A41 40� Person County Health
Weil Permit
�- �-93 �rt
Owner: -du�1--d
Location/Directions:
Department �
�
Subdivision Name: Lot #
Drilling Contracwr.
W F.i .t . c'ONS'i'RUCTION
Distancc from Nearest Property Line Distance 5rom Source of
Polludon
Total Depth: Ft Yeld: GPM Stadc Water Level FG
Water Bearing Zones: Depth Ft FG Ft Ft.
Casing: Depth: From to F� Diameter: • Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve: Yes No
WeighG Thiclmess: Height Above Crround: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No �
Method: Pumped Pressure Poured k
Depth: From to Ft �
Materials Used: No. Bags Portland Cement Weight of 1 bag „�
lbs. �
If m'vcture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes No
�
From To Formation Descri don
"d
�
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCI'ED IN ACCORDANCE WITH REGULATIONS SET ,�
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �
Signeaae of Contractor Date
L'f%G�� 1��GG+-r�s�- !D " �%�.3
Sanitarians Signattue Date Issued
Sanitarian's Signature Date Completed
Sketch well locarion on reverse side.
..,
�
�
� ��
;�i
�6� Je��rS
Person County Health Department
Sewage System Improvements Permit
Date: a" 7' This Permit Void After 5 Years Permit #
OWfler• _ �
Location,/Directions: � i�ru�� �"-e-r=�
Subdivision Name' t #
Lot Size: ��-r��- Type of Dwelling: �� _
Water Suppl : Private: L' Public: Community:
Bedrooms: � Garbage Disposal �l/' o
' Basement� N� Basement Fixtures � o
1NFORMATION CERTIFlED BY •
Environmenfal Health Specialist: t�J �.�L2ow,�a rc�� res+ en�`
REPAIlt: -� REEVALUATI�N: ---
Size of Septic Tank: /�"�a7 gallons Size of Pump Tank:
Nitrificadon L'ine: �00 �X 3 �
Depth of Stone: 12 inches `
Max Depth of Trenches: C• L .
Aitematiye■5vstem: Ccnv. n LPP PumD —
- - .� _. . .. _.
Date Well Approved: Well should be 100 f� from any sewer system
gy Environrriental Health Specialist
Date Sewage System Approved:
gy Environmental Health Specialist �
CERTIfICATE OF COMPLETION •
Contractor. . ' •
-------------------------�.
Sewage System location. installation, 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
nitrificadon 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 plans or intended use change this pennit is subject to revocation.
(G.S.130 A-335F�
: L,ocation of sewage ciisposal sewage system sketched on back.
(OVER)
.�.. ___,..,.... ....,..M.�.t�»�,-�,�......�.�....:•..�..:,
�
.�
�
CC
a
`
Tax
PERSON COUNTY HEALTH DEPARTMENT
WE � SEWAGE SITE, LOCATIOl� I��VIl'1ROVEMENT PERNIIT
Map # ,�� Parcel # �f—�J
ig Township �' `
A 1476
Subdivision Name Lot#
,, , , r i . !/
1'
� � �
� �
� ,,, „
�
. , �. .
i
� � r i I
', .
� � ,
� ...
� /�'� � /'
r ,-�� ^ �
� �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area f d�ic,� Size of Tank l��
SFD Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms� Nitrification Line yc a o�X3
Max Depth Trenches ��
.
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is altered or intended use changed.
Well and Septic Layout by%�fC.� .F=���t�v�-v-..
Comments:
Date `6' ^
by,
� a�-g �
Approved by
�
_� ' / � " 'WELL SYSTEM SPECIFICATIONS
Individual�Semi-Public Required Slab �
Public Replacement Air Vent -�
Site Approved +�%� Required Well Lo� �.s
Well Head Approved -✓ Well Tag �-
Crrouting Approved r/- (�{- 6-t7 �� ,°`j �- _
Comments:
Date /o / 6� Installed by /-�.,,, � LQ,_ Approved by
This report is based in pazt on inforcnation provided the homeowner or his/her representative in the application submitted for this pernut The
environmental health specialist is not �esponsible for false or misleading information contained in the application The environmental health specialist
is also not responsible for concealed conditions on the properiy or for statements in this repoA that may have resutted from false or misleading
statements provided to him in the appticatioa Neither Petson Cowrty nor the environmental health specialist warrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amiprolpertnitsam Ol/95 rev.1.0
ORIGINAL
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
�� �
Date: d
Owner: _�
�
SR#
Subdivision Name: Lot #
Drilling Contractor:^ c��t( � 2,�.� � r�c
� WELL CONSTRUC`I'ION—�
Distance from Nearest Properry Line 1 c1 Distance from Source of
�..
Pollution ( G a
Total.Dep.th: IZO Ft. Yield: 34 GPM Static Water Level o'�.f' Ft.
Water Bearing Zones: Depth�_Ft�O� F�. Ft� Ft.
Casing: Depch: From Q to Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
� Weight: Thickness:� � Height�Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No -
i
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason: �
Grout: Type: Neat Sand/Cement / Concrete
Annular. Space Width Inches
W.ater in Aruiular Space: Yes No
_ .. Method: Pumped � - Pr:ssure � Poured � . _ . . �� �
Depth: From O to � C� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtule (sand, gravel, cuttings) = Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes i 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 COuivrl'Y HEALTH DEPARTMENT.
. -1_ QO
ignature of Contractor D< i