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�ey��on Couniy ealth Departrnent
S��A��ge Systern Improvements Rermit
Date:y -`��.'I't►is Permit Void Aft r 5 Years Permit # E�-�" �=� `"`�
_�� r.
Owner: ��'� �'� � SR# ? '�_
Location/D'uections: , �
r _.., z �. ,� , � � Lot # ��
Subdivision Name: -
Lot Size: `' `'G Type Dwelhng:
Water Supply: 'vate: �� Public: ' Community:
Bedrooms: _ �_ Gazbage Disposal
` Basement Basement Fix es
INFORMATION CERTIFIED B '— � �.
Environmental Health Specialist: ' ,' � r or tepres, tative
REPAIR:. REEV UATION: . `�`''J"
��j -------�- --�,,� � �-1
Size of Sepdc Tank: _�!c��
allons Size of'Pump Tank: L�� ,�.5
Nitri�cation Line: ���� �� . ., ,,
Depth of Stone: 12 inches �` � �%- ��l�---a' � t«� ., '�
r t�"� v�o �� �,. .t,-r
Max Depth of Trenches:
Alternative SysGem: Conv. Pump Lpp Pump � �� p`�"`'�- .
. ,� , _
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Date Well Appmved: ��� 1"`y� Well should be 100 ft� from any sewer system
gy � Envi onmental Health Specialist
Date Sewa ��stem Ap ro, • " `� " ��
gy .,�. r• �,� nvironmental Health Specialist
CERTIFTCATE OF COMPLETION ,-3
COIItraC[OI: �+'h"'` v � +�+� � � - ?C
����.���������.��.������������� ��
Sewage System location, installauon, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shatl be maintaineci
by owner in such manner as not to create a public health hazazd. Septic tank and �'>
nitrification line must be inspected and approved by a member of the Person County y�
�
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change 's permit is sub'ect to revocadon. i� �
(G.S. 130 A-335F) /� �`,�7 _�� [ I�� D`�� „,� ✓ � �a
�/� � Ti �,T
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Location of sewage disposal sewage system sketched on back. �,��,1 v.�,,,r' - u.
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. (OVER)
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`�°�� ����ric� ���0�� ��p����������
CASWELL - CHATHAM - LEE - PERSOP�I COUNTIFS
����r S�pply a�d ��w�g� �s���a���
INdPROVEEe!lENTS PEAtdl�T No._—
DBtE' ." ,..3, �}. - ^ �_-,_�—_�
.. ; .'�
-� � �''�`� Contractor: ' "' "' -"
.M�^`�� �
', f,�r�,��r� � Wa3er aupplp: Private , Public
., ,.W.. } --
;..
� _ :.'.. � 1 ,' �.�` �1. _ , � ,� z
� �. .
�6 I i—�+ . , ..� � r , i
Sewaqe Disposal Faeiliiies: PTo. bed;oocns �- Dishwasher; �isposal,
.��-...,_.
washing machine,..otirer �automatic appliances "'�y�
'` + '.i', �r '
� Siz�-of -t�`iilc � � � ` ` y� `� `Nitri�Ication line ` ,
, � ,—'.t l r s�r , �- . .
Other di�gsaY �ilixy,s� � .r_ � � ' : � .- ':, , ` - �
�.w ;� : ,;, „ v , , , . a,
,�,.,.,,,.,..�,�,. `' � �
Water p � nd sewage• disp„osab�•fa�iT'i�ies location, installation and
protect' must meet st�te�`�nd local regulations.
5eptic tanlc shou�.�tie'�pumped out every 3 to 5 years aii3 sh211 be ma�n-
tained by, ow,�eP'in such a manner as not to creatQ a puulic health hazard.
S�eptic tan`""i'�c and nitrification line MUST BE IPISPECTED ANU 11F'-
PROVEI} BY A MEMBER QF THE DTSTRICZ` HEALTH DEPAR'P1�F:t•t'I'
STAFF BEFORE E1NY PORTION OF THE IN$TAI.�.ATIOT� j� �'�J�i- i
ERED AND PUT INTO USE./� f • � � . � � ,
�'�� S i�i: u2 la '�i� 5"fC:s�7 �; i%� �
�• C3-Y'1 %"��:BLi i�l° ii/1'I 1 `�' ' `; � ; ; ji�.: � � SYt4 ;�, ,R � x
Date appr ved• Signed f r" t J, �% ;,�,�, ,.
� j '�a itarian �
Well: �� `
•-----
,
Sewage Disp s 1:� '1� — Counter- f'� �' � 1
signed x�'''�''�r''s�:•�''�' �'�'�!.��
By: (Owner or his representativ�).
�..�� '� � «��
r• ,,
Cesifi'icate mf Completion r` �/ �; � h,,;t�
��+�� y ` t
.. .�` � �1..-�.`Y �!�'� � ( , '� �,�f _'�'�,
PP � 1.;�+�J � '�'% � i r
Date A roved: � BY`� �� , —•
. � Sanitarian ' � .
(OVEA)
Location oi well and sewage disposal facilities sketched on back.
�����ra ���r��� �e�i�h �ep��t��r�t . . �
VV��! Perr�i� �
�
Date: 3-- --� 3 This Permit Void After 3 Years --. � . a�T
Owner. � � �- � -- L 1 / �S n, t-�'' SR# ! .�36
I.ocadon/Directions:
Subdivision Name: - �i� n ���`��'i� >>`�� ��'' -Lot #
Drilling Contractor. _, =' +f � - .,- (-ei . �/ �.-
Distance from Nearest Property Line �. z��a �- Distance from Source of
Pollurion,; >: 4' �!�- � �' T; .��
Tatsl Depth:.���i F� Yield: �`.�-- GPM Static Watez Level `' �%'"�'"; F�
Water Bearing Zones: Depch ��' F� Ft. F� F�
Casing: Depth: From �`�_ to �� F� Diameter: ��_ Inches
TYPE: St$el Galvanized Steel =•-'� �
If Steel� dces owner agpmve: �'es �f No
Weight: �' �.�� Thicirness: ° Height Above Groimd: � Inches
Drive Shce: Yes �''� No
Were Froblems Encountezeci in Setting the Casing? Yes No '
If "yes" give reason•
Grou� Tyge: Neat � SandlCemznt "''Concret�-
Annular Space Width .-�� Inches
Water in Armular Space: Yes No =�-` �
Method: Pumged Pressure Poured �s- x
Depth From x�'; to .y-�� F�
Materials Us�d: No. Bags Portland Cement � Weight of 1 bag ,�
. �,� lbs. .,�
ff mix�ure (sand gravel, cuttings) - Ratio: � to �_ �"
ID Plates: Yes ' a// `" No I
. 4 x 4 slab Yes ✓— No ._. ..
I HEREBY CER'I'IFY THAT THE A�OVE �1FORMATION IS CORRECT AA1D THAT �
THIS.WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGUL.ATIONS SET r-
FflRTH BY THE PERS�N C�UNTY HEALTH DEPAR'TMENT. �
Sanitarians
Dace
�iyr�
Date Issued
Sanitarian's Signature Date Completed
Sketch well locarion on reverse side.