A27 121. z
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Person County- �t� Department �°
Sewage System Improvements Permit
'� �"� �� This Permit Void After 3 Years
r m�=�-^�—�-�������n�— �R# �` � �- �
Subdivision Name: � ' ; ;j � '� �� # `�
Lot Size: _ .�� �� t-e Type of Dwe mg: �'' �.
Water Supply: Private• Public:
Semi Private: If not Private T� Map# 4
Parcel # of Water Supply or Name of b
Supplier# !
Becirooms: Gazbage Disposal -
Basement Basement Fixtures; ;' ;
INFORMAT��J�I C�ERT,,IF7ED BY � ,i � t .-.;- �; ,1 . � ! .
�,
$ffi11t8fiN1: 4 ' •.-� l' ^t. � j� � -" • owner or represaitative
REPAIR: `� � REEVALUATION: �
------- — �
----- ------------
�
Size of Septic Tank: i' V�� rt gallons 'r
Nitrification Line: � , � ' 3 �t
Depth of Stone: 12 inches
Max Depth of Trenches:
OPERATIONAL PERNIIT; yes no
Remazks:
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Se e s m� pprov •_�ll� f�1 -�'�;
BY � � Sanitarian �
TIFICATE OF COMPLETTON �
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 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.
L.ocation of sewage disposal sewage system sketched on back
(OVER)
NO ': Make of installation sh ' g lot size and shape, location of house, septic tanks, privies, water
supplie etc. No pecial problems e sting on lot. Write in measurements in order that installations may be located
;at later ate. N ' n oi w r supplies on adjacent lots.
;(1) (2)
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A�olication Date: • � - � � 6 �{ � � . Tax iWao #� /� � 7
�lmourrt Paid- 0 0
Rec�_P�.� • 2- .. ParcE! �: �� �
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APPt]CATtON F-0R SEi�ViC� • -
!F THE INFaRMAT10N IN TNE APPt1CAT10N FOR AN IMPROVE�I(ENT P�32MIT 131NCDRRECT. FALSiFi�i].
C}�IANGm. OR THE S1TE' IS ALTERE�. THEi�I Ti-lE IMPR�VVEiIAAENT P�MlT AND AUiHORlZATiON TO
CaPISTRUCT SHALL BE�OME IN�/ALID.. -
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1) Permii requested by:
Home Phone:
8us�ness Pt�on�
(Owned�entlprosp�tive ownerj: ��b�uo.S- `�- ,Tel-eSc�
Address:
2) Name azul .addrass of carrent ow�er: �
3) PraQedy D�ption; Lct size: 3•4`� Taw�uhlp: 61 � v� l�� 9u�divisii
Dit+eci3ons ta the property (induding rvad names an_1d numbets)�
� ., Ln� �iJ ��'QT �U� l7r
I
►�]
�
4) l�ropased U� ansi Shu�tuure Desariptlon: answer eaci� af the fdlowing questions:
� a) ProPosed ! Existing , Type of Struc�.�re: Wtdth: � �epth: . �
b) Number of �edrocros � Number of �xupants or people to be served: •'
c) Basemerit Yes . No �( , Will thers be plumbing ir� the trasemetrt?
� d) c�',ar�age Dtspasal: Yes . No ,� .
5) Water SuPPhf TYPs: Pr{vat� ,�(new ar e�stina ). Pubiic_, Commundy , Spring _. .
Are any weils on adjoinin9 pra�/? Yes_ No _ If y e s, Pi�ase indicate a p � pro�mate I�atiori cn the
.siae pian.
by Does your proQerty ca�tai�i pr+eviousiy ide�rtifi�1 jurisdictio�i w�lacids? Yes_ Mo,�-
�� PtEASE NOTE THE FaLL01MNG:
➢ A PLAT OF THE PROPEi2TY OR S1TE Pl.�W MUST BE SU8M17TE� 1NITH THi3 APl�LlCAT10N.
➢ PROP'Ei�TY L1NES AND CORidEiiS MIJST BE CLPARLY NARl�D. •, � .
