A40 212.� �
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� Person County Mealt�h Department �
Se � �e System Improvements Permit
Date: �dr �'� `�`+ This Perrnit Void After 5 Years Permit # � �-� -a 3 9 3
Owner: 'TPJ-•-n ��rw�Q - - SR#
Locadon/Directions: �.lu, � l.5'7 4-o p1a �-�,�-�o,,. ��'•
m
Subdivision Name: ����' �����' p�aK�a�°`^ Lot #�' �_
Lot Size: 1(�-� Type of Dwelling: Mob;�e No.�-e
Water Supply: Private: �— Public: Community:
Bedrooms: 3 Garbage Disposal '
Basement Basement Fixtures
INFORMATION CERTIFIED B
Environmental Heallh Specialist: � ,,. °�r tive - �
REpAIR; REEV UA ON:
-------------------------
Size of Septic Tank: 1�00 gallons Size of Pump Tank:
Nitrification Line: h� d L, r
Depth of Stone: 12 inches
Max Depth of Trenches: o� h' "
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well
BY
Date,B�vv�
BY /Y/� .-
'��'� Well should be 100 f� from any sewer system
� Environmental Health Specialist
. Environmental Health Specialist
5
5
F
�
3
V" " -, RTIFTC TE OF COMPLETION ,..j
Contractor. �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 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and �
nitrif'ication line must be inspected and approved by a member of the Person County G,
Health Department 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) R�
Location of sewage disposal sewage system sketched on back.
(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
. . - -- - � — . �
k
, � Person County Health Department
/ Well Permit
Date: �o/��(9�` This Permit Void After 5 Years
Owner.- aw=; SR#
Location irections• � N� a l.�'7 +O a� a;��, ve��-
Subdivision Name: ��'-' -; ��- aw «. � o-�. Lot # 3�_
Drilling Contractor: s u
WELL ONSTRUCTION
Distance from Neazest Property Line i� � Distance from Source of
Pollution „� ' '
Total Depth:��� Ft. Yield: S GPM Static Water Level��Ft
Water Bearing Zones: Depth Ft. FG L p� FG �t.
Casing: Depth: From � to�Ft. Diameter:�Inches
TYPE: Steel � Gaivanized Stee] ��
If Steel, does owner approve: Yes No
Weight: Thickness: / B" � t Above Ground: 2 2- Inches
Drive Shoe: Yes ��No
Were Problems Encountered in Setting the Casing? Yes No c�
If "yes" give reason:
Grout: Type: Neat � Sand/Cement Concrete
Annular Space Width l 3 Inches
Water in Annular Space: Yes No
Method: Pumped Pressure Poured '---=
Depth: From (%�to ? t� Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag_Ibs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes�o
4 x 4 slab Yes r� 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.
_ �
Signature ontra r ate
�—�"- `� ! 0/�l �
�S ' 'an's i ature Date Issued
/
ani 'an's i ature Date Comp eted
Sketch well location on reverse side.
`�C
z
" NQTE: 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
x� located at later date. Note locadon of water supplies on adjacent lots.
(1) (2)
Ijmount paid iV�• �
' Receipt 0 � (j
- ' � -
Improvements Permit.(Establishcd/Rccorded L.ot)
Imarovcments Pecmit (Unrecorded Lot)
► Improvements Permit (Mobile Home R�
_ Improvements Permit (Addition)
4 -aa-9 �
Date
• • -:�;;� �'. �:�:.a,�,
,.. ...,�.�..'"s.1t..:.:�:.zr� �Ytiir.�= �..'
Reinspection of Existing System (Loan Closing)
RepaidRepiace existing Septic System
Permit for New WeII
_ Replace Existing Weil
I. Permit requested by: . n 7. Dimensions or Proposed Struccure:
owner/prospective owner/a�ent: ���1��'I 0'0� � Width: Z�
Address: s;��v�. %��1�l�c� �i� Depth: �o �
'' � G Z7 7 8. What type (if any, aeditions, expansions, or
� cepIacement is anticipated to the struc[ure or iacility
w tha[ this sewage disposal system is intended to secve?
v Home Phone n: �'S9 9—� yOS
� usiness Phone n: � ���
a
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z
f�
and address of current owner: 9. Water supply t}'pe:
;"' � ` �� ✓P.e/! / private �. public ❑ corununity ❑ spring ❑
' ,` i�G �' Ci �- �- Are any wells on adjoining property?Yes� Noj�
?A��xo �c Z7S7.� If so, identify location:
. Propecty Description: Lot size:
Tax Map�: . . /� `�'v
Parcel�: � �
Township:___ � I _ ie.i v�
Directions to property: Sta[e Road n& Road
ames,�tc.
_�cs � 1�owardS h•�urd/e /Yl�'//S
�/A 7` /Zi�✓2r %�14rll�i�,arr
I�Iumber of occupants or peoplc to be servcd: Z
10. Type of structurelfacility: Proposed: DExiscing:�,
-,
Type of dwellin�: i
House: ❑ Mobile Home:� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposai? Yes ❑ No�
Basement? Yes ❑ No�If so, # of basement fixtures:
CLEARLY STAiLE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'Son COunty Health Department for a site evalua[ion for the on-site
sewage disposal system for the above described property. I agree that tl�e contencs of this application are true
and represent the maximum facilities to be placed on the propecty. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I undecstand that before an Improvements Permit can be
issued, I must present a survey plat of the propeRy to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Healt pt. within 60 DAYS after date oE the evaluation of
the site by the Hcalth Dept., this application sh be me void and all �pa�icrJr"`eited.
Si�ne� �+ncr or Authorized Agent
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Yerson County Health Oepartment
Existing Sewage System Report For: '� Mobile Home Replacement .
Addition
Requestee: f'� /leN� �/ /,n�� �/'��`N�C�q _ Home Phone# s9g-/��
3yQ N;s�vr;c (/,'��aQ� I?�. susiness#
��ox�o<o �%C a�s73 'Pax Map# ��C� a��
/� n j ,
Location/Directions: /S%S ��e> /S�i/C/ /'�a�Ta �o,v
Lo� 3y
Original Permit Located 7es
Septic System Uesigned For: _
Kesidential ✓ Business Other (speciEy)
# Bedrooms � # Employees Other
Uate Installed i/^�Gv9y Water supply �@`/
Type ot System �oN�e���^��-�
Nitritication Line yUU �1�3 �
Tank Size /ODU
Certified Operator Required ��
On site wasL-ewater disposal system showes no visually apparent
malfunction on '�-27��9
Yermission is granted to: l-�p�ace .S � w��t� --/���� _
According to the attached site plan.. -
Comments: ���Co��eNc�' __��v_�P ���9 �-a/���c �a.,�k �ve�i/
5 �ee �s
Environmental Health �a. � �^"�' �`""`
�,..:
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�,a::i_ ___•—_.__._�- . . -. . _ _._.'___.. �... ..__ .. . . — �.._ ' . .
�/- 27 `�
DATE