A40 41Az
Person County Heaith Department �
Sewage System Im�ov�ments Permit
l' S ha�n na. �+-y o r
Dace: "-S" 1 Th�s,�Permit Void Aft�r 5 Y�us Pennit �,�
Owner: r '' S� -� �%
I,ocadon/Directions: • - S � � /�',
{ i'1 !t 'i.t'"� �, y-�::r� ' l�- �+r- �� f.,L�r.p
Subdivision Name: � I,� #
Lot Size: + L� C� P<' Type of Dwelling: �"t�i t�
Water Supply: Private: Public: Community:
Bedrooms: .3 Garbage Disposal
Basement Basement Fixtures '''
INFORMA'I�T�1 �R�D BY
$Bllltili'18I1:.i t/�,)�r �ty � Jti���? ,; � owneror entative
REPAIK: REEVALUATION:
Size of Septic Tank: _� �ons Size of Pump Tank: ----
Nitrification Line: _ ���� "�)C .S' �
Depth of Stone: 12 inChes � � 00 '�C 3� C,F'-r �. ar, S-1� -�
Max Depth of Trenches: _ iI?�
Altemative System: Conv. Pump LPP Pump
Remazks:
-------------------------
Date Well Approved:�C��� Well should be 100 ft from any sewer system
BY Sanitarian
Date Sewage ystsm App ved: �"/5(-g�
BY � Sanitarian
CERTIFICATE CO LETION
Contr�tor.
Sewage System location, installarion, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 yeus 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 Counry
Health Depazunent 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)
L,ocation of sewage disposal sewage system sketched on back.
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NOTE: Make sketch o! installation showing lot size and shape, location oi 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)
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