A24 135f�epa ,'� %���r�,'� issu.2c� by
' ' f�a.�-�Y a - .
.; �
Person County Health �epartment
Sewage System Improvements Permit
Date: �-�s -92This Permit Void After 5 Years
Owner: To�.� -�%���' SR# �32Z
Locauon/Directions:
SubdivisionName: Gl�k %�o�.�.�-e Lot# `�v
Lot Size: l. '7� a� Ve S Type. of Dwelling: .
Water Supply: Privatc: —� Public: Community:
Bedrooms: .3 Garbage Disposal
Basement Basement Fixtures
INFORMA N CERTIFIED BY
$�1��: owmer or representative
REppIR; REEVALUATION: -
Size of Septic Tank: �_ gallons Size of Pump Tank: f �%
Nitrifica[ion Line: sd 0�?�� �S �� �iC3 ` a.at�ui a�
Depth of Stone: 12 inches 4y S�''ES ,� _ S-2o�Y1
Max Depth of Trenches: �
Altemative System: Conv. Pump � LPP Pump
Remarks: �
�
�
Date Well r�� :�L Well should be 100 f� from any sewer system
BY� Sanitarian .
Date Sewag� Syste Approved: S-ZO-9Z �v�li �'-e%�
BY �9 �- Sanitarian Co v<�.r� d w/�
CERTIFICATE OF COMPLETION Sv i/,
Contractor. T�r+r��i Lo,,,•; *
------------------------- �
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tanlc 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'd
nitrif'ication linc must be inspected and approved by a member of the Person Counry �
Health Depar[ment before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G.S.130 A-3SSF) �
Location 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
.r.�c later date. Note location of water supplies on adjacent lots.
S1) �� �2>
��
���������
���������
T
4l=
/ sP/ r'vc r' puP
' �
}-�,e a.►.,�3ia�� cy4 >'�9 rsa�ds.
l;��a S,i,� n�i r�-�I r/% —� ���
I i,%'� Ct=�' �(�l^It�r f' `_:> /.'- i'`;� ,o� �
�� . � � � z
C� �P
Pers�r�ountyy�iealth Department �
Sewage S�/stem Improvements Permit I�
Date• ' is Permit V id After 5 Y s , a� �
Owncr: ' �10 n�i1 R# � zZ --- ,
Location/Direcaons:
� �.
Subciivision N e: "� ��� F� Lot #
Lot Sizc: Type of Dwclling: �
Water Supply: Privalc: � Public: Community: I.
B��ms: G age Disposal
Basement Basement Fixtures G
INFOR N E T D B � �`S~
,+ $�1� M � _ J�A��' _' I owncr or rep rntative j
�pp�; REEVALUATION:
' Size of Sepuc Tank: gallons `Size"of Pump�Tank: �
�' Nitri�cauon Linc: f s n�
. �.
Depth of S�one: 12 inches 5 � Lr � .� -%
1VI�uc Dcptt► of Trcnchcs: �'"" �• ' � ., ��
Al�emalive S stem: Conv, Pump LPP T'um� ''
. Remarks: ,� ✓ �' .,:1 �7 i' X � � r: � �r
„ `� •s �, , .�.,.! s' � i � ��_� .� j� , , L�_,; -t � ;�, 7, .
----- . . -�----
Date Well Approveci; Well should be 100 ft� from an sewer%system1`
gy � � S�nitarian � � ..
Date S c st proved: ' . -" v
' gy sanitarian . f
R CATE OF COMPi,ETION ( ht
Contractor. n, �,-;; � � , a °�-�-�
� ' �-------- ----'---- -----�------- �,
� Sewage . System location, installation, and protection must mect st�te and local '�
regulations. Sepuc tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tanlc and'b
nitrif'icauon line must be inspected and npproved by a member of the Person Counry �
Health Deparcment before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation. �
'; (G S. 130 A-335F) , . . ,... . ` ,
, . .. . ; �
• Location of sewage disposal sewage system sketched on back. �
(OVER)
�rson County H�aitM Department �
�-^ Well Permi.t �
Date: .�'-�3 �/This Permit Void After 3 Years o� '�
Owner: T'�ti► S►� j�o� SR# 13 2 2
Locaaon/Directio�ns�-
Subdivision Name: Lot #
Drilling Contractor.
WELL CONSTRUCi'[ON ►�
Distance from Neazest Propeny LineTl$r Distance from Source of P�-'
Pollution cD.
Total Dep�FG Yeld: �GPM Stadc Water Level �F� �
Water Bearing Zones: Depth Z.�/- .� Ft �� �` Ft �
Casing: Depth: From �_ to ��, �/" Diameter: Inches
TYPE: Steel ' Galvamzed Steel
If Steel, does wner appmve: Yes No
Weigh� � Thiclrness: �' Height Above Ground: �� Inches
Drive Shce: Yes ._,�,� No
Were Problems Encountered in Setting the Casing? Yes No -�
If "yes" give reason: ''d
GrouC Type: Neat Sand/Cement Concrete �
Annular Space Width � Inches
Water in Amilular Space: Yes No�
m
Method: Pumped Pressure S Poured - .
Depth: From to FG,
Materi Used: No. Bags Portland Cement � Weight of 1 bag ^
C� ] /
If r(sand, avel, cuttings) - Ratio: �_ to
ID Plates. _l� No .�
4 x 4 slab Yes No� � M
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
_ I G " cs.�ir"—' S'��% i
r ' Simanae-e�nntractors _ .wl
Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.