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DUANE K. STEWART & ASSOCIATES, Inc.
onsu ttng ngineers
3325 Chapel Hill Boulevard, Suite 230 Durham, North Caroliva 27707
(919)490-2999 FAX (919)490-6165
Permif No: NCG550000
Cert of Coverage: NCG550736
Permit Dafe: February 2, 1995
Permit Name: Michae/ Oien Residence
Sand Filfer Discharge Sysfem
Person County
ENGINEER'S CERTIFICATION
l, Jeffery H. Lecky, as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observe:
j�ocj periodically () weekly ( J full-time
April 24, 1995
the construction of the project Michael Oien SinQle Femilv Residence Sand Filter DischarQe S1�stem, for
the Permittee, hereby state that fo the best of my abilities, due care and diligence was used in the
obsenration of the construction such that the consfnrction was obsenred to be buili within substandal
compliance and intent of the approved plans and specificabons.
Note that the plans have been revised to show existing conditions. E<<,s�� �!"���,�,,�
Signatu -� -' � + Registretion No.
J e . Lecky, .E. -
,
o8re:
cc: MichaelOien
Jimmy Lewis, Jimmy Lewis Contracting
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` � � P�.RSON COUNTY HEALTH DEP.ARTMENT �
` WELL AND SEWAGE SITE, LOCATION IlV�RdVE�ENT PERNIIT � '
�
� Tax Map # ._ %� � 1.�. %�- x Parce( # -_ /,�� ,
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Zonin� _ , . `FownslvU G»H:��i�t,1��rn' ------`
Owner/Contractor
L cation/Address
��e 6�� -
Subdivision Name
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� 5�+�,�'AG� SXSTEM SPECIFICATIONS
R�pair Lot Area �I� �./ q a-� Size of Tank
SFD Mobile Horrie Size of Pump Tank ` P
Business # of Bedrooms�_ Nitrification Line `�- � �
Nfax Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Percnits may be voided if site is altered or intended use changed. .
Well and Septic Layout by_ _ -
Comments:
Date
Installed by
by
� � WELL SYSTEM SP�CIFICATIONS
Individual Semi-Public Required Slab �
Public Replac ent f'..ir Vent �
Site Approveci � I�:ec�i;ired Well Lo�
W�11 Head Approved Well Tag �
Grouting Approved
Corn�-nents:
Date
This repod is based in part on information provided the homeowner or his/her representative in the application submitted for this pemtit The
environmental health specialist is not resporuiUle for false or misleadin� Wormation contained in the appiication. The environmental health specialist
is also not responsible for concealed conditions on the property or for slatemenis in this repoR that may have resulted &om false or misleading
statements provided to him in the applicatioa Neither Person County nor the environmental health specialist warrants that the septic tank system will
continue to fundion satisfactorily in the future or that the water supply will rcmain potable. c:�arttipro�pemtitsam 01/95 rev.1.0
ORIGINAL '
;u � �
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I
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant SNARoa G�Li3��
Address ioc� SA� C«�u�p� �O County PERSON
Collected By Q. Sn►�
Date Collected 9 �`� I l� Time Collected I 1; �5 At�
—r—�
Source: '�4 Well ❑ Spring ❑ Other
Location: ❑ House Tap ❑ Well Tap
� No Charge � Charge
�.Other (,O�rCs�o�, SPtib�'�
........................................................................�
************************************************************************
Total Coliform
FecaUE. Coli
Results
Present A sent
❑
❑ �
Reported By �
Date Reported � - Jf- % �
Report Called ❑ YES �NO
Called To:
P�RSON COUNTY �NVIIiONM�NTIIL [IliALTI1
WrI,L LOG
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Date:. ���5�
Owner: , , � ,� / �-�-�-- -- SR#
Location/Directions:
�;;1„��_V1S1011 �,T�ll11L:
Drilling Contractor:
Lot #_ �
WELL CONSTRUCTION
Distance from Ncarest Propc:r�y Li��c �S ��/� s llistarice: from Source of
Pollution l o � �0 /us ,
Total Dep.ih:_ �_ Ft. Yicld: .� GPM S[atic Water Level � J~ F[.
Water Bearing Zones: Depth ��Ft.�1�Ft. Ft. �t.
Casing: Depth: From�_to� Y.�Ft. Diameter._ ��y Inches
TYPE: Steel - Gaivanized Steel '� �
IF Steel, does owner approve: Yes No
Weight:��_'I'hickness: l8'� ,Height Above Ground: 11._._. Inches
Drive Shoe: Yes ✓ No
Were Problems Encouncered in Setting the Casing? Yes No ,.._--�
ii �'yes" give reason:
Grout: Type: Ncat ' Sand/Cement `� Concrete
Annular Space Width -� Inchcs
Water in Alinular Space: Yes No ��
Method: Pumped Prc;ssure Poured t--
De�th: Fr�m U to ,-� � rt.
Materials Used: No. Bags Portland Cement�_ Weight of .1 bag�lbs.
If mixture (sand, gravcl, cuttinbs) - Ratio: �_ to I
TD Platcs: Ycs ✓ No � � �
4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE A,BOVE 1NFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORTH �3Y�THE PERSON CnUNTX HEALTH DEPARTMENT.
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Si�naturc of Contractor � Datc
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