9 THE PROPOSE� LDGATION OF ALl. STRUCTURF� MUST BE STAi� OR F�A►G�.
➢ THE S1TE 11AUST 8E R�ADILY ACL'E�SiBLE FflR AN EVALUATiON BY THE HEALTH DE3�ART�AE�17'
STAFf'. .
1 hereby maka aQpiicxtian to the Person Caurty Health Departrnerit ior a siiee evalua#ion for the on-siie sewage disp�sal
system for the abave-described pro�tty. I agree ti�at the car�tents af this appi'u�tion are true and re�esent the maximum
faaiiiies to be p�d n the pt�q�y. 1 undersfand if the ''s aitered or the irrtended us� cfianges, the permii sf�a11
6ecame irwalld. � \ 1` 1 �
or
�II-Ib-64
Date
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� ddF�s andlar directiion� to PresPaty: . CY' ro� �.rn nn [� l,�L��—r��
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G't y�s �I no �oes t�e si�e co�in �uy jurisdictaonal �e�Iands?
II yes II no Daes �e site �aniain any �g �rasi�wa�r systems? .
II yes L� �z� �s a�yy Fraste�rat�r �oing to b� ge�rar�d oa r�e sit� oth�rr �tan dome�tic s�a��`? ���
Q y� II n.Q 3s the side snbjectto appmval bjr any ot�r pnblie agen�}�?
�1 yes Q no Are t�ere any easements orri�ht of�vays on this propeny? •
('rF��' is oh�cker� Flease provide supportiag doc�me�eiian)
�;} ���°at�se� �'�� �� "�`�� t���s��: �
f��E�;eeliiiai
��ie��r Sir! ;l� Fami�y R.�sid�ctce i�Fa:�nvm numis�r af b�raoms:
Q Expansion af �asting 33�Eem . If e�pa�sion: CurranE nunzber o�edraams: a�,.
Ci Rep�ir m:v�..alfunciznnmg Sys�u R►itI iaer� be a�as�� f� y� II na YJ'�h plt�aUin; � a� a�
Qi�I��P.�I3�f�? '
; krna �� TO s�.�`L117� �Ol'd� O��ii3�t�tii� ._._.._�—
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�rT�muiii m�ti�ET c�e�nj?I4ye25: !1/�2�III1ii3II �itib�F 0�8L'SfS: --
g) '`�'JsEei ��?��=_3r II New..velI Q F�ting FiTeII II Cammuniiy g1eII � Publie �tlater Q�gring
�xe �here aay �g aeILs, sPrin�, or e�s�ag ��er2ines on ihis ProFert�t I� Yes Q no
�i} a. i �r�3���' �'#�' `�iie."��383���� � �u�?5�E'�efsfi �3�..3� �€�6�� €?�T_'€'�� �Ft3 �36�5�0
L� Con�►entional � Accaptsd Q%ma�ive Q Ait�rnaa�ve Q ot�er �.�._ Q�Y
�certz'fy � the u,r�"orrt�tion,pPavided above is corapleie ar�d co:�ect I rlls� z�u,�ers�C�[IIhQF f1't�22 �Pt1o�o�t.t71'o�ided 1�
usaeeu�ate, ap if F.�t� sm� is s�i&re��ue�tly aItet��d, or the intende� � chan�s= a7I pe�ntts mid ap,�rcrvals slzali be i�valicl. ;
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docament�inn r�qu�ea.
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A ^.��p� `����ar�Fon� �� � �c��a_� �:.-�g �������? ae��� a �e g,t��ag.
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T�x M�� ; P�.rcel #
S�u�bcilivis�ion �! •
Fh��s�e�Sect+ion'Lot =
w
Improvement Peranit
Permit Valid for � ive ears � No Ezpiration �
Type of Facility: g�' �- New Addition Water Supply 'e��
# of Occupants �� # of Bedrooms Projected Dail Flow �� g.p.d. �
Proposed Wastewater System: Ck 'v-�- ' Type: �
Proposed Repair: • Type:
Permit Conditions:
Owner or Lega1 Represe
Authorized State Agent:
cr
6 `�
Date: �d'-2g "�
Date: '�
The issuance of this permit by the Health Deparhnent in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me� This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmentai Health
Specialist warrants that the septic tank system. will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_�. v"`+�n'1 �� �� v�'^"' '
Proposed Wastewater System:�j/L�,� �✓����U'e- Type �, q Wastewater Flow `7�.p.d.
