A40 241� er�on County Health Dep�rtrrient
Sewage System Improvements Permit
Date: "��! U This Permit Void After 5 Years Permit #
Owner: SR# /�rl
Location/Directions:
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SubdivisionName: G. +v�j- f� o•I.at# � �
Lot Size: r' Type of Dwelling:
Water Supply: Private: Public: �` ?�^ ^�" Communiry:
Bedrooms: 3 Gazbage Disposal
Basement Base ent ix
INFORMA D
SBrlltari8rl:' owneror tati
REPAIIZ: REEVALUATION: �
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Size of Septic Tank: � gallons Size of Pump Tank:
Nitrification Line: _ _ (Z(� r ?i 3'
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks:
Date Well Approved: ' �"� Well should be 100 f� from any sewer system
BY i' � Sani • .
Date Se ge ystem pproved: - '-
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BY— - - -n—.-. n-, ., — - - � lLe�►1z
v � �.a;a� a -a�,ra a L. va' �.vi�u La: i avi � �
Contr�tor. ��( ��'�c v� �
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Sewage System location, installation, and protection must meet state and local �
reguladons. 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
nitrification line must be inspected and approved by a member of the Person County ,�
Health Departrnent before any portion of the installation is covered and put into use. If �
the site pians ar intended use change this peimit is subject to revocation. fi�
(G.S.130 A-335F) _
L.ocadan of sewage disposal sewage system sketched on back. Q�
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Person County Heaith Department
/� Well Permit
Datei. r �" T�'�V • �� VV � V� �Yl.. f�
Owner• SR# �.�
Location/Directions: _
Subdivision Name: ,
Drilling Contractor:
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WELL CONSTRUCi'ION ►�
Distance from Nearest Property Line Distance from Source of �'
Pollution c��,
Total Depth: � Yeld: �GPM Static Water I.evel FG �
Water Bearing Zones:. D��JiG� Ft FG �i� F�.
Casing: Depth: From to �r FG Diame� E ti Inches
TYPE: Steel Galvanized S[eel
If Steel, does owner approv�� No
WeighC Thiclrness• Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: 'd
Grou� Type: Neat S ement Concrete �
Annular Space Width � Inches
Water in Armular Space: Yes No
Method: Pumped Pres�y� Poure�
Depth: From --� to (� FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, gr ve , cuttings) - Ratio: to _
ID Plates: Yes No .d
4 x 4 slab Yes � No �
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I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT -3
THIS WELL WAS CONSTRUGTED IN CORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY TH DERAR
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S' f �hmactor � Date
Sanitarians Signature Date Completed
Sketch well location on reverse side.
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NOTE: i�al�tion�24� '�o iz nd sha e, loca�n of house, septic tanks, privies, water
supplies, etc. Note speci• 1 pro l�r�xisting on lot. Write in measurements in order that installations may be located
4` � at later date. ote -of'�f— supplie "�n adjacent lots.
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