A24 86, Person County Health
-� `�/� ��1 Wetl Permil
���r�• �.,�� 1Th�Pc�nmit 'Void After 5 �ears
Subdivision Name:
i�rillin Contractor•
Department
SR# � �
LAL #
$ WEGL CQNS'TRUC.ITQii
pistm�ce from Nearest Property �.ine t�� Distance ftom Source of
Pallutio a a �.P ',
Tc��ul Depth:,,�BlL Ft. Yicld: � Static Water Le'vel � � F�
Water Bearing 7.ones� Dept}� Ft. Ft. Ft Ft.
Casin�: D�ptl�: Prom 15 to� Diameter: � Ir.ches
T`YPE: Stee�,,., � Galva�uzed Steel
lf Steet, d es owner approYe: Yes No • _
�r�6�.,�� ri.n�..�...... tt..��.{.. .•.ti... _ o....�.a '-7 �'-f .�._.
Drive 5hoe. Yes ��o
WEre Problems Bncountered in Setsing the Css"vtg? Yes N�
If "yes" give reason: '
Grout: Type: Neat SandJCement _ Concrctc '
Annul�r Space Width � Inches
Watcr in Armular Space: Yzs' __-___ No ���
.Mad�od: Pwnped Presswv � Poure�i `''��
De�th: Frosn �? tc�_�a Ft.
Maurials Oscd: No Aags Portland Cemen�WEight of 1 bag.��ibs
If mixteue (sand, gravcl, cuTtings) - Retio' to ( `
ID Plates: Yes v o
4 x 4 slab Ycs�o _
h7 •
r�
z
I HEREBY CERTIFY THRT "!'�� A�OVE INFORMATION IS CORRECT ANDTHAT �`
�'NIS WELL WAS CONSTRUCC�D IN ACCORDANCE WITH TiEGULATIONS SE'i'
FORTH BY THE PERSON CC3UN'�'X H�ALTH DEPARTMENT. ;�
�
��_,�/� �,�� � s �,a-t :
� anue of Contractor pate
��"�� :
an.itarimi s i ature Date Issued ;.
�� � — --------
�y�,ti�o� Sanitariaris Signature Date Completed
Sk t� 1! j �on on re r�a si� �,�` �� - •. I
e c. we oca ye _
,���-i �a6
. �
� PERSON COUNTY HEALTH DEPARTMENT ~
' � WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax tMap # �,.2� Parcel # ��
Zoning Township CUn n� n �m
- � n _� .
Location/Address
�o %,d� sID � 11� Y
Subdivision Name�
Iayout
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n � er�1 �•, � Lot�
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sn�33` SEWAGE S TEM SPECIFICATIONS �
�1
Repair Lot Area S lr . Size of Tank r
SFD Mobile Home Size of Pump Tank `�.
Business # of Bedrooms 3 Nitrification Line � �
Max Depth Trenches ...� � "
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' en d e anged.
Well and Septic Layout by
Comments:
Installed b� � �` � Approved by.
���x��
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent �
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved t� �-�� 2-�� 56
Comments:
� ./� � -� lI
Date - � Installed by Approved by.�����z�� ����
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the propeRy or for statements in this report that may have resu(ted from false or
misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic
tank system will continue to func[ion satisfactorily in the future or that the water supply will remain potable. c:�amipro\permitsam 01/95 rev.1.0