A40 214- " z
� i�erson County Health Department �
Sewage System Improvements Permit �
Date:��`�
Owner: �
Locauon/Direc�ons:
Permit Void After 5 Years
Subdivision Name: _ r�l��" �t v�r._�lt.�'� {� � Lot #��� ;
Lot Size: �•Q /(l C✓e�Type of Dwelling:
Water Supply: Private: —� Public: Community:
Bedrooms: Garbage Disposal �
Basement Basement Fixtures
INFORMA R D BY
$�1��: owTer or representative
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: __7� gallon� Size of Pump Tank:
Nitrification Line: t"1/'? �,� �'
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP P�mp
Remarks:
-------------------------
Date Well Approved:
BY
Date S e ys
BY
Well should be 100 f� from any sewer system
c.,..:�.,r.,,, _
Contractor. ' � " � `
---- -------------------- �
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'd
nitrif'ication line must be inspected and approved by a member of the Person County �
Health DeparUnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemu[ is subject to revocation.
(G.S.130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
.Person County Heaith
" Well Permit
Date:�"�_T� s Permit Void Af r 3 Years
Owner: A/ i` n C ti /� ��
Subdivision Name;
Drilling Contractor:
"„_
Department �
� �
SR�IS%S�� I
Lot #
�
WELL CONSTRUCTION ►b
Distance from Nearest Property Line Distance from Source of r�,'
Pollution ;r
Total Depth: t Yield: ��GPM Static Water L,evel Ft
Water Bearing Zones: Depth �� Ft. Ft
Casing: Depth: From �_ to �V Ft Diamq�r. Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: { No
WeighG Thiclmess: � Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason• �
GrouG Type: Neat San enc Concrete
Annulaz Space Width Inches
Water in Armular Space: Yes No
Method: Pumped Pres Poured�
Depth: From � to FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand �avel, cuttings) - Ratio: to
ID Plates: Yes � No ►b
4 z 4 slab Yes � No �
I HEREBY CER'I�Y THAT THE ABOVE INFORMATION IS C
THIS WELL WAS CONSTRUCTED IN CCORDANCE WITH
FORTH BY THE PERSON COUNTY ��PAR'�(ENT
1%L\ A a �I I
Sanitarians Signature
Sketch well location on reverse side.
�RECT AND THAT I
: LATIONS SET
I Date
f—
G9
�
Date Issued
Date Completed
�
'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
iat later date. Note location of water supplies on adjacent lots.
(1) (2)
Iris - Internet Regional Information System
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http://gis.personcounty.net/Iris/Map/CGI/Iris.exe 4/19/2004