A23 161! "_--�,��� �'1 � C�U �
. P�'��son County Health Department
��``�`�ge System Improvements Permit
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Date:Z-"/'`�JY This Permit Void After 5 � �"Permit #
Owner: R9�1E� rt ��r k@�^�/i,�1�iWCs� �
SubdiviSion Name: � � � Lot #
Lot Size: � ry�'r � S Type of Dwelling:
Water Supply: Private: � Public: Community:
Bedrooms: � Garbage Disposal
Basement Basement ' ctures
INFORMATION CERTIFTED BY
Environmental Heallh Specialist: or repr s�uve
REPAIR: REEV UATIO :
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Size of Septic Tank: �� gallons / Size of Pu�np Tank:
Nitrification Line: ' ����,�. � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
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Date Well Approved: Well should be 100 f� from any sewer system
BY Environmental ealth S ecialist
Date Se S St roved: + - �
BY �' Enviro,nmental Health Specialist
� �CE�tTIFT A'�E OF COMPLETION ,�
Contractor. � � � � � • �' � � �
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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 yeazs 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 Coun
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intended use change this pennit is subject to revocadon.
(G.S.130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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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
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PET%S(J�t COUNTY HEAL i H EPARTMENT
� WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # '�2;3 Parcel # /� �
Zoning . ►^ . Town�iP
Owner/Contractor 2.' Date --��
Location/Address „ � , _ n n ,�, , , �
Lot#
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SE AW GE SYSTEM SPECIFICATIONS
Lot Area
Mobile Home_
# of Bedrooms
Permit Void after 60 months. l
Permits may be voided if site is
Well ���,�� Layout by
Comments:
Date Installed by
or i
Size of Tank
_ Size of Pump Tank
Nitrification Line
Max Depth Trenches _
if not in compliance with zoning
Approved by.
�-� - «
� ,s,� ✓ � WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab _z �
Public lacement Air Vent
Site Approved � Required Well Lo�
Well Head Approved Well Tag
Grouting Approved � 2- � '�
Comments:
Date Installed by.
Approved by
This repoR is based in pazt on information provided the homeowner or his/her representative in the application submitted for this pe:mit The
environmecrtal health specialist is not responsible for false or misleading infonnation cocrtained in the application The emironmental heahh 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 Coumy nor the environmental health specialist warraats that the septic tank syscem will
continue to fundion satisfactorily in the future or that the water supply will remain potable: c:lacnipro�permitsam O 1/95 rev.1.0