A23 129Person
Sewage �
Date: JU� This
Owner: �
Locaaon/Directions: _
Coun�ea�th bepartment z
, �
�ystem Improvements Permit �
�Years Pennit #
�n SR# /3� t
Subdivision Name: �/ P1� � 7�a�y /70✓ Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement Fixtures
INFORMATI D BY D
5���: owner or tauve
REPAIIt: REEVALUATION:
-------------------------
Size of Septic Tank: � gallons Size of Pump Tank:
Nitrification Line: ���j� �, �
Depth of Stone: 12 inches
Max Depih of Trenches:
Altemative Systsm: Com. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: Well should be 100 fG from any sewer system
BY Sanitarian
Date Sewage System Approved: � D- z L- 9�
BY W.�:cl�n� ,�,..na.�Cf Sanitarian
� CERTIFICATE OF COMPLETION
Contractor. ��� '�— - �..�
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc 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
nitrification line must be inspected and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this petmit is subject to revocation.
(G.S. 130 A-335F)
L.ocatian of sewage disposal sewage system sketched on bx
�vn � �-�� �` �� �� ���a �sf-
(O R};�
n
�
�
s�
�
:► � � � � � �-e �' c�c�.'► �-- A 13 0 7
�
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # & �3 Parcel #
Zoning Township n r1 �
Owner/Contractor ��, }-1 � v . }�� � n �,/ D te �-I - � � -
Location/Address � p� � p.� �;� a. l
La"; �nL � �� S.R.# 13� 1
Subdivision Name }-�..Q�- �� ��-{ ��' �� Lot# l ��
I SEWAGE SYSTEM SPECIFICATIONS I
Lot Area � . � b /-�C.
Mobile Home
# of Bedrooms 3
Size of Tank
Size of Pump Tank
Nitrification Line
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed. „
Well and Septic Layout by
Comments:
Date
Installed
Approved by
WELL SYSTEM SPECIFICATIONS
Individual f Semi-Public Required Slab ✓
Public Replacement Air Vent nd� S�� ��+�t�j -f1��
Site Approved Required Well Lo� �� �/q'$ Q�L
Well Head Approved Well Tag ✓
Grouting Approved � � �,� q �
Comments:
Da`�e In'�talled by�,���,nW;11;2m�r�pproved by -�.�2 ...u�
This report is based in part on information provided the homeowner or his/her representative in the application mitted for this pemvt. i
environmental health specialist is not responsible for false or misleading infoRnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank systetn will
continue to function satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c:�amipro�permitsam Ol/95 rev.1.0
: L� l,�?TC�1 C�TP��"COIZS
P�RSON COUNTY ENVIRONM�NTAL H�ALTH
�
WELL LOG
Date: �" ��"� � �� �� . SR# _
Qwnc:: �
Location/Directions: . ,
Subdi�����on Name: d�LU
D 'llin Contractor: �a
c
L�t -�
ri g � WELL CONSTRUCTION
Distance from Nearest Properry Line _ Dist�uice from Source of
Pollution
Total.�ep.th: Ft. Yield: 3 GPM Static Water Level Ft.
Vtiater Bearing ,�.ones: �er� F=. Fr. FG �t.
Casing: Depth: From=to 3 Ft. Diameter: �_o ��4 Inches
✓
TYPE:
Grout:
Steel � _ Galvazuzed Steel
If Steel, does owner approve: Y�s No_
Weight: __ Thickness: • � Height Above Ground: Inches
Drive Shoe: Yes No � . ►
Were Problems Encountered in Setting the Casing? Yes No
;f "ycs" givc rc:,►son: .
Type: Neat Sand/Cement Concrete
Annular Space Width 12. Inches
Water in Annular Space: Yes _ No_
Method: Pumped � _ Pressure_ Poured •=
Depth: From O to 20 Ft.
Materials Used: No. Bags Portland Cement_. Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to '__
ID Platcs: Ycs � No � �
4 x 4 slab Yes ✓ No
T HEREBY CERTIFY THAT THE ABOVE 1NFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
. ,
• �1-13 �8
� Signat�ire of Convact � Datc
