A25 158Person County Health Department
Sewage System Ir�provements Permit
Date: ��� This Pecmit Void Af�er 5 Years Permit #�� �
Owner: __ r c�r(�,,. �'e� �,� v�+ SR# 1� G��
I.ocation/Direcaons: n . ► r _. ,
Subdivision Name• i � Lot #
Lot Size: �� Type of Dwelling:
Water Supply: Private: Pnblic: Community:
Bedrooms: � Gar g Disposal '
Basement Basement Fixtures =�
INFORMA y � '
$��jan' er or �ep tative
��: ALUA ON:
Size of Septic Tank: _��� gallons Size of Aunp Tank:
e�
Nittification Line: '2 ���? /
Degth of Stone: 12 inches
Max Depth of Trenches:
Alteinative� System: Conv. Pwmp LPp Pump
Remazks: -- .
� � � � � � � � � � � � � � � � � � � � � � � � �
Date Well Approved:
BY
Date S ge � st
BY
We�l should be 100 ft from any sewer system
Sanitarian� � ) / _ Gl /
Sanitarian
OF GDMPLETION
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Contracwr. _ ��` I l�$���,���� � �
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Sewage System locauon, installadon, and protection tnust meet state 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 create a public health hazard. Septic tank az�d -�
azd
ni�ifica6on line must be inspected and approved by a member of the Person County �
Health Departrnent before any portion of the is�stallation is covered and put into use. If
the site plans ar intended use change this pelmrit is subject to revocation �
(G.S. .130 A-335�
"1
Location of sewage disposal sewage system sketched on back. �
(OVER)
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. P'erson County ;Heaith Department
. W�eil Permit � . -
Date: '� This� P�ermit Void After 3. Years
.QWI1P.l� . (ys'tS V`� r� cn . _ .Sr� �J `{�� 2 Yn $R# I/3 g�
_
LACad011ID1!'CCCIOILS '- . •
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LOt #
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Distance � t Ptope�ty'line� .."" Distance frnm Source of
Polluaon�
Total Depth: FG Yeld: �sZ GPM Static Water I,evel �Ft
Water Beffiing Zones: Depth ��,Q_ FG �3.? Ft. FG FG
Casings Depth: From � to ..�� FG Diametec: 6' Inches
TYPE: Steel Galvanized Stee1 .�--
ff Steel. does owner apptove: Yes No
Weight �� Thickness: .,L�CHeight Above Ground: _L_�Inches
Drive Shce: Yes t�" No
Were Pcoblcros Encoimtarui in Sctting [he Cesing? Yes No �—_.
If "yes" give reason:
�� TYP�� Neat .Sand/Cement �--- Concrete
Atuiular space width: .-� Incaies
�: w� i� �,n,�ffi:s��: Yes .. No_��- . ,..3
� . Method:' P�mped Pressure Poured =--- '�', . j
DePth:` �From - rL � FG �,
Materials Used: ' No. Bags:Portland Cement �_, Weight of 1 bag �
Ibs. �
If ' tute (sartd, gravel. cuttings) - Ratio: _Z� w 1
ID Plates: Yes No �
4 x 4 slab Yes No
I HEREBY CER'T�Y THAT
EIIS�WELI:,-WAS CONS'
�RTH,BY:T.EiE_P.ERS.OI
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DRILLING LOd :
.:,Formation Deacri flon
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THE ABOVE'WFORMATION IS CORRECI' AND.THAT �
,UG�ED IN ACCORDANCE WITH REGULATIONS SET ,�
:QDNT.�C.HEALTH_ .EP�IRT�ENT.--; -- - - =: _ � : - �: - i
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:;:...; Si _ , .of _ . ....,
� ,Date '
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� . .: .;� ....Sardtarian's:Si , ..Date tssued :.: . ,
�• Sairitnrian's 9ignanue Date Completefl
Sketch well location on reverse side. �
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