A40 216v
�
Person County Heaith Department
Sewage System Improvements Permit
Date: �' � � daTt
Owner: _ �
Location/Directions:
Void Af/ter 5 Years �+ �%
r2 A S�!_�Pr� .S� l� !�
Subdivision Name: f`"1 �t ► /� ( V PY (��� n`� ] la» Lot #.��i
Lot Sizc: �- !2_.� �� y c' s Type of Dwelling: _
Water Supply: Private: _ ''� Public: Community:
Bedrooms: Gazbage Disposal �
Basement Basement Fixtures
INFORMA E IED BY
5����; oµ�ner or repcesentative
REPAIR: REEVALUATION:
Size of Septic Tank: �� �allons Size of Pump Tank:
Nitrification Line: 1 ii 3�
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemadve System: Conv. Pump LPP P�mp
Remarks:
-------------------------
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
n�^—�TIFIC/�C(�MPLETION
Contractor. _1/l ✓ d Y _ Lo,�
_�
Sewage System location, installalion, 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 Counry �
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is sub,ject to revocation.
(G.S. 130 A-335F)
L,ocation of sewage disposal sewage system sketched on back.
(OVER)
,
NOTE: Make sket of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note sp ial problems existing on lot. Write in measurements in order that installations may be located
at later date: Note loca 1'ofi.of water supplies on adjacent lots.
(1)
��/
�
(z)
. ,�
��
Person County Health Department �
Well Permit �
Date: 3–� This Permit
Owner:
3 Years
'�
S�/ w / I
Subdivision Name: — . Y � Lot #
Drilling Contractor. �
WELL CONSTRUCTION �
Distance trom Nearest Property Line Distance from Source of _ti
Pollution ^ �?.
Tatal Depth: Ft Yield: �Q GPM Static Water Level F� ` �
Water Bearing Zones: Dept� �t�� FG Ft '
Casing: Depth: From ,�,,�_ to .� FG Diarpeter: Inches \�},
TYPE: Steel � Galvanized Steel '�
If Steel, does owner approve: No
WeighG Thiclrness: � 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 emen Concrete
Annular Space Width � Inches
Water in Atmular Space: Yes No
Method: Pumped Pres Poured �
Depth: From _�,� to FG
Materials Used: No. Bags Portland Cement Weight of 1 bag ..
lbs.
If m'vcture (sand, grav�l,�cuttings) - Ratio: to
ID Plates: Yes � No ►�
4 x 4 slab Yes �� No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANEE WIT�i REGUI/ATIONS SET
FORTH BY THE PERSON COUNTY H�Ai�H LIEPARTI�p'�]'T. /(
Due
Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
l
� NOTE: Make sketch of instailation 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)