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A24 105w � � .�'�v�.�� ~ .31.� ' .i/� ..��0 G�I'7�3��v�Jx!IC� dJ•T`"G�1 / � ..7G.1 � C71� � � �(�'l.✓itJ-@%= ���%Yj iv/�in 3I N i6'•-251 o,r� .�ry:�;;�s�,`.t✓c.✓��aivz. � �� tn O'; Oq a� o C? .. � � � V y n• cy+. �. f9 e�+ �D C7 v � a N � N f/! ^� w �N c � w y �. "a � M fD � �1 � m fD ,,,� y . 5 b � �►. w .+ o �, N y � M � � �• � � � �. � .._ H \ - -- , � � �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`�"`'�- . . ,� , _ � � 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 \. Location of sewage disposal sewage system sketched on back. �,��,1 v.�,,,r' - u. � . (OVER) � _ � '.� � ' ' � ( �. v 0 `�°�� ����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.