A27 172��son County Health Department z
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Sewage System improvements Permit
Datc. -�-"-�- —•-�?�� Ttus PeRnit Yoid �1f�Fp� 7� $�I�i11L �__----- ^T�' C
8wne.�- 1�0 '^_T�. � L �� �-,,..��- SR# !.�-;< � :
LOC3ii0I1/D1T8Ct10i1S: - �
Subdivision Name: ('��UP►� (iYP� Lot # �C %
Lot Size: ,t, Sf r C'lr25 Type of Dwelling:
Water Supply: Private: _t� Public: Community:
Bedc+ooms: Garbage Disposal
Basement . Basement Fixuu�es
INFORMA D I'
.S8fl1fafldll: � O C( .� CJIIe,[t�f
REPAIK: REEVALUATION: a�'.�i2. �/"� �
Size of Sepdc Tank: _��� g�ons Size of Pump Tank:
Nirrification Line: _ _ � .�f'� /� � X',� '
Depth Of Stone:'.12 inches
Maz De�xh of Trenches: �
Aliemative Syshem: Conv. Pump LPp pump
Remarks:
� � � � � � � � � � � � � � � � � � � � � � � � �
B te Well Approv ��� -�� Well shaild be 100 f� from any sewer system
anitatian
Date Se a e S -
BY _ Sanitarian
'�`" - ` '� T "ATE OF COMPLETION
Contractor. � i �
3ewage System location, installaaon, and protection must meet staze and local
-egulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
ry owner in such manner as not to create a public health hazard. Septic tank and
utrificadon line must be inspected and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If
fie site plans or intended use c}�ange this pecmit is subject w revocation
;G.S. 130 A-335F)
:.ocation of sewage disposal sewage system sketched on back.
(OVER)
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- ��erson County Health Dr artment �
Well P�ermit - . � �
Date: ' - C This Permit Void After 3 Years ti�f' ►�
Owner. `� u, i P -�- �{�� ,,,., SR# I 3�,/3
Location/Directions:
Subdavision Name: � Lot #�
Drilling_ Contractor. -
� WELL CONSTRUCTION ,b
Distance.from Nearest Property Line_/�� L�.r Distance from Sounce of �'
. Pollution� -i6� �.., .. ; . : ,, , .. • . � .
Tatal Depth: �.�Ft Yeld: �� '• �,PM S�adc Wa[er Level� F�, �
Water Beazing Zones: Depth �[�Ft_jfy_FG F� �'t, �
Casing: Depth: From �_ to � FG Diameter: 6' Inches
TYPE: Steel ` Galvanized Steel
If Stecl. dces owner approve: Yes No
WeighG �.3,_ T!u'c�k ess: eight Above Crrotmd: �j��ches
Drive Shce: Yes No �
Were Problems Encountered in Setting the Casing? Yes No +----
If "yes" give reason: �
GrouG Type: Neat � Sand/Cement Concrete
Annular Space Width .'3 Tnches
Water in Armular Space: Yes No ✓ .
Method: Pumped Pressure Poured i�
Depth: From �— co �.�_ gG �
Macerials Used: No. Bags Ponl�d Cemenc Wei t of 1 ba
��. ��- . �.-=�--- gh g
� fNlkflifC (59ria. $tave�. cuttings� - �atio: �_ �p , .
ID Platacc Ype V . N..
I HEREBY CER'TIFY THpT T'HE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATION5 SET
FORTH BY THE PERSON COUNTY HEAL'I'Ii DEPARTMENT.
�VV � ��
�Sarutanan's Sigr�ture Date Issued
. �.� � ��� /o �-�j
Sazutanan's Signa e Date Completed
Sketch well location on reverse side.
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