A26 133z
Person County Health Department �
.� S��aiirage System Improvements Permit . �
Date: •- Z This Permit Void After 5 Years Permit # =� -��
Owner ��� I n I,�� SR# �� I
Location/Directions: _, . -�—,�
Subdivision Name: � '� � � ' Lot #
Lot Size: T pe of e' g:
Water Supply: Private: Public: Community:
Bedrooms: � Garbage Disposal
Basement Basement Fixt�
INFORMATION CER'I'IFIED BY Y
Environmental Health Specialist: ""1er�re'`e"�u�e
REPAIR: REEVALUATI . «
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Size of Septic Tank: � allons Size of Pump Tank: �
Nitrification Line: � �C 3 j �'
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks: � � r %� r
Date Well Approved: Well should be 100 f� from any sewer system
BY Environ en Health Specialist
Da Sewage Syste ed: �� ��� �
BY ` Environmental Health Specialist
ATE OF �OMPLETION
Contractor. ��—+�—+•.�� / d��� �+
Sewage System location, installation, and protection must meet state and lceal
regulacions. 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 hazud. Septic tank and
nitrification 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 pennit is subject to revocation
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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NO'�'E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at �dater date. Note location of water supplies on adjacent lots.
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
'Tax Map #�},� (o Parce] # �33
Zoning . Township �' V►� n i n,�� ��+
Location/Address S � !
Subdivision Name��
Iayout
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As I�stalled
C� [ r A"j-�a�
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SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area�S �u�c� Size of Tank �'�--�
FD Mobile Home__� Size of Pump Tank n��R
usiness # of Bedrooms � oy Nitrification Line �L7C� ��.3 �
less 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 ' nd u c nged.
Well and Septic Layout by
Comments:
Well Permit Paid
Installed by.
pproved by ��
WELL SYSTEM SPECIFICATIONS
3ividual V Semi-Public Required Slab �/
�blic Replace nt Air Vent �
te Approved Required Well Log ✓�
ell Head Approved Well Tag �/
•outing Approved
Installed by
r`'` S� Approved
0946
This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed condi[ions on the property or for statements in this report that may have resulted from false or
misleading statements provided ro him in the application. Neither Person County nor the environmental health specialist warrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam 01/95 rev.1.0
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I'L•'Lt;.iUN I:UUN'I'1' IiNV11lUNML•'N'I'AI. Ill:AI,'C11
WELL LOG
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Date: �
Owner: —�� �.S � �ci � ���5 SR#
Location/Directions:
�nii •
Silbdivision Namc: �' O� 11'1 � �t ��
Drilling Contractor: � � � C
WELL CONSTRUCTION
Distance from Nearest Properry Line Dist::::ce froin �ource of
Pollution��
Tota1 Dep.th: 1`t Ft. Yield: � GPM Static Water Level Ft.
Water Bearing Zones: Dcpth � F�. Ft. Ft. :�:.
Casing: Depth: From�_to � Diameter: �� Tnches
TYPE: Steel � Galvanized Steel �
Tf Steel, does owner approve: Yes No
Weight: Thickness: � .Height Above Ground: Inches
� Drive Shoe: Yes No
, Were Problems Encountered in Setting the Casing? Yes No
. If "y�cs" g:vc : c�;on:
Grout: Type: Neat Sand/Cement ✓ Concrete
Annular Space Width�. Inches
Water in Annular Space: Yes No
. Method: Pumped Pressure Roureci �
D�pth: �rom O to � Ft.
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
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS� CONSTRUCTED IN ACCORDANCE WITH RE�ULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTM NT.
, � ,;
Signature of Contrac r �.-� Datc