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Person County Health Department �
�wage System Improvements Permit
Date:'�7 -1,!' 7'?" This
Owner: �Q,
Location/Directions: _
Void ter 5 Years Permit # E��ap3 �
�n vi /_t. SR#
Subdivision ame: Lot #
Lot Size: ,'�%`� � � Type of Dwelling:
Water Supply. ivate: �� Public: Community:
Bedrooms: 2 Garbage Disposal
Basement Basement FiRtur�
INFORMATION CERTIFIED BY �
Environmental Health Specialist: o r or .s c'
REPAIIZ: REEV UATIO :
Size of Septic Tank: �a� allon§ Size of Pump Tank: ----
Nitrification Line: �r%/ � � � �
Depth of Stone: 12 inches
Ma�c Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
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Date Well Approved: � Well should be 100 ft from any sewer system
BY Envir nmen 1 H al Specialist
Date S age ys m ppmved• -- -
BY Environmental Health Specialist
�E�tTI�TCATE OF �OMPLETTON ,,..3
Contractor. �� r`� � /� � �e
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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 �
nitri�cation 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 .-il
the site plans or intended use change this pennit is subject to revocation. i
(G.S.130 A-335F) �
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Location of sewage disposal sewage system sketched on back.
(OVER)
y NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks; privies, water
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- 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.
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'� Person County Health Department
Well Permit
Date: ��1� Thi i V id A ter 5 Years
Owner. SR# �
LOC1ti0n/nirPrtinnc; �� ���
Subdivision Name: ' t #
Drilling Contractor:
WELL CONSTRUCI'ION
Distance from Nearest Property Line Distance fmm Source of
Pollution
Total Depth: Ft. Yield:�_ GPM Static Water Level F�
Water Beazing Zones: Dep Ft. FG FG
Casing: Depth: From to Ft. Diameter: Inches
TYPE: Steel alvanized Steel�
If Steel, does owner approve�No
Weighr. Thickness: e�ght Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: . /
Grout: Type: Neat San /Qement Concrete
Annular Space Width ��' Inches
Water in Armulaz Space: Yes No v
Method: Pumped Pr u e Poured
Depth: Fmm�to�FG
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: 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 EjC�CORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY H��,�•HjD�PART�IENT. (�
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Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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� NOTE: Make sketch of installation 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 at later date. Note location of water supplies on adjacent lots.
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