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A27 180� L Person County Health Department S wa e System Improvements Permit Date• .-' - This Pe it Void Af Y s Owner: SR# � .,3 Locaaon/Directions: t f � �' �i1 T a+�..r Subdivision Name: � � J �' Lot # Lot Size: �'% r;i n �� s, Type of Dwelling: �j { �-- Water Supply: Private: � Public: • Semi Private: If not Private Tax Map# P�rcel # of Water Supply or Name of Supplier# _ Bedrooms: � Garbage Disposal Basement Basement Fixtures � � INFORMA'I'f�N C'�RT�FIED� '�'�� ' ` �,/.�' %�� ,� � � Siillit1i18It' h`�-kPr �r!�7 �,_,_,'r` r•�,1s,{J, � owner or representative REPEIIR: `"� ' REEVALUATION: -----------------� ------- Size of Septic Tank: 1''�_ gallons Nitrification Line: � � j( � � Depth of Stone: 12 inches � Max Depth of Trenches: OPERATIONAL PERMTT: yes no_�� - Remarks: Date Well Approved: � BY BY S� � S�/ m;1, % -, � z -� 0 � � n � Wel'. should be 100 R from any sewer system r " � CE CATE 9F COMPLEiTON �y?�'' � Contractor. 1 � � � ------------------------ � _ � Sewage System location, installation. and protection must meet state and local � regulations. Septic tank should be pumped out every 3 to 5 years and shail be maintained by owner in such manner as not to czeate 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. v 1 L,ocation of sewage disposal sewage system sketched on back. ^- � (OVER) (� � Person County Health Department � Weil Permit ��� � Date: -� This Permit Void After 3 Years '� Owner: SR# -,��,�-I �— I.00B[tOnmireCtion4• O� /� Subdivision Name:. Drilling Contractor. Loc # 3 S I � WELL CONSTRUCi'ION �►� Distance from ea;est Property Liney ,�D/cc�S Distance from Source of �' Pollution � o w S � cr Total Depth: Ft Yeld: GPM Static Water Level �� F� � Watet Bearing Zones: Depth -�FG FG Ft� �Ft. Casing: Depth: From 0 to .S Ft Diameter: _c.f, Inches TYPE: Steel � Galvanized Steel � If Steel, does owner approve: Yes No WeighC _1,3- Thiclrne�ss:� eight Above Groimd: ��_ Inches Drive Shce: Yes N'r o Were P�blems Encoimtered in Setting the Casing? Yes No �`� If "yes" give reason: GrouG Type: Neat Sand/Cement Concrete Annulaz Space Width �� Inches �- Water in Armular Space: Yes No Method: Pumped Pressure Poured [�� Depth: From Q to .2� Used: No. Bags Portland Cement � Weight of 1 bag Ibs. If m turc (sand,g{ave�l .cuttings) - Ratio: _� to ,�_ ID Plates: Yes �/ No 4 z 4 slab Yes t� No I HEREBY CERT'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT TI-IIS WELL WAS CONSTRUCTED IN ACCORDANCE WiTH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALT� I)EPARTMENT. � Signanae of Contractor � Date � �t/-� �-��-.- � �' sazy�ri '�t���ate Issuea �C Sanitarian's Signature Date Completed ,� NOTE: 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 later date. Note location of water supplies on adjacent lots. (1) (2) ■�■��■�����������e�������■ ■����■���■������e���������■ ■���������������������■���■ ■■���������■ ■■■�����N���■ ■■■�1������■ ■ ������������� ■��������������■■�O ■��■ ■■ ■�����������������■ ■��■ �■ ■�����■ ■�����������������■ ■�����■ ■��v ■����������0■ ■�����������■ ■�����������■ ■���■s�������■ �������■�n�■ ■�����■���������������a■ ■■ ■