A40 229._ - �, � .., z
Person County Health Department �
Sewage System Improvements Permit �.
Date: -�► n This Permit Void After 5 Years
Owner: � SR# �� � �
Locaaon/Direction .� , r� ,� , � �' � T � iS
Subdivision Name:
Lot Size: �; ���+–�_ Type of Dwelling:
Water Supply: Private: — ''� Public:
Bedrooms: �_ Garbage Disposal
Basement Basement Fixtures y
INFORMA'I'I D BY
Sallitariall: oi��ner c
REPAIR: REEVALUATION:
Lot #
Community: ��
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Size of Septic Tank: —��� gallons Size of Pump Tank:
Nitrification Line: .11i�)� I �X3 �
���
Depth of Stone: 12 inches
Ma�c Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:���_ Well should be 100 f� hom any sewer system
BY Q� Sanitarian
D e Sewa e S tem Approved: Tf —1 �"� 8
BY Sanitarian
� �C�E1RTI CF; ATE pF COMPLETION
Contractor. '� uri�
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Sewage System location, installation, and protection must meet stnte and local '�
regulations. Sepdc tanlc should be�umped 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'Z7
nitrif'ication line must be inspected and approved by a member of the Person County �
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)
I.ocation of sewage disposal sewage system sketched on back.
1
(OVER) �
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/'1.�� `� / - �
NOTE: Make sketch of instaliation 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
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- � �erson County Health Department �
� r7�� Weil P�ermit �
Date:�� 'I7ii Permit VoC�id After 3 Years SR# ��� �
Owner. � �
Locadon/Directions: -
o � S ��
Subdivision Name: Lot #
Drilling Contractor: tL,a- � S -� -
WELL CONSTRUCi'ION b
Distance from Near t Property LSne_j, ��/�.0 Distance from Source of
Polluuon a u- b o �
Total Depth: ) Ft Yield: GPM tic Water Level �Ft �
Water Bearing Zones: Dep�h Ft FG Ft F�
Casing: Depth: From �_ to FG Diameter: � Inches
TYPE: Steel ' G anized Steel. v
ff Steel, does owner approve: Yes No
Weight �� T7uc3mess: ��Fieight Above Ground: 1_�Inches
Drive Shce: Yes '� No
Were Problems Encoiu►tered in Setting the Casing? Yes No `�"
If "yes" give reason: "ti
Grout Type: Neat ✓ Sand/Cement ` Concrete �
Annular Space Width 3 Inches
Water in Armular Space: Yes No ✓
Method: Pumped Pressure Poiued_(,�
Depth: From �_ to .� { Y'j„rFt
Materials Used: No. Bags Pordand Cement � Weight of 1 bag
,.. ..
_ �ttS, ., �
If mix e(sand,`gravel, cuttings) -. Razio: '� to �_
ID Plates: Yes ✓ No ' ►�
4 x 4 slab Yes �— 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.
Date
� 7 ��
Date Issued
Sketch well location on reverse side.
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����,rVl� ►\2 Y�� 0 1� Ca� � l��W �o .
N SfiE: Make sketch of installation showi�gy'
supplies, etc. Note special problems existing on lc
at later date. Note location of water supplies on
cu
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��' %�,c tij I.uC�( %J lo%-,� �.�. i� r�!.� /���e un �✓
size and sha�e, location of house, septic t�k� pf vies, water ��
Write in measurements in order that installations may be located.-_
djacent lots. ��~
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