A27 193' �
Person County Health Department �
Well Permit �
Date: -�� is Pennit Voi After 3 Years - a�-� '�
Owner: G r SR#
L,ocation/Directions: � �
i� �e ' I S �
Subdivision Name: ' #
Drilling Contractor.
WELL CONSTRUCI'ION ►b
Distance from Nearest Property Line Distance from Source of �'
Pollution _ �
Total Depth Ft reld: � r GPM Static Water Level Ft. �
Water Bearing Zones: Dept}� � Ft Ft. FG
Casing: Depth: From SZ_ co F� Diameteyt Inches
TYPE: Steel Galvanized Steel r
ff Steel, does owner approve• No
WeighL Thiclrness: � Height Above Ground: Inches
Drive Shce: Yes No
W Probl E tered in Settin the Casin ? Yes No
ere ems ncoun g g
If "yes" give reason• �
GrouG Type: Neat Cement Concrete
Annular Space Width �_ Inches
Wazer in Annulaz Space: Yes No
Method: Pumpeci Pressure Poised�
Depth: From —� to �,�._ FG
Mazerials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand. gravel, cuttings) - Ratio: to _
ID Plates: Yes � No
4 x 4 slab Yes �— No
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT
THIS WELL WAS CONSTRUCfED IN�C�RDAN� WITH�EGULA
FORTH BY THE PERSON COUNTY H��'1� pEP MENT
AND THAT'
Sanitarians Signature Date Completed
Sketch well location on reverse side.
" NOT'E: 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)
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Person County Health Department
Sewage System Improvements Permit
Dat,e: -I (- 4-�'IT�is Pern►it Voi�After 5 Years , Permit # o�.�_
Ovmer: � - SR# �Q�
Location/Directions: c�- e� ,9 � r1� �r vf d�C Y, c� ��
Subdivision Name: `" � �.ot #
Lot Size: ��r'�L� Type of Dwelling: ��, ���
Water Supply: Private: —i.� Public: Community: _
Bedrooms: 3 Garbage Disposal .
Basement Basement Fixtures �
OW[ICt Of
REPAIIt: ` ' REEVALUATION:
-------------------------
Size of Septic Tank: -�`�6`— allons Size of Pump Tank:
Nitrification Line: ��i/ � X3 '
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative Syst,em: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date S e s pproved: -
BY Sanitarian
CERT� CATE OF COMPLETION
Contr�tor. `�r^ 1 � 1.L1 �S
Sewage System location, installation, and proIection 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 heatth hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person Counry
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G.S. 130 A-335F)
L,ocation of sewage disposal sewage system sketched on back.
(OVER)
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