A27 220. ,► z
` Person County Health Department �
�
Sewa e System Improvements Permit
Date: " T„�s��i�VQid Afte�,� S fG� SR# 1,3U�
Owner: _f— d �--�/ ��-
Location/Directions:
Subdivision N e: G � ��fLot #
Lot Sizc: �- � t P�— Type of Dwelling: .
Water Supply: Private: —j„� Public: Community:
Bedrooms: �— Gazbage Disposal
Basement Basement Fixtures
INFORMA CE D Y '
$�1��: oµner or rep entative
REPAIR: REEVALUATION:
Size of Septic Tank: (��v gallons S}ze of Pump Tank: �
Nitrification Line: ��3 `
Depth of Stone: 12 inches
Maac Depth of Trenches:
AltemaUve System:� Conv. Pump -LPP Pump
Remazks:
---=---------------------
Date Well Approv : � Well should be 100 ft, from any sewer system
BY Sanitari
Date Se e proved:
By Sanitarian
CERTIFI ATE OF COMPLETION
Contractor. ._,�_�. � I �LES �
------------------------- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Sepdc 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 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) �
I.ocation of sewage disposal sewage system sketched on back. N
(OVER)
. � Person County Health Departm
Well Permit
Date: � 12-�/ Permit Void After 3 Year `L
Owner: ,�� I/c� ��',�.1����_ SR
Loca[ion/Directions:
Subdivision Name:.
Drilling Contractor:
ent �
�
�
# 1/ �b�
#—�
b
Distance from Nearest Property Line Distance from Source of �-�'
Pollution 0 c�,
Total Depth: t Yield: � GPM Static Water Level FG �
Water Bearing Zones: Deptjy� '��� FG Ft FG
Casing: Depth: From �J to �✓Ft Diame�i Inches
TYPE: Steel � Galvani�ed Steel
-- If Steel, does owner approve: No
Weight Thiclmess: � Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encoimtered in Setting the Casing? Yes No
If "yes" give reason: _ / ''d
Grou� Type: Neat S d�ement Concrete �
Annular Space Widch � (— Inches
Water in Annular Space: Yes No
Method: Aunped Pr Poure�
Depth: From � to Ft,
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand. gra�j(cuttings) - Ratio: to
ID Plates: Yes No ►b
4 x 4 slab Yes Z No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN CORDANCE WITH RE ULATIONS SET
FORTH BY THE PERSON COUNTY H P ENT.
S zq ��
s� n� c �x3� , D�
Date Issued
Sanitarians Signature ' Date Completed
Sketch well locadon 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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