A24 137� I�erson County Health Department
Sewage System lmprovements Permit
Date: "'�1� This Permit Void After 5 Yeazs Permit #
Owner:_ �/�j��` • SR# �Z-
Location/D'uections�
Subdivision Name: � v Lot #
Lot Size: - Type of Dwelling.
Water Supply: Private: Public: Community:
Bedrooms: 3 ' ' Garbage ' posal
Basement Basement ixture
INFORMATION CERTIFIED BY
Environmental Health Specialist: O1
REPf,IR: REEV � UATION:
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Size of Septic Tank: 'a�� gallons Size of Pump Tank: '
NiUrification Line: _ _ _ _ �(�(�j�3 °
Depth of Swne: 12 inches
Max Depth of Trenches•
Altemative System: Conv. Pump LPP Pump
Remarks:
� •
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Date Well Approved: Well should be 100 R from any sewer system
BY Environmental Health Specialist
Date a Approv
BY Environmental Health Specialist
„� CER CATE OF COMPLETION ,�
Contractor. _ _ � � � � .c2,��,n'c �
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Sewage System location, installation, and protection must meet state and local �
regulati�ms. Septic tanlc should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to crea{e a public health hazard. Sepdc tank and
nitri£r.aticm line must be inspected and approv�d by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernrit is subject to revocation.
(G.S: 130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
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: :�:P'��� °���D���,�����i� ������i��� '
• � ����� ���l��t �
Da,te;.,f ��= r..��his PermFt Voad After 3 Years � ���
Ownea: _ �o�. I.�,�c�.. � �SR# � �? .?
I.ocarioaNirec�ans:
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Subdivisian Name: ��i�,_ ��1 r��. Lot #�__�___�.
- 1 I?n�lingCon�ct�; _,'` WFI- -S� �iIitltT ON
�:Distsrxaatroan Neanst Fropary line_�;,��s Distar� fman Saurc� af
' �`'Po1l�at_,��a d �f�c
To�iI bepti�.�F� Yield:�j�GPM Static `�latez l.evel ���.
Waex Beazing Zones: Depth �� Ft.�lZ'F�. F't. Ft.
� Casing: Depatti F�+om �_ w��, F1. l?iemeter: � Inches '
TYP& Steel Gatvanizcd Steel -�
� � � �i If SteeJ. �does o ���""�' No
, � w�si� -�_ �i ��� c��a: .,.,�_�h�
Drive Si�c: Yes No
Were Problans Eroou�►tered in Seping the Caseng? Yes No '
, If'jres" give ressoe�•
Grou� 'Ij►pG I1cat 3andrLement `�Caaiaete
Am�uisr Spaca Width � . - ��
' Watei in Annu2ar Spac� Yrs No ��
Me�3bod: Fxe�v� P'o�a�ed " —
Dep�h: Froan to --�----� �'
M Used: Na Bags Poati�avd Cemera __�_.,, Weight of 1 bag
s .
� .
If m�xlute (sar� gravel� cumngs) - RaCo: �_ oo __�______
iD Y1stc�: Yes ✓ N�
a x 4 slab Yes '-�� No -- —
- - . �
I HEREBY C$R'T]FY THA'� THH AB{ZY6 iNFORMA3`IgN IS CORRE(.'T AND�'i'!iA'� �;
THbS WELL WAS C°�QdSi1tUC'TED ]N A�L'CORDANCB WP3'Fi itEt3i3LA'r'IONS 5Ei' ;
�OA'FH BY THB F`ERSON GO1JN'!'Y HLAL'I}i DEPA�ENT. .-
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Sanitaiians Signature Date Com»ieted