A24 154 & 155.. � �''�,�son County Health Department
�ewage System Improvements Permit
Date: "�' 7Z' �1 This Permit Void Af r 5 ears Permit #
Owner: V r� v�_ � r� / ici ry� � SR# �,3�
LL)C8[lOi1�D1ICCt10i1S:
v r� v-r- o s tt N/33 � w'" "
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Subdivision Name: Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement Fix[ures � �f,� i.�
INFORMA (�R D BY . _
S1Rlfc'itlan: 2• �, q,� ow er or repcesen��ta '�
REPAIIt: REEVAI.UATION:
--- -- -- �,
Size of Septic Tank: d�� gallons Size of Pump Tank:
Nitrification Line: d` r _
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pamp
Remarks:
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Date Well Approved:l - • �
BY
Date S e s rov :
Well should be 100 ft firom any sewer system
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BY Sanitarian �
TIFTCATE OF COMPLETTON ,�
ConUactor. � E�� g�,s�( � �
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Sewage System location, installation, and prote�tion must meet state and local �
reguladons. Septic 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 tank and �
nitrification line must be inspected'and approved by a member of the Person County• �j
Health Department 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) �
L.ocation of sewage disposal sewage system sketched on back.
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�- R�rson County Heaith Department �
�' '� Well Permit �
Date: �� - This Permit Void After 3 Years '�
Owner: � � SR#
Location/Directions:
Subdivision Name: �t
Drilling Contracwr. �R � �1 U�t/`i'
WELL C0— N� N �
Distance from Nearest Property Line " � Distance from Source of
Polluaon ;P,
Total Depth: �G Yield: � GPM Static Water Level � F�
Watet Bearing Zones: Depth � Ft /�FG Ft FG
Casing: Depch: From D to �v F� Diameter: Inches
TYPE: Steel ' Galvanized Steel �
If Steel, does owner approve: Yes v No
Weight: �� Thiclm_ es,5.� N� 8 Height Above Ground: 1� Inches
Drive Shce: Yes V
Were Problems Encoimtered in Setting the Casing? Yes No
If "yes" give reason: �
Grout: Type: Neat Sar�d/Cement � Concrete
Annular Space Width y' Inches�,
Water in Armular Space: Yes No ,/►
Method: Pumped Pressure Poured V
Depth: Fmm f� to �_�
M enals Used: No. Bags Portland Cement � Weight of 1 bag
_ �� Ibs. !
ff m'vcture (sand grav�cuttings) - Ratio: � to
ID Plates: Yes i No ►d
4 z 4 slab Yes —�— No �
I HEREBY CERTTFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH PAR ME'
-�-�1
Si�. e f n a r Date
2
'tarian s Signa Date Issued
Sanitarians Signature Date Completed
Sketch weli location on reverse side.
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!' NOTE: Make sk f i tallation showing lot size and shape, location of house, septic tanks, privies, water
"-supplies, etc. Note sp ia roblems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Person County Health Oepartment
�xisting Sewage System Report For: Hobile Home keplacement
�ddition
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Requestee: � V��� �" �� � Home Phone# .7Y9 '��9�
��i�ps //1�1j/IP.2-� %�l��! � Businessx
�J•���� IV� cX�� 7� 'iax Map� �' %7�lS.S�
Location/Uirections: /l/ C ���j �� ���
ll /__ ��. � i/ �_ vr�C�/ �/
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Original Permit Located `C.0 ,
Septic System Uesigned For: 3 U�x��m ��m�'- _
Kesidential � E3usiness Other (specifyl
K Bedrooms � # Employees Other
Uate Tnstalled ��' � Water supply
Type ot System
Nitrification
Tank Size
Line �� � �� r
1 doo �
Certified Operator Required ►V� _ �
On site wastewater disposal. syste�a showes no visually apparent
malEunction on � f 0�71� �
Yermission is qranted to:
b� ' ' �
According tc the attached site plan.
Comments:
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Environmental Health $�C..
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pr�oar to �►rr tba ��o �+re � p� Rr+�le �e ma�ta�rad �
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��olication Date• � -� � �
3�!r �ount Paid: 1 DO, O�
`� R�i #:
Psrson Cauntv Health Departrnent
Environmentai Heatth Section
APPLICATION F�R SE9iViCES
�ax �1Aa� �• � �'
Parc�! #• � �� `i- ���
IF THE INFORMATtON IN THE APPLlCATION FOR AN IMPROVEMENT PERMIT IS FALSIFiED. CiiAP1GED. OR THE SITE 1S
ALTERED. THEA� THE IMIPROVEI�AE�IT PERMfT AND AUTHORIZATiON TO CONSTRUCT SFIALL BECOME INVALlD.
)� Permit requested by: Ownerla errt/prospective owner): �� -t- vd � � �( � l 0.� �
Home Phone: -8� '�t Addre,ss: � Ja � t��
P <
Business Phone: �C�ivta Irct � u�r .� ?3�i.�
2) Name and address of cumerrt owner.
3) Property Descrtptlon: Lot s�: Township:
DirecUons to the property (Induding road names and numbers): �--� O 1J /�C-��� �- M��' �
M.� N 1- es S�
4) Proposed Use a ttvalure Descrlption: answer each af the following questions:
a) Propos , Existing ❑
b) Sbcfc Built �, Modular �, Single Wde �, Double Wide �
c) Number of Bedraoms: d) Number of occupants or people to be served:
e) Basement Yes �, No � if yes, # of basement fixtures: �-
fl Garbage Disposal: Yes O, No ❑ /� _
g) Dimensions of Proposed SUvdure: Wdth: �� Depth.Z� ls-(��'A �
5) Water Suppiy Type: Private ❑(new � orexisting �), Public �, Community �, Spring ❑
. Are any we!!s an adjaining property? Yes � No � If yes, location
6) Please Indlcate Desir�d System Type: (systems can be ranked in order oi ycur preferenca)
Comrerrtional _Modifled Conventlonal _ Altemative _Innovative
Othe� (specify): .
CL�IRLY STA6CE ALL CORAtERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF�ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLICATION
t hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-desctibed property. I agres that the contents of this application are true and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the irrtended use changes, the permit shail become invalid. I understand
that as applicant, I am responsible for identifying and marldng property lines, comers and making the site acc�ssibie for the
personnel of the Persan County Health Departrnecrt to condud their evaluations. I understand that I am responsibie #or notifying the
Heatth Departrnent if my proQerty corttains any wetlands as designa#ed by the Army Corps of Enginesrs.
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Owner or Legal Representative Date
PCHD, rev.10h2199