A24 136z
` person County Health Department �
Sewage System Improvements Permit
Date: Z- - 3 This Permit VRid After 5 Years Permit #�•
Owner: �ti v�n /�/ 1 C�Gl Y I lir� eI SR# ���
Location/Directions:
Subdivision Name: � Lot #
Lot Size: �--��e s Type of Dwelling:
Water Supply: Private: Public: mmunity:
Bedrooms: 3�0� b���'°'" arbage Disposal '
Basement Basement Fix `
INFORMATION CERTIFTED BY
Environmental Health Specialist: ` "�`� "`'e
REPAIIt: REEVALUATIO :
Size of Septic Tank• gallons Size of Pump Tank: ����� L��
�------- ' --•--
Nitrification Line: - ��� � J. _ _ /'> � �
Depth of Stone: 12 inches �n��� ��
M� Depth of Trenches: �''�
Altemative System: Conv. Pump LPP Pump �
Remazks: r1 � � . � � /' - ,A , l
Date Well Approved: Well should be 100 f� from any sewer system
BY Envir nmental Health Specialist
Date Sewage System Approved: ✓ ' � '� `
BY� � Environmental ealth Specialist
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,,,i CERTIFICATE OF �OMPLETION ,..3
COIIiCdC[Ol: �� ^ �• � � � r �
_ _ _ _ _ _ � _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ �
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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 s�li manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person Counry
Health Departrnerit before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemiit is subject to revocation
(G.S. 130 A-335F)'
L.ocation of sewage disposal sewage system sketched on back.
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•� Person County Health Department �
Well Permit �
Date�-`I-°� 3 This Permit Void After 3 Years o,F�
Owner: �'w. ,M L�► ✓I a,,�-� SR# r 3 z 2
Location/Directions:
Subdivision Name: U��C I�� 1►1`j�. Lot #��
Drilling Contractor.
WELL CONSTRUCi'ION
Distance from Nearest Property Line Distance fzom Source of
Polludon
Tatal Depth: FG Yield: GPM Static Water Level Ft
Water Bearing Zoncs: Depth Ft Ft. FG Ft.
Casing: Depth: From to Ft Diameter: Inches
TYPE: Steel Galvanized Steel
If Steel, does owner appmve: Yes No
Weight: Thiclrness: Height Above Ground: Inches
Drive Shce: Ycs No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
GrouG Type: Neat Sand/Cement Concrete
Annular Space Width Inches
Water in Armulaz Space: Yes No '-�
Method: Pumped Pressure Poured k
Depth: From to FG
Materials Used: No. Bags Portland Cement Weight of 1 bag „�
lbs. �
If mixture (sand �avel, cuttings) - Rado: to
ID Plates: Yes No
4 z 4 slab Yes No
De th
From To Formation Descri don
•d
�
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECf AND THAT �
'THIS WELL WAS CONSTRUCfED IN ACCORDANCE W1TH REGULATIONS SET ,�
FORTH BY THE PERSON CO HEALTH DEPAR'TMENT. �
C-'^y `` - —� of Con�actor Date
��' � '� z q3
I rj,,,` �v�.,� ' anitarians SignaNre Date Issued
�
Sanitazian's Signatuze Date Completed
Sketch well locadon on reverse side.
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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Person County Health Department �
Well Permit �
Date:�"y� � 3 T�h�isp etmit Void After 3 Years
Ovmer' �` M �+�1 C FA YI � N�
Location/Direcdons:
Subdivision Name:.
Drilling Contracwr.
o T�
sR# I 3 � z
L.ot #
WELL CONSTRUCi'ION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft Yield: GPM Stadc Water L.evel FG
Water Bearing Zones: Depth Ft Ft. Ft. Ft.
Casing: Depth: From to Ft Diameter: Inches
TYPE: Steel Galvaniud Steel
If Steel, does owner approve: Yes No
WeighG Thiclmess: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encotmtered in Setting the Casing? Yes No
If "yes" give reason� / '
Grout: Type: Neat SandlCement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No "
Method: Pumped Pressure Poiaed
Depth: From w FG
Materials Used: No. Bags Pordand Cement Weight of 1 bag
lbs.
If mixture (sand, gravel, cuttings) - Ratio: to _
ID Plates: Yes No
4 x 4 slab Yes No
I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON CO HEALTH DEPARTMENT.
�� � of �actor Date
� � � �.�. � yj`�3
� U,,,,, a.,.,l ` anitarian's Signature Date Issued
Sanitarieri's Signature Date Compleud
Sketch weA location on reverse side.
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 oi water supplies on adjacent lots.
(1) (2)
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