A27 211NOTE: 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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4�� � ' �1 �i:��1'
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� � ` .Person County Health Departm
Well Permit
Date: ��� This Pe�} it Void After 3 Years
Owner. ��.�Ik-l� �� 2 t-� SR#
Location/Directions: . � ' ' _ ^ . . ,,, �
Subdivision Name: ,
Drilling Contractor.
�nt �
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, -
WELL CONSTRUCTION _ . �� �
Distance from Nearest Property Line Distance from Source of
Pollution _ �
Total Depth: Ft Yeld: �� GPM Static Water Level FG
Water Bearin Zones: D Ft Ft �j
Casing: Depth From � to F� Diametetz � i�ir►ches
T'YPE: Steei ' Galvanized Steel ��
ff Stecl, does owner approve: No
Weigh� Thiclrness: Height Above Grotmd: Inches
Drive Shce: Yes No
Were Problems Encoimtered in Setting the Casing? Yes No
If "yes" give reason: ' � �
Grout Type: Neat S ement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No
Method Pumped Pres re Poiaed �
Depth: Fzom � to Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes v No ►�
4 x 4 slab Yes �— No CD
DRILLING LOG �,
. ,
I HEREBY CER'fIFY THAT THE ABOVE INFORMATIpN IS C
THIS WELL WAS CONSTRUCTED IN ORDANCE WITH
FORTH BY THE PERSON COUNTY H AR
Sign f c
Sazutarians Signatu
Sanitarians Signature
Sketch well locarion on reverse side.
AND THAT
,TTONS SET
� Date
—�/�/�o
Issued
Date Completed
�
Person County Heaith Department �
Sewage System Improvements Permit
Date:�_ �� is Permit oid After 5 Years �
Owner: .a��¢� ��—��1 j Ah SR# � 3 U� �n
Location/Directions: �
D ' "" o (�
Subdivision Name: Lot # " j
Lot Size: , Type of Dwelling: _ �
Water Supply: Private: Public: Community: �
Bedrooms: Garbage Disposal �
Basement Basement Fixtures �
INFORMA n, ¢E���D BY
e.,,.:..,.;.,., �l/Q i... aner or reo rve
REPAIR: `� REEVALUATION:
Size of Septic Tank: __�� gallons Size of Pump Tank:',������,
Nitrification Line: �� �� 3 � ��
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative Sys[em: Conv. Pump LPP Pump
Remarks:
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
D Sewag ys� proved:���- �--/�-4-�
BY .�I Sanitarian
RTIFTCA �O�j COMPLETION
Contractor. � \ � >����iJ-Gz..c� /
------------------------- '-3
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Sewage System location, installation, and protection must meet state and local '�
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and`d
nitrif'ication 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 intended use change this pernut is subject to revocation.
(G.S. 130 A-335F)
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Location of sewage disposal sewage system sketched on back. �
J
(OVER) �
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