New � Repair Expansion Soil LTAR: • o��l � g.p.d./ ft 2
Type of Facility: � • Basement �Yes _ No
�- Wastewater System Requirements
Tank Size: Septic Tank: � dG�gal Pump Tank: ��fl gal Grease Trap: gal u pS��
Drainfield: Tota1 Area: ��� sq ft Total Length �� ft Mazimum Trench Depth �_/ in �
Trench Width � ft Minimum Soi1 Cover: � in Minimum Trench Separation: ( ft�'G i
Distribution:
Specifications:
Distribution Box S
o Au��.,r' �— �•�! c
Authorized State Agent: __��
Permit Expira on Date:
��
�
x Pressure Manifold
Date: �� r� �S�
The type of system permitted is Conventional � Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: � Date: � 0'� �- 6�
��� -� PCHD 1/17/2003
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• Date . . .
Systens aompo� �'F'�.' �r..,.......� __-�urs on3'. The �r �.�g � �'ste»s p'i°r't°'
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lh�dergrvia�d Cable Ir� Cooduit
�iith Scsicable Sealer In Boch
Fsids Of Co�duit
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Efflu�t PtsrQ �`�P�
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. �Supply Line ?o �� `
� . Dianeter S�edule 40 PVC
..• pi�
• 1(�i � �T�IP�ti� �
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• Gate nalve
.
Thceaded Union .
• . Qzeck Valve
3/16" 5y� Br�� ��ole
� Ioddrx� Str�s Ata� A,tl Ct�r3�
� Alarm Flaat (eievation)
„f� On" Float (elevativn)
' ` "Pucp Of£` Flaac (���°n�
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., � �q j Zo�-� I�r' Or
�i�u,tValth�
.� PUHP RATING
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�s �ik� sau be af a sta� � A�p ��'
� � s� be r.� � a�.t� .
P[JMP SYSTEM DETAII� SHEET
pump Iiust Be Rated To Deliver
�0 Gallons Per Hinu[e
Against Fee[ Of Tota
Dqnamic Head (IDH).
See Following Sheet For
Add's[ional Specifica[ioces,
Noces. And Explanations.
9� �:t��-���-+ s' Ta„x
4�` + i,�6�s' = 59�� �
�
,c�ota � (� s�a����$�
, �ry� u n c F .
*Block, Brick
or poured
*Cleanout Ptug
*Note: C(eanout nluQ adapted to accomodate
stand pipe to adjust pressnre head, or and
additional tap may be used to accomodate a
stand pipe for pressure head adjustment
� in. Threaded Tap or
saddle tap Sch. 40 PVC
Sch. 80
PVC
Pressure Head to be set at � ft.
�
Taps and �
valves
Mechanical
. Connector
Nitrification
.. ._,
,,. : • ,.�.:..�
pRESgURE 11iAN1FOLD DETAIL
SiDE VIE�V
� in. Manifold
, _ Sch. 80 PVC
From
—�_Dosine
Tank
Support Straps
Concrete Pad. Le�•el
END V1E�V
Gate Valve
To Nitrification Lines
Support Strap
Support Block
Conctete Pad. Lrvel
TOP ViEW
ig
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ng
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t���i�� ' � �a ��y��� .
�`1���� .11..
����m� � ���g ���Il�
SIfiE. SS�TC]H[
e Lacy (,J i nS-EC0.d . Tag Ma.p #� 1 Parcel # I� LL_
ub �o �- �orr10.. . . Section/Lot#' C%
� I i-Il-oa
Authorized State Agent - � Date . .
sy� �o�o� �� �p���� �ry. The �tructor mrest, flag the system prior to�
begtnning the installai�ion to insrsre that pr�vpergrs�de rs maintained
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5�o��d mt�'�
Erts �� s�t�
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ConS
-�rt.�G��On
Co� �����G`'.
