✓' r _ .
Drilling Contractor. L.ot #
. W �.4L
Distance from Neamst Property Line c� Distance from Source of
Polludon d r,�s
Total Dep :��Ft Yield: ,�` GPM Static Water Level �_F�,
Water Bearing Zones: Depth ��Ft Ft. FG Ft.
Casing: Depth: From �. Yo,��FG Diamet � 1� s, Inches
TYPE: Steel Galvanized Steel T
If Steel, does owner approve; No
Weight: .�_�'r}u��; Height Above Ground; _ 2— Inche�
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? yes No `
If "yes" give reason:
GrouG Type: Neat ��and/Cement Concrete
Annular Space Width Inches
Watet in Armular Space: Yes No �—`-" _
Method: Pumped Pressure Poured C__—__
Depth From � � � Ft
Materials Used: No. Bags Portland Cement � Weight of 1 bag
�_ lbs.
If m'vcture (sand, gravel, cuttings) - Ratio: _�_ �(
ID Piates: Yes �o
4 x 4 slab Yes No
G
IHEREB����T�� r ��RM��
� S CORRECT AND THp
'THIS WE AS TRUCTED IN ACCORDANCE WTTH REGULATTONS S
FORTH BY THE PERSON CQU�T�� DEPARTNIENT.
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Si tiae f C ac Date
3 /3
Sanitarian's Signa r Date Issued
Sanitarian's Signature Date Completed
Sketch well locadon on reverse side.
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