A24 126PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
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Date of Inspection System Installation ate Type Tax Map Parcel #
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Properly Address
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM: YES / NO ���5
Evidence of leaks ? ❑ � � I�p
Tank risers accessible, free of ��Q e� l U'P►^.� �! 7i r
infiltration and surface water diverted ? / .
Septic tank needs Lm �ng ? � � � �.ert-�- � 1 Li Q � d� �yt�l �1�(i�
Inches of solids. � �J
Septic tank filter cleaned ? ❑ �❑ N
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ? ��
Inches of solids(pump/dose c):�
Elapsed time readings ?
Counter readings ?
Drawdown rate:_
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DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? �-
Diversions/swales properly maintained ? �
Vegetative cover maintained ? �
Protected from traffic/unauthorized uses ?
Distribution devices in good condition ?
Field free of settled or low areas ?
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PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑ �
Pressure head properly adjusted ? ❑ / ❑ �
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
ADDITIONAL COMMENTS:
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PERSON COUNTY ENVIROI�IMENTAL HEALTH
• WELL LOG
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Subdivision Name: _ �t #
Drillir:g Contractor: lleri� /3���� Y-r� �—
. � WELL CONSTRUC'I'ION
Distance from Nearest Properry Line Distance from Source of
Pollution
Total.Dep.th:�_ (�o F� Yield: 6o GPM Static Water Level 25 Ft.
Water Bearing Zones: Depth SSt t. � F� � F� �t.
Casing: Depth: From O to 3o Ft. Diameter: �%N Inches
TYPE: Steel • Galvaniaed Steel x
If Steel, does owner approve: Y�es No
' Weight: Thickness: •! �d' HeighrAbove Ground: '/ 6', Inches
Drive Shoe: Yes_�_ No � .
Were Froblems Encountered in Setting the Casing? Yes No_�
If "yes" gir•e reason:
Grout: Type: Neat Sand/Cement JC Concrete
Annular Space Width Inches
i�ti ater in Armular Space: Yes No
_.. Method: Pumped Pressure � Poured 1� � ..
Depth: From O to 2d Ft.
Materia]s Used: No. Bags Portland Cemen� Weight of .1 bag,__ibs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes x No � �
4 x 4 slab Yes 1{ No
I HERERY CERTIFY THAT THE ABOVE INFORMr�TiOiv iS CGRRE� AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SE7
FORTH BY THE PERSON COUi1TY HEALTH�DEPARTMENT.,
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ignaturc of Contractor Dat�
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�_ P��:�on -County Health Department
Sewage System Improvements �Permit
Date. : - " - --Thts:Permit Void�After�Years - ?'f�
Ovmer.. T,�,�II�M gS. . 5�,� P�FS/`'��� .:�SR#- �..��
LOCa[lOiif D1teCf10I1S: '
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Subdivision Name: � .� . - L.ot # .��
I.ot.Siie: tY�' Type of Dwelling: .
Water:Supply: Private: Public: Community:^_
Bedrooms: 3oY � Gazbage Disposal, _
Basement '"`—�' Basement �ztures
INFORMA� ]r/�..,ff /�rD BY � ' � .. . —
C�nitarian• � /�w�.s ����OWIIC[OiiCpIESCR',2.[1V8"���
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REPAIlt: REEVAL ATION•
S�' e� of Septic Tank: �� gallons ''Size of mp_T
.
Nitrif'icadon Line: �t!').:�- / K-`3 ,trA�r► �� .
Depth of Stone: 12 inches _ - `
Max Depth of Trenches: _�
Alfemarive System: Conv:�i�mp :... ,. - LPP Pump --
Remazks: �
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Date Well Ap
BY�Date Se ge ;
BY �.n/h
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100 ft�� from any sewer system
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Sanitarian � '
Contractor. J, L.ax,ut3 .; l' ,�(��5 a� a..,,.1�� �—
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Sewage System location, instailation, and pzotechon musC meet • state an�i local �
reguladans. Sepdc tanlc should be: pjomped out every'3� to 5 years and shall be maintained
by- owner in such manner as not;`to create, � public health hazazd. Septic tariic and'•d
nitrificatian line must.be .inspected'...and': approved by a member of the Person County �
Health Deparnnenrbefore anj+ poition;of the installation is covered and put into use. If
the site plans or intended use;change.this peIInit is subjecrto'revocatiun. �
(G:S.130 A-335F) �
I.ocaaon of sewage disposal sewage system-sketched on back. �
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