- Fa1lo� P���
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�pe��� F�ca-���s
..._. Plac.� 5 at� vulv � c�.-t
(Y1ci.ni �I� . Enc[os� man(��fd
Q�'1d qa-�c-va[Uc, jn �.
u
�-�x or SP���K��r box,
Scale: � !,' l OQ
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�o'
t�°s`�5
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PQ3D, rev. 09/12/Ol
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�_. = ' � � � � � 1l �
�an.�-asc-c��aa�����.� ����n:���
Appiicant: d� ������
Location: � _ r �. ,' � � � 9T
Tax M�p / � Parcel #
su,hci�i�ision �
.
Phase Sect�ion Lot #
# of Bed�rooms
�perat��r� Permit
System Type (in Accordance With Table Va): �! �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLIfVA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE iMPROVEMENT PERMIT AND COMSTRUCTION
AUTHORIZ�►'r10N.
�
Installed By:
r� S�Gt e�
��p�; j�'
-t�
a
, q-�q-ps
;ate Agent Date
, ���� �
�1�t/`t -�,`,` s Date:
��3�� ���PL��u .
Z" 7'3" �r3,r
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13ir G.i3�t r ir �
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PCHD, rev. 07/29/04
0
SEPTIC TANK INSPE�'�ION C�iECKLIST (Type II -11n
Tax Map # ,.� Parce! # System Type (Table Va)
Owner/Applicant Subdivision
Address/Location Sec/Phase Lot #
� Septic Tank n�tia / ate �tr� icat�on �nes n tia ate
State ID/date �-� � Trench Width � ft. 5✓
Ca aci al. � Trench De th in.
Tee and Filter T.rench Len th ft.
Baffle Trench Grade
Sealant Trench S acin
Riser if a licable � Rock De th and Quali
Tank Outlet Seal Dams/Ste downs etc. --
Permanent Marker Pressure Laterals �
Pump Tank Hole Spacing --y
State D ate � v� o e ize —�
Ca aci al. .� Pi e. Sleeve `"'
Wate roof /Sealant Tum-u s/Protectors' �--
Riser Required Setbacks :
Water Ti ht � t� p From Wells �
Pump From Prope lines
Check Valve/Gate Valve Structures/Basements
Anti-si on o e itc es raina e a s
Floats/Switches Surface Waters �
Alarm visable and audible Public 111/ater Su lies
Electrical Com onents � Vertical Cuts >2 ft.
Rate m Water Lines
A roved Pum Model Vehicle Traffic
Block Under Pum Ad'acent S stems
Pum Removal Ro e/Chain - Easements/Ri ht of Wa s
��Distribution. System Other
Serial Distribution Easements Recorded
ressure ani o ert' ied erator ontract
Low Pressure Pi e Tri-Partate A reement
A r. Pi e Material and Grade
Valves
Comments .
pchd rev. 3/13/01
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WELL PERNIIT
1'LEASE SEE A'TTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: a� Parcel # �a � Tocvnship � � J V C. � If �(
Applican�
�d TO,� F�-�-Z� e
L-C�'�O Section: v Lot
Subdivision: m C�
Lopxion; J��-t C.�rm i t
�
T�e of Water Sunvlv:
Requirements:
V Indiviclual. Communi Public
— tY
Site Approved bp �' � y-� � �
Gzouttizng Approved byC' Sf L/ - s-��
g
We]1 Log C�
Well Tag_SS
Air Vent SS
Hose Bib �
Concrete Sla.b
� -8 -�s
L
26 OS'
�s�-o
,�, o ' � .�,�� Rna,1-
��
, �� �
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Well Driller. �v�Aas �e.� ��Z�.u-s.�
Well Approved B. Date: g Zd o
'�°5ee Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any bu�ding founda.tion.
Qther conditions: � C'� p(��- (( ��� rr�m St (�� G � � O� � Fror�
rct,K t F pdsSi�tc
PC�ID, rev. 09/07/Ol
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]�+ �wau-��aa�m�rad�.Il IHL�mll�]�n
WELL PERM�,T
(New _, Repair ✓ )
Tax Map: 21 Parcel: �
Subdivision:
Applicant's Name: � � L
Mailing Address: 6
Ro (,orQ P1C� 2757
__ /ifn �e.lf O _
Phone Num'
Location of
Lot: �—.
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry Yegulations governing construction and setbacks apply
3.) permits expire S years from the date of tssue.
