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Person County Health Department
�ewage System Improvements Permit
;.��=-�or.4-This1 Permit Void yAfterj)Yeazs �� C v�d v�
Pr• . `�.��� , A 1•/1(n %�✓ft�5'"/YL4if'`Io.�i 1�. �.SR� J.�
Subdivision Name: �v '✓Lot #
Lot Sizc: � r� T of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement Fixtures
INFORMA���IE BY
SaI11taI'Iall' - w'n or rc resentauvc
REpAIR: REEVALUATION: �� ���
Size of Seppc Tank: gallons Si � of Pump Tank: �`�
% �;
Nitrification Line: '
Depth of Stone: 12 inches
Max Depth of Trenches: �
Altema[ive Systcm: Conv. Pump LPP Pump `��
Remarks:
z
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Date Well Approved: Well should be 100 ft. from any sewer system
gy Sanitarian l(/
Date Sew,a �� ys p oved: x�•— /�` '��
gy Sanitarian
� CERTIFiCATE OF COMPLETION
Contrac[or: --�"�'�'� �--e��s
�
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 ycars and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and �
nitritication line must be inspected and approved by a member of thc Person County
Health Deparunent before any portion of the installation is covered and put into usc. If
die site plans or intended use change this permit is subject to revocation.
(G.S. 130 �-335F)
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Lo� n o�'"sewage disposal sewage system sketched o{l back. �?!-'�' '
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-�`-=�er�on County Health Department �
• Well Perrnit �
Date: �- �� '�is Permit Void After 3 Years �� `' '' �l tS�
Owner• �'�, I� 1� r1 t. C,o ►� S'�'� � c-�.,�, (.d . SR# 1:3 .>.Z l
Location/Direcdons: U
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� .� y: �:- Lol # -1
Subdivision Name: � �
Drilling Contractor: �'J n s � �
WELL CONSTRUCI'ION rd
Distance from Nearest Property l.u►e w�5 Disiance from Source of E"-n+
Polludon ��.,� ��-� �
Total Depth: �,�5.`�t• Y�eld: ,� „� __GP� Staric Water l,$vei Ft. �
Water Bearing Zones: Depth '�2;� F�• Ft. Ft. Ft.
Casing; Depth: From �_ ��- F� Diameter. 6:�_ Inchcs
TYPE: Steel Galvazuzed Steel '�
If Steel, does owner approve: Yes No
Weight: __� �___ Tluclrness: -�'� Height Abova Ground: �� Inches
Drive Shoe: Yes '�� �o
Were Problems Encountered in Setting the Casing? Yes Noti-"'�
If "yes" give reason:
Grout: Type: Neat Sand/Cement v'" Conaete
Annular Space Width � inches
Water in Annulaz Space: Yes No _.. �--"
Method: Pumped Ptessure Poared C..-�
Depth: From �_ to �— Ft.
Materials Used: No. Bags Portland Cement _,�. Weight of 1 bag
� 4 lUs.
If miicture (sand, gravel, cuttings) - Ratio: _�_ �o _�..__
ID Plates: Yes V M�
d x d clah Yes +�r NO
�
I HEREBY CERTIFY THAT THE ABOVE INFOR.MATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSOId COUIV'TY HEALTH DEPARTMENT.
J � • `�`- � � � 2_-.-
,�
c:..., ti e,. nn�a� Ynil .Date `
Sketch well location on reverse side.
Date Issued
Sanitarians Signature Date Completed