A25 171�
�, •
� Person Count
Sewage System
Date: • � �
Owner: �
Location/Directions:
y Health Department
Improvements Permit
Void After 5 Y s Permit #� �� � �� 7
��iJ v vvi 't SR# -1�'`�-7�—
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Subdivision Name: Lot #
Lot Size: o ' e , Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: Garba e Disposal �
Basement Basement Fi� e
INFORMATION CERTIFIED BY e
Environmental Health Specialist: er or r� �
REPAIR: REEVALUATIO :
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Size of Sepdc Tank: _��gal�loX Size of Pump Tank:
Nitrification Line: 3 Q 3�
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternauve System: Conv. Pump LPP Pump
Remarks:
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,
,
Date Well Approved: Well should be 100 f� from any sewer system
BY Env' onmental Health Specialist
Date S� e s pprov
BY Environmental Health Specialist
,C RTIFI A OF C�OMPLETION
Contractor.
Sewage System location, installation, and protection must 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 and
ni!rification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this perniit is subject to revocation.
(G.S.130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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