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PERSON COUNTY�H'EALTH DEPARTMENT
SEWAGE DISPOSAL
IMPROVEHENTS P� IT NO.
Zssue Date: v
Oaner: � � i� V(' ✓
Location: _ 1 1 - -,y�p
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Septic Tank Contractor: �-•• �
Building Contractor: �'
Water Supply: Private�Public
' All wells should be 100 ft. from sewer system.
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Lot Size: �yP S 1/� 1/'1 �(�
Sevage Disposal F es• o. bedrooms - /
Size of tank: ����� �� Nitrification line:
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to S years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line MUST BE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS. � �
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Date Well Approved: Sign d. �
By: Sanitaria •
Date Sewage Disposfal Approved:
1� � �/ -� Counter- �
By: � signed ��
(Owner or represent tive)
Certificate of Completion
Date Approved: ^ u B �//� �<�
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Sanitarian
(over)
Location of well and sewage disposal facilities sketched on back.
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Person County
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DATE'ISSUED: DATE DRIL
OWNER: 1..r
ADDRESS: ��
DRILLING CONTRACTOR:
NAME
,
Health Department
Permit
d �
ADDRESS
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WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Tota1 Depth: Ft. Yield: � GPM Static Water Leve Ft.
Water Bearing Zones: Dep �Ft. F� Ft.
Casing: Depth: From to Ft. Diam� Inches
TYPE: Steel Galvanized Steel
If Steel, does owner ap� Yes No
Weight: Thickness. eight Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Settipg the Casing? Yes No
If 'yes' give reason: ' /
Grout: Type: Neat San Cement Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
Method: Pumped Pr s re Poured �
Depth: From �to �� Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, grayel, cuttings) - Ratio: to
ID Plates: Yes �� No
4 x 4 slab YesT No
DRILLING LOG
De th
From To Formation Description
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I HEREBY CERTIFY THAT THE ABOVE INFORHATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET RTH BY THE
PERSON COUNTY BOARD OF HEALTH. R�' V A THREE RS.
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Sia e aif CBntracto � Date
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Sanitarian's Sigaature Date Completed
Sketch well location on reverse side.
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