A35 132The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Da e �_ / _ ��
Owner: ��(��T�� �� Sn .�_
Location:
S� (�3�-;r-�„�.� ;
o� s� 5
Contractor. � -�
Waier Supplp: Private Public
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposai,
washing machine, other auto atic appliances
Size of tank: �' Nitriflcation line: `����(,� 3�
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local _ regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
5eptic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE I ALLATION IS COV-
ERED AND PUT INTO USE.
Signe
Sanitarian
�f r
Counte GZ�
aigne�
(Owner or his representative)
�mit _VO1D
afi�r 3 y�rs
CerliAcale o! Com�pletion -
Date Approved: � �� � By. `�'�"
Sanitarian
(OVEii)
Location oi well and sewage disposal facilities sketched oa back.
�f �j� �� �p I x
���..,_ � � S73
WELL PERMZT
Casvell-Chatham-Lee-Peraon Counties
DATE ZSSUED: DATE DRII.LED:�� COUNTY:� S�
OWNER: ROAD/STREET:
ADDRFSS. ^� �ERliZ_ T�YOIIIA� t ' Ij{�, S�1 �C
DRILLING CONTRACTOR: IV�1•�)r�.��JJ IV �3�
NAME ADDR£SS
idELL CONSTROCTION
Distance from Nearest Property Line ' Distance from Source of
Pollutioa
Total Depth: FL. -Yieldz � GPM Static Hater Level: Ft.
:latu Bearing 2ones: D�th:�. � Ft^ �Ft.
Casing: Depth: From�to D ter: �_iacbes
TYPE: Steel Galvanized Steel
If Steel, does ovner appr Yes No
Weight: Shiekness: � Height Abave Ground: Inehnz
Drive Shoes Yes: No:
liere Proble� Eneountered a.a SetLiag t�e Casanq? Yes No
Zi 'pes• give zeason: —
Grout: lype: Nnat Sand at: Concrete
1►unular Space width ��IncIIes
Nater in JWnular Spaee: Yes No
Methodz Pumped �s�ure Poured�
Depthz Froa � V p�,
Materials Used: �+o. Bags Portlaad Ceseat Uteight of
1 bag lbs.
2f mixtnre (sand�avel, entLis�qs) - Ratio: to
ID Platess Yes No Chloriaatioa: Yes No
4 s 4 slab Yes-r%� No
. : ..
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rf_��11r.� i .:.
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I F�ItE87 �RTIF7 TfiAT T!� JIHOVE IHFORlS7lSION IS COitREGT SHAT SHZS
iTELL iJAS COKSTRUCTED ZN 11CCORDAHCE REGULJI KS SiT RSH 87
CASi�iELL-CHATfi11!!-LEE-PEIi50N DIST.
.
. Sags�ature of Coa:racLos Date
FOR HEALTH DEPARITSEA2!' USE ONLY
REASON FOE lq ZKSPECTIOH:
Sketch vell locatioa on.reverse S a�z�vs���stablisa a r��r�nc�e
poiats.