¢.) Issuance of a permit does not guar'ante a Potable water supply
Other Conditions/Comments:
Permit issued by:
QPiew Weil:
EHS/Date
Location: .�.—
Grouting: �—
Well Log: �—
Well Tag: �—
Pump Tag: _..--
Air Vent: ____--
Hose Bib: �—
Casing Height: __
Concrete Slab: __
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
,
Certificate of Completion
Date: qis �S
�,�� w� ��
�iner:
EHS/Date
(
Depth: �� Cj Z�-��
Grout: � ��
DAbandonment:
Date: —
Method/Materials: _
License #: �—
License #: �—
Date: �—
Date Results Mailed:
Person County Environmental Health , Phone: 336-597-1790 Fax: 336-597-7808
325 5. Morgan St.,Suite C
11/26/13
Type III (b) System Inspection Checklist
� Tax Map Parcel # : PIN
Owner: � Subdivision:
Address: �.�D �/1«�nr]n Ln. Ph/Sec/Lot:
Location:
1) EstabHshment
a) type, size and sewage flow in
accordance with permit
2) Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structtually
sound, watertight
c) sanitary tee(s) in good working condition
d) tanks pumped, cleaned out as needed
3) Efflnent Dosin� Svstem
� a) efEluent appears clear, free of excess solids
b) required pumps piesent, 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
� Drawdown rate•
4} Ground Asoration Field(sl
a) no evidence of effluent reaching surface
ar surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditcshes, swales, tile drains are
well maintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from tra�ic and destructive uses
fl distribution devices in good condition,
working properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted
Summary,
YES'
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NOT CHECKED RRMARKS
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[ ] [ l Se� Suw�vnat�/
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~'a, ���T��� �1lv4iWll1 _�A,�.0 .ifL�/ LIr�II���
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�ai�na-Q►�sa�a�ax���.]i �3[ae�.m.AtG�ia � � � �� �-_d� �
Grout Log
Owner: _ l �.y,. � fz � a„f,..- /� Tax Map �-7 Parcel #_�
Location:
Subdivision: Lot # �_
WeII Constraction
Distance Frorn nearest Property Line {Minimum 10 feet) �
Distance from Septic Systtm (Minimum 60 feet) c�
Total Depth: _�_ ft Yie1d: � GPM Static Water Level: ft
Waur Beanng Zones: Depth -� ft,�� ft ft ft
D�From �v to !� ft. Diameter: 6%� �in
Type: Galvanized Sieel v ��
Weight: ' Thiclmcss: l�� Height above Ground: � v in
Drive Shoe: Yes No Any problrms encountered while setting casing7 �Yes `TVo
`if "ycs" givc reason• `
Gront:
Neat: SancUCement � Conctete GraveUCement
. Annular Space Width 3 inches Wa sr Space Ycs �=iJo
Method of Grou� Pumped Pressure oured ✓� Depth _�_ ta � Ft.
Materi�ls Used:
No. Bags Portiand cemcnt Weight of l Bag � Pounds
If milcture (sand, gravel, cuttings) — Ratio 2 to _�
ID plates: -✓Ycs _ No 4 x 4 slab �!Ycs No
Llner: •
�p�: Date Installcd: Cnout: Instailed by:
Drilling Log
Locadun DrawinQ
From To Formation V
� _ ,
- J `
I hereby certify that the above information is c�rrect and that this well was c�nstructed in accordance with regulations set forth
by thc Person County Health Departmcnt '.
8i�ns►ture of Contractor � ,�. �. .. - - �ID,# �o� DAte�_o�
Pamp Installment
F'ump Installation Contractor: State Regishation Numb�r:
Purnp Depth: _ ft Static Water Levei: ft
Pump Make & Model: Pump Size and Rating: hp gpm
I heireby certify *.hat this pum� was instailed and the well head completed according to the Person County WeII Rules in effect
on this date and that a copy of tbis record has bcen provided to thc well owncr,
Pninn i»a+ollor Ci.r....F.�.�n .. .
l:l a091i6S9CC 4=1e�H �i_uawuo��eu3 0� uos�od W l�Ol 5 OS�BL%t0