A23 108z
- �e�son County Health Department �
Sewage System Improvements Permit
Date:_��-% �is�it j?oid �lfter��.'ears f �G2- ` ���
Subdivision Name: � e ''�
Lot Size: � Type of Dwelling:
Water Supply: Private: 1� Public: Com
Bedrooms: �— Garbage Disposal
Basement Basement Fixtures
INFORMA N D BY
owner or repies
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$c'1711(c'1t1c971:
REppIR: REEVALUATION: � �
Size of Septic Tank: �DU gallons Size of Pump Tank:�
Nitrification Line: � 3� •t ��A e o/►
Depth of Stone: 12 inches � "21 � gO
Max Depth of Trenches: 's R13
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:� Well should be 100 ft� from any sewer system
BY ;� Sanitarian
Date Sewa y Ap ved: � d'
BY Sanitarian / , , .� ,��
R ATE OF COMPLETION �,� 5�,�: �! �,�..�r� �j
Contractor. " ` ' � ' / "�'�
----- — ------- ----- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'�3
nitrif'icapon line must be inspected and approved by a member of the Person County �
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemtit is subject to revocation. �
(G.S.130 A-335F) _ m W
�
L.ocation of sewage disposal sewage system sketched on back. ,—
J a�Q
(OVER) —
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Person County Health Department �
. Weli Permit �
Date: �." `� is Permit Void After 5 ears ) "�r �
Owncr. ,� �' � '4'� �� /` ,f?,�2/� SR# / 3Z � �
Subdivision Name: G o t h Lot #
Drilling Contractor:
WELL CONSTRUCTION
Distance from Nearest Property Line Distance fmm Source of
Pollution
Total Depth: Ft. Yield: GPM Static Water Leve] FG
Water Bearing Zones: Depth Ft. FL FG FG
Casing: Depth: From to Ft. Diameter: Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve: Yes No
WeighG Thickness: Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
ff "yes" give reason:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width Tnches
Water in Armular Space: Yes No
Method: Pumped Pressure Poured
Depth: From to Ft.
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 ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
Sigr} e of Contractor i Date
I% s \ ,-
� �f/i f� � � j ') k�— �; —15f— `Jt-/
'�V C��, (
S�arutarian's ignature 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.
. . �'1 ,_,.. S It�� l � ?. 2