A23 130` � �
Person County Heaith Department �
Sewage System Improvements Permit
Date:.�' �.�=a� �'his Permit V'd After3Years @� nd 0�
Owner:—�[.�— �r� S��Y� SR# %�� �
Location/Directions: � �� �� ����
Subdivision Name: � �r�yLot # /�
Lot Size: A►� T of Dwelling: _
Water Supply: Private: Public: Community:
Bedrooms: 3 Garbage Disposal _
Basement Basement Fixtures
INFORMA IE BY
$�1��: owner or representative
REppIR: REEVALUATION:
-------------------------
Size of Septic Tank: gallons Size of Pump Tank:
Niiri�cation Line: l�i�� � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: Well should be 100 ft from any sewer system
BY anitarian n
Date S S ved: "' ��!
By Sanitarian
TIFT ATE OF COMPLETION
Contractor. _.�TW��,�jl�» r -
------------------------- �
Sewage System location, installation, and protection must meet state and local �
regulations. Sepdc 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 hazazd. Septic tank and'd
nitrificaaon line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernu[ is subject to revocauon.
(G.S. 130 A-335F)
L.ocadon of sewage disposal sewage system sketched on back.
(OVER)
SC`�.� �-�,-\-I`TOTE: M�tk
� . 3upplies, etc.
� ,
a at
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+ .�
l3.
of installation showing lot size and shape, location of house, septic tanks, privies, water
^ia� lems exis in Write in measurements in order that installations may be located
�tio�6f �va r s pplies on adjacent lots.
I\ �-�,�
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.�?erson County Health Department �
Well Permit �
Date: - y-qz This Pennit Void After 3 Years �P�c� af '�
Owner. � ���r, SR# I 3.� /
I.ocadon/Direcdons:
Subdivision Name: Lot #
Drilling Contractor: �` � � Z
4' � y_(o 7 Y—% i y�j ELL CONSTR CiTON l�/e6.�� ��' �'' Z� ►�
Ihstance from N�t Property Line�� �tan� fr�m�ource of Z�3 �� P-�'
Pollution /�
Total Depth:�o FG Yield: �GPM ta 'c Water Le�l F4 �
Water Bearing Zones: Depth Ft. � Ft. Ft. Ft.
Casing: Depth From '�� to . 3��'LFG Diameter: ' Inches
TYPE: Steel � Galvanized Ste� 1
If Steel, does owner approve: Yes C/ No � �)
WeighG i` Thic� � Height Above Ground: �1� Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason: ''d
Grour. Type: Neat Sand/Cement Concrete �
Annular Space Width � Inches
Water in Annulaz Space: es No �� �
Method: Pumped Pressure Poured
Depth: Fmm �3-L to �„� D FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, gravel�ut �gso - Rado: to _
ID Plates: Yes �/ .d
4 x 4 slab Yes No t� :;
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEAL D A M
�� ���— -` Si f Con actor Date
�� �, �,,, �4 �y��2
� v� po�i�� Sanitarians ignaNrc Date lssued
1 ��U �' '
Sanitarians Signature Date Completed
Sketch weli location on reverse side.
� 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
.rat later date. Note location of water supplies on adjacent lots.
� , �1) (2)
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