A24A 1 & 2�' T,�e District 1-lealfh Deparfinent
� �raage, Persoa, Caswell, Chalham, Lee Counties �`
SEPT�C TANK PERMIT
` ,� �»� / ?� � - � �
� p Name of owner: Y►C-�r o�Mi`�-� ._
+ }� i Name of contractor: � j��( I" 1 C� 1'j"� � iJ I`l GC� l�l
d
� � li,� Address and Directions �
� �� -�-�1'� c� F N��u�� � � 4.�
Person or firm doing installation: _�i �1 n"� )'��,` .F' i1,��� �
Address __�:_� � � � c�'�,`d � �; C'�t� , +�, ,
No. of persons to be served Bedrooms 1,�2 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine ' `� � �1 �'�
Recommended: —�1_ Septic tank ? ') (�� �
�j r �
Nitrification line: b, ��� %� �.4
.`
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecled and
approved bp a member of the District Heallh Department sfaff before
any portion of the installation is covered.
Date Approved: / y `— ��
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
'`' TE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
r adjacent property, etc. Write in measurements in order that installations may be located at later
, date.
r +SUG�ESTED INSTALLATION (Date ) FINAL INSTALLATION (Date )
p� - (Road or Street) (&oad or Street)
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�erson County Health Department �
= Well Permit � � �
Date: ' -� �s Permit Void After 3 Y,e,ar� � e'�
Owner:�_j r�'o✓ `�Zr�� SR# > � l�
Locauon/Duecdons:
Subdivision Name:
Drilling Contractor.
Lot # � �
� WELL CON3TRUCi'ION
D'utancc from Nearest Property Line� f� Distance from Source of
Polludon d
Tatal Depth! FG Yield: ,��GPM Static Water L.evel �� FG
Water Bearing Zones: Depth /�� Ft FG FG Ft.
Casing: Depth: Fmm �_ to �Q_ FG Diameter: 6,� Inches
TYPE: Steel Galvanized Ste�el �—
If Stecl, does owner approve: Yes No
Weigh� �_ Thiclrness: ,�Q' Height Above Crround: Inches
Drive Shce: Yes �� No
Were Problems Encountered in Setting the Casing? Yes No�,
If "yes" give reason:
Grout: Type: Neat Sand/Cement_.� Concrete
Annular Space Width � lnches
Water in Armular Space: Yes No �' �]
Method: Pumped Pressure Poured ' k
Depth: From �_ to �� FG {,�!.
Materi Used: No. Bags Portland Cement ! Weight of 1 bag .�
___��1bS. –T�
ff mix (sand, grave tings) - Ratio: 1.- to �_ �
ID Plates: Yes No
4 z 4 slab Yes ��i:� -
De th
From To Formation Descri tion
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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 DEPARTNIENT. �
.'G� �� .���
Date Issued
Sanitarian's Signanue Date Completed
Sketch well location on reverse side.
s��-� a oa 1206
• PEI�S ON COUNTI' HEALTH DEPAR 11 �, ',N'T
•` • WELL AN� SEWAGE SITE, iU�;��'.'1`ION IMPROVEMENT PERNII'T
Tax Map # /� � �� Parcel # / � 2 __
Zoning Township rr�
- - � ^
Owner/�ontractor
Location/Address
1�- �- arti Q.'.
Subdivision Name
�yo� E �+ i�r
,�
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� � n�ver � us�
W►.,'�.�. �"f , �jrr�z-
( -� �^� �Ps�1-`'I � �
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Dat !�!—_��'�
P,• �� �....
_ � �nd S.R.# 3 a'� �he��;-z�
Lot# ��e� �'
,� � /�
SEWAGE SYSTEM SPECIFICATION$'
Repair Lot Area Size of Tank t`
SFD Mobile Home Size of Pump Tank ,
Business # of Bedrooms Nitrification Line � -
Max Depth Trenches �(� ���i
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered o e ed se c nged.
Well and Septic Layout by
Comments: __ �
Date
Installed by�1
Approved
WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab
iblic Replacement Air Vent
te Approved Required Well Lo�
ell Head Approved Well Tag
�outing Approved
Comments:
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=�n� e�'�
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6-e.e,� v�.
Date Installed by Approved by _
This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this pecmi� The
environmentai health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist
is aiso not responsible for concealed conditions on the property or for statements in this report that may have resulted &om false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank sy�tem will
continue to fundion satisfadorily in the future or that the water supply will remaia potable: c:�amipro�permitsam Ol/95 rev.1.0
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Special Note: Each application for a Zoning Permit shall be
accompanied by a plat, drawn to scale, showing accurate dimensions
of the lot to be built upon, accu.rate dimensions of the building to
be erected, its location on the lot and such other information as
may be necessary to provide for the enforcement of this ordinance.
AUTHORIZATION PERMIT #: .G�- � ���
PERSON COUNTY HEALTH DEPARTMENT
- AUTHORIZATION FOR ZONING & BUILDING PERMiTS TO Bfi ISSUED, -
, , (G.S. 130A - 338)
OWNER: �% I C.�� � SI�� � PHONE # �. a�°� � 9 �'� �%
ADDRESSa a� I 3 c� ,'F1a�-i c�c� S�- . Gree� sboro _�'C � a7�-0'7
LOCAT I ON OF PROPERTY: �� S�P- � 3 ��{
LOT S I ZE : �� • l. � 1. .,� e.r e> �-o't a� � A� CYc�
: ,
TOWNSH IP : CV� JJu � �J aM
SUBDIVISION NAME: eS6o�'o� �� �
P , ,�
NU1�iBER .OF BEDROOI�{S { � }
HOUSE { � MODULAR HOME { }
�.o �- i _ a q �-i
TAX MAP #: t-o � z- -� a4 �" z
LOT #:
�
1 ��
MANUFACTURED HOME { }:
OTHER { } SPEGIFY:
,
DATE : �� � 8- 9� ��o K e ..,� c� ��ZI
NEW SEWER SYSTEbt { } EXISTING SEWER SYSTEM {'�� �
C�o us er� e�- - Co;�pte�-�o(
I�fUNICIPAL SEWER SYSTEbt { }
�rev�ouS��
Environmental Healih Specialist
**,�******«**«*******«***************«****«,�,�*******,�*,�,*,�**,�*******«
Certificate of completion or operation permit`issued:. (130A-337)
and comp"liance with local well rules where applicable. (130A-339)
DATE: ������ �1�s1 e /�l/'I.. �_
/ �/t t-�C_ "" w �J
- vironmental-He th Specialist
*�*************_**«*,�*«************«**«***«*******,�***,�*,�********«**.
This is to certify t.hat the above named addition to my property
will not cause an increase in sewage flow or interfere with the
operation of my sewer system. I cer_tify that my-sewage disposal
system is functioning properly.
Owner.or Agent
YOU MUST OBTAIN PERMITS REQUIRED BY THE PERSON COUNTY ZONING AND
BUILDING CODES BEFORE ANY CONSTRUCTION ACTIVITY IS STARTED.