A23 49Person County Health Department
Sewage System Improvements Permit
Date:���3_q3 Thi Permit Void After 5 Years Pe it # �- -/ -�
Owner: � P�' �rn e /�1 c i�a r7a �� SR# �
I,ocation/D'uections: CL�-, �.-,.�, ,�;�-
Subdivision N e: P 11 '� � Lot #�
Lo[ Size: ype of lling:
Water Supply: Private: Public: Community:
Bedrooms: �_ Garbage Disposal
Basement Basement Fixtures
INFORMATION CERTIFIED BY r, _� pl .� �
Environmental Health Specialist: � ner or er,�u�e
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: �� gallons Size of Pump Tank:
Nitrification Line: �('�n � i�.3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: �- � 0 � /_� l�,�.,-� -��a�.,,,;�'-
Date Well Approved: Well should be 100 f� from any sewer system
BY Environmental Health Specialist
Date Sewage System Approved:
BY Environmental Health Specialist
CERTIFTCATE OF COMPLETION
Contractor:
Sewage System location, installation, and protection must meet state and local
regulations. Septic tank 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
nisification 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 pemrnit is subject to revocation.
(G.S. 130 A-335F) _
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
��
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)
(2)
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