A40 265�� . , . , .
� B 1298
.....,_.--....
PERS�N COUNTY HEALTH DEPARTMEN'I'
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # ,4 yo Parcel # ���
Zoning Townshi �.a T� v�2
Owner/Contractor - ��'► aD�Y/����/9�
Location/Address —� � o.aN v.av�s z�4a � o�
�4 yn�Es �.a ✓'E2.+.� .tZo�4D 5� � . �� o.�/ C9S.R.# //YL
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,�-, y7 a c.
SFD � Mobile Home
usiness # of Bedrooms 3
w ��t�' ``v
v Pe �ts may be voided if site is tered or int�
� Well and Septic Layout by �P �
p+ Comments: ��,ti pi.•,�� i � .v �
. Lo i' .3 �_ cJ� v. s�'
-a � Installed by
Size of Tank /000 G�a. c.
Size of Pump Tank �ov� G.w c.
Nitrification Line �' k3 �
Max Depth Trenches �c '`- Z y"
Ei+s C �tc�l/�
d �d' ___�_ � _ _ �
P WeU Permit Paid �� WELL SYSTEM SPECIFICATI S
Individual ✓ Semi-Public Required Slab �
Public Replacement Air Vent �
Site Approved ,/ Required Well Log
Well Head Approved ✓ Well Tag ✓
Comments:
Date 5'-/ v- 9 9 Installed by
by
Approved by
o.� �1�
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nnr the environmental health
specialist w�rrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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o SSS. IS
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� `��,�� • � 28,.� �.
� A 100 YEAR STORM �
FLOOD HAZARD AREA
TRACT D
SADIE �. HESTER
HEIRS
EXISTS ALONG �� IS IS — — — — — -_.. _. ._ _ _
CREEK. . -'
PHILLIP H. REAMES
D.B. 236, P. 151
CONTROL
CORNER IF
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DRAINFIELD EASEMENT
FOR LOT A
0.25 ACRE
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1 1. 08 A C.
INCLUDING DRAINFIELD
EASEMENT
IS
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Date: o � � z
- Owner.
Location/Directions:
Subdivision Name:
Drilling Contractor:
Distance from Nearest Properry Line �d Distance from Source of
Pollution 'oo ' ,
Total Dep.th: op Ft. Yield: �� GPM Static Water Level f� Z Ft.
Water Bearing Zones: Depth �y o . � Ft� � Ft� �`'� �t,
Casing: Depth: From b to (g � Ft. Diameter: Inches
TYPE: Steel - GalvaniZed Steel �'
If Steel, does owner approve: Y�s No
� Weight: � Thickness: IFSk HeighrAbove Ground: 6 ti Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ✓
If "yes" gi� e r�ason:
Grout: Type: Neat Sand/Cement_ ✓ Coricrete
Aruwlar. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . - � �Pr:ssure - � Poured-✓ ��� �- . . . ,, _ : .
Depth: From O to_ �. � Ft. � -
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttin�s) - Ratio: to
:ID Plates: Yes ✓ No � � ' •- � -
�� 4 x 4 slab Yes—�_No �
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG '
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SR# : _ _ , . .
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I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH $y�THE PERSO�t C��i�'I'Y HEALTH DEPARTMENT. �
� ---
�S gnature of Contractor Date
i
0
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
12 - i l��- � ?� � r� -� � -�-�— --�
Date of Inspection System Installation Date Type Tax Map Parcel #
Property
Instructions: Check yes or no for appropriat;, items a.nd :,xplain in space provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N' and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Required pumps g:esen: & functional ?
High water alazm operating properly ?
Fioats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ? �
Inches of solids(pump/dose ):
Elapsed time readings ? N A
Counter readings ? N.� ---
Drawdown rate: !J
YES / NO
❑ � ❑
❑ � ❑ ���
❑�o _
REMARKS
Se�h'� -�anK n�' accessi bfe
❑ / ❑
� � � �- Purv� -f-anK not aaessi �(2
��� —Co,rMo j�pan� � over f6wn W tf%
� � � S}�r�b�et i �Uulci �i'1�'�' ACCcSS
�
DISPOSAL FIELD:
Evidence of eftluent surfacing ? ❑ �
Evidence of effluent ponding in trenches ?❑ /
Surface water effectively diverted ? � /
Diversions/swales properly maintained ? ❑ �
Vsgeta+ive cover maintained ? � !
Protected from tr�c/unauthorized uses ? � /
Distribution devices in good condition "❑_,,//
Fieid free of settled or low areas ? UV I
�utH.� f"D S�riA� d1�r�buflWl
PRESSURE DISTRIBUTION SYSTEiUI:
Tumups/cleanouts/valves/taps intact & ,'`
accessible ? ❑ � ❑ "i+t� (�
Pressure head properly adjusted ? ❑ /❑ tJ'�r I'ur�n�ri �� j✓Id ��jn�(d /L' �P4v1��5 1���
COMPLIANCE:
Compliant ❑
Non-compliant �
Needs Maintenance
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