A24A 38M�
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A 001029
PERSON COUNTY HEALTH DEPARTMENT
' WELL AND SEWAGE SITFy I,OCATION IMPROVEMENT PERNIIT
Tax Map # Parcel #��
Zoning Township _ r�!-t rt i�� Cr�
Owner/Contractor � C.� � ��v /G /o� Da� / o - � 2 - H �
Location/Address �� � ��r���� � � ' ��
� N9;-� � Sr��- ir vs �� � �� � . � �.� �t S.R.# /3 /`f
Subdivision Name � � Lot
SC�,��3
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SEWAGE SYSTEM SPECIFiCATIONS '"
Repair Lot Area . Co 3� �-+'e Size of Tank ��� -� '•� S
SFD Mobile Home Size of Pump Tank /DUU �'
Business # of Bedrooms 3 Nitrification Line ��a L���( �j >(3 '
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 ' d u e cha ed.
Well and Septic Layout by
Comments: „ . -
Date ll --10� Installed by
� ,d — - ,,7��'2'`T[
S Approved "T�" y �, a:
11 / n7 u. y- -4C %�
WELL SYSTEM SPECIFICATIONS
Individual '� Semi-
Public ac
Site Approved
Well H pproved
ting Approved
Commer,ts:
Date -/� / Installed
�ir Vent
Required Well
Well Tag �
�.�
This repoR is based in part on infocmation provided ihe homeowner or�»s/her representative in the application submitted for this permit The
environmental heakh specialist is not responsible for false or misleading infoanation cotrtained in the applicatioa The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the applicatior.. Neither Person Couirty nor the env¢onmental health specialist wazrants that the sep!ic tank systcm will
continue to function satisfactorily in the future or that the water supply will remain potable. c:lanupro�pennit.sam O 1/95 rev.1.0
. Person County Health Department
�Sewage System Improvements P�rmi�
- `�'"� � r Years {: �, . l �S
,a�: This P it Void Af �-� ,j�,�
` `, r.� �..� - r-_'�.� SR# �.
�wner: •-�; -, ,
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ocauon/Directions:
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ubdivision Name: � � �� � � r•�p v' �.,'��` `. .� ri, �� s Lot # ���,• �
,ot Size: • - . '� Type of Dwelling: .
Vater Supply: Private: ��f Public: Community:
tedrooms:_--- Gaibage Disposal �
tasement � � Basement Fiictii�'a�s—�— � �
NFORMAT�OI�� By , , • .., ' � _ �..:�,1 � . r:_�. �
� 1 � ,'' owneror representative
ic1(11i8T13I1: �' / �'�l.l`r• f
tEPAIR: ' . REEVAL.UA'1tIflN:
------- –5- — ----;, �.,,�
� �J allon Size f Pum T • i}
iize of Sepdc Tank: g pc
r ,� � 9 � .
litrification Line: k�� - G„
�epth of Stone: 12 inches �,,, g �
vlax Depth of Trenches; �
�ltemative System: Conv. Pump �'` � �PP �mp
temarks: . � `'r.� � , ^�
_ �._ �_ r
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Date Well Approved: Well should be 100 f� from any sewer system
BY � Sanitarian
Date Sewage System Approved;
BY Sanitarian
CERTIFICAT� OF C MPLF�,TION
Contractor. �- � �%� "F'° ��-'�'— _ _ ,_ _ H
Sewage System location, installation, and pracection must meet stute and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to cceate a public health hazard. Septic tan]c and �
nitrification line must be inspected and approved by a member oE the Person County
Health Deparcment before any portion of the installation is covered and put into use. If
the site plarts or incended use change this pemut is subject to revocation.
(G.S.130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
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P��son County Health Department
�� Well Permit
ate: �"d' � This Permit Voi�d �jfte,� 5 Years �':� d°�
wner G 7�Y� /�,'/z.,li'�_�'�.- SRi� +J:�� a•uc/
Subdivision Name: �� � Lot #
Drilling Contractor: �t' '� �
WELL CON, S7'RUCTION
Distance from Nearest Property Line_�__ Distance from Source of
Pollution�
Total Depth:�t� Ft. Yield:�_ GPM Static Water Level Ft.
Water Bearing Zones: Depth �Ft. Ft. Ft �t.
Casing: Depth: From_�_to��Ft. Diameter:���Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner approve: Yes �1'� No
Weight�_Thi kness: /�� Height Above Ground: %�"Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No X
If "yes" give reason: ��
Grout: Type: Neat Sand/Cement �� Concrete
Annular Space Width -� Inches
Water in Armulaz Space: Yes No t' � �.;
Method: Pumped Presswe Poured
Depth: From --- t7 to �': y_FG
Materials Used: No. Bags Portland Cement� Weight of 1 bag_lbs.
If mixture (sand, gravel, cuttings) ' Ratio: to
ID Plates: Yes�_ No
4 x 4 slab Yes No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONS'fRUCfED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY �ALTH DEPARTMENT. ����� �) (� j��i„�J �
�11 �.�z:�.
Si re o Conua or Date
_��-.a'��
azu 'an's Signa ure Date Issued �
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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Type III (b) System Inspection Checklist
Tax Map 1���- Parcel #: ,--3 � PIN
Owner: t'�/�ii:f: .// . l j, A_. Subdivision: '�, _ s � r., � 1%�'� �n ��
Address: Ph/Sec/Lot: � �
Location:
1)
2)
3)
4)
Establishment
a) type, size and sewage flow in
accordance with permit
Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good working condition
d) tanks pumped, cleaned out as needed
Effluent Dosin� System
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and components
in good condition, operating properly
Ground Asorption Field(s)
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains are
well maintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from trafFc and destructive uses
fl distribution devices in good condition,
working properly
g) repair azea properly reserved, maintained
h) pressure head properly adjusted
Summary of Im�
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YES NO Remarks
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Repairs Neede �
lilr 1l >Rld it. ��s,C',�
Authorized Agent , Date �- lJ� � 0.