A27 143�
Person County. Health Department
Sewage. System Improvements Permit
Dake: -'' is Pemtif Void. 5 Years '
Owncr. f ���f?���"�oL-�— SR# ��
L.ocalion/Directions:
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$ubdiviSio ame: Lot # -- � "
Lot Size: Type of Dwelling: - _
Water Supply: Private: � Public: Community:
Bedrooms: 3 Garbage Disposal
Basement � Basement' F'ixtures
r
INFORMA D BY T +�
. . . . ._. ..
Sanitariant `�`
REPAIIZ: � REEVALUATION:
Size of Septic Tank: �����'�, gallons. Size of Pump Tank:
Nitrification Line: -4,/lE'� � � '� `
Depth: of Stone: 12 inches
Max Depth of Trenches:
Altemarive System: Conv. Pump LPP Pump
Remazks:
Date Well ApprovE
Date
BY_
���" .o Well should be 100 ft from an_y;sewer system•
� ved: S� .� „� Q� _.
� � -. Sanitarian
TIF�CATE OF COMPLETION
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Conuactor. ��, �� '
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Sewage System location, installation, and grotection must .meet .state and local �
regulations. Sepdc tank should be pumped out every 3 to 5 years and shail be maintained � '
by owner in such manner as not to create a public health hazazd. Septic tank and'd
nitrification. line must be inspected and approved by a member of the Person Counry � '
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intende� use chaiige this pemYit is subject- to-revocation, .
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back.
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Person County Health Department �
Well Permit �
Date: ���� �s Perm' Vo'd After 3 Years ��� ��
Owner: _ a �'------,- � � c, ��_ SR#
Locaaon/Duecdons.
��-� L 3c1� ,n �„4
Subdivision Name: �� #
Drilling Contractor. �
WELL CO S RU N b
Distance from Nearest Property Line Distance from Sout�ce of r�,'
Polludon � � � , 0,�/cc�'
Total D th: �.
ep /�Ft Yield: _�GPM Static Water Level �_F�,
Water Bearing Zones: Depth �,� FGJ��Ft. Ft. F�,
Casing: Depth: From .�_ ��� FG Diameter. 6' Inches
TYPE: Steel � Galvanized Steel ��
ff Steel, does owner approve: Yes No
WeighG .�,�'1'����s: ��Height Above Grotmd: % �— Inches
Drive Shce: Yes `� No
Were Problems Encountsred in Setting the Casing? Yes No �—�
ff "yes" give reason; ,,,d
Grou� Type: Neat `� Sand/Ceme,nt Concrete �
Annular Space Width 3 Inches
Water in Armular Space: Yes No �� ' .
Method: Pamped press� po�d l/
Depth: From �— � F� � �t "�
Materials Used: No. Ba s Pordand Cement '�
g --�_ Weight of l:.bag ,,,. ,
�_ lbs. � i
If mixture (sand, av , cnttings) - Rado: _ �_ � �_
ID Plates: Yes No
4 x 4 slab Yes �— No �
I HEREBY CER'TIFY THAT THE qBOVE INFORMATION IS CORRECT ANp'I'HAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SETI
FORTH BY THE PERSON COUNIy HEALTH DEPARTMENT. ,.1
�
Sanitarian's Signature Date Completed
h well location on reverse side.