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PERSON COUN"rY HEAL'TH D�PARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # �� � Parcel # l
Zoning Township 0�: Y2. -�: [�
Owner/Contractor `�Y-1� M� �� _ Date
Location/Address
Subdivision Name
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Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair t/' Lot Area Size of Tank ���� �C�. — IDZ�U �
SFD � Mobile Home ti� Size of Pump Tank N��—
Business # of Bedrooms_�_ Nitrification Line � X�'�X� � �la.
� ' 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 intended use ch ged.
Well and Septic La o t by
C� � � �h` X� �
Comments: �
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WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Replacement Air Vent ,
Required Well Lo�
Well Tag
Installed by � �Approved by.
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This report 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 infonnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resutted from false or misleading
statements provided to him in the application Neither Person County nor the environmental health specialist wazranis that the septic tank system will
continue to function satisfadorily in the fuhue or that the water supply will remain potable. c�amipro�pemtit.sam Ol/95 rev.1.0
ORIGINAL
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Person County Heaith Depas Permit
Se�vage System Improvement
�ate:y�0�(S permit Void Aftcr 5 YP s SRN L�--'�-
�wncr:
.,ocalion/Dirccuons:
.r. _. � ! '1 1 - �' YPS'— LOt #
iubdivision N
Al S1ZC: �
Natcr Supply:
3asement
�Type of Dwelling: �_
Public: Community:
Garbage Disposal _-----
Basement Fixtures�-/J �� , ,�, _
z
Nt'VKlvlt� �•• --- icr or rcprescn�«•� �
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iaflitNl
�P�: xEEv�.vA�oN• ----------
'- — K all ns Size of Pump Tank: __----
iize of Septic Tank: ���� 3.
1itriCcation Line:
�epth of Stone: 12 inches _
�Iax Depth of Trenches: Lpp m
�ilemative SYstcm: Conv. Pum� • —, ��u,� �s��,g - o"��.f
temazks: _ �- / fo - 9�
- — — — —" "-'-' sewer system
�ate Well Approved:_------
3Y
�ate Sewage System pro�ed:-
3Y �,$--��L
Well should be 100 f� from anY
� �_ ia-90
. Sanitarian
TE OF COMPLETION
�ontractor. ,_, _ _, _ ._ ._ — — — `'�
otection must meet state and local �
;ewage System location, installation, d out every 3 to 5 years and shall be maintained �
egulations. Sepdc tank should be pumpe
�y owner in such manner as not to cteate a public heal�h hazard. Septic tank and �
iitrification line must be inspected and approved by a member of lhe Person Counry
iealth Department before any portion of �mstallabt�°n o c��ov�aa n!d put into use. If
he site plans or incended use change this p Je
G.S.130 A-335F)
,ocation of sewage disposal sewage system sketched on back.
(OVER)
S�9- 7� �1 F
erson County Mealth Department � �
- Weil Permit � � ' �
Date: �" �7 ��'I'his Permit Void After 3 Years
Owner:�� •� C ��- G r,_ d SR# l`�Z
L.ocaaon/n;recduns: , ,
Subdivision Name: D Lot #
Drilling Contractor:
WF.t.t. �ONS'i'RUCi'[ON �
Distance from jProperty Line� Distance from Sonrce of .
Pollution
Total Depth: Ft reld: �GP Sta6c Water I.evel �FG
Water Bearing Zones: Depth Ft FG f�Q FG
Casing: Depth: From _� to G D�ameter. Inches
TYPE: Steel ' G v Stcel
If Steel, dces owner approve: Yes No • � '�
Weighr. � Thiclrness: Hei ht Above Ground: _L_ Inches
&
Drive Shce: es o _�
Wcre Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: �
Crout Type: Neat Sand/C ent Concrete
Annular Space Width �_ lnches /
Water in Atmular Space: Yes No_��
Method: Pumped Pressure Poured - � """
Depth From � to ___� Q__ Ft ,
Materials Used: No. Bags Portland Cement Weight of 1 bag
�G � lbs.
If mixture (sand gravel, ttings) - Ratio: � to �_
ID Plates: Yes _y� No �
4 z 4 slab Yes �,L_ No '
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SEI'
FORTH BY THE PERSON COUNTY H TH DEPARTMENT
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Sketch weli location on reverse side.
Signature
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r� Date� d
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Date Ltsved
Date Completad
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._..__ -----._....�--__._.
NOTE: Make sketch of installation showing lot size and shape, location of house, ; Se�itiC; tanks, privies, water
' supplies, etc. Note special problems existing on lot. Write in measurements in order that .�nstallations may be located
� at later date. Note location of water supplies on adjacent lots.
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