A35 156Address � f'� Y'1 G T�1 E� l
No. of persons to be serve� Bedrooms 1, 2, 3� .
Additional appliances to be used: Disposal, dishwasher, washing
machine ��,, � ���
Recommended: Septic ta �
Nitrification line: �� ��' ��'�--�� '
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspected aad
approved by a member of the District Health Department siaff before
any portion of the installation is covered.
Date Approved: � � �� "
By:
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
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SITE SK�TCH
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ivi i n N 1� Section/Lot# '
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� Authorized Sta.te Agent � Date
System components represent approximate �contours only. The contractor must flag the system j�rior to
beginning the installation to insure thatpropergrade r's maintained
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3D E�st�,r�;cn
PGHD, rev. 09/12/Ol
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WELL 1'E�tNII'I'
]P�SE SEE A'1'I'AC�D PLAN FOR WEI.L SITE LAYOU7C
TaxMap#: �s Pazcel# ���o Township �..70�Sc�a�C
gPP�� �d � c, Z � �mcrm�n
s,�a�o�: N rr�
T nr�tinn• 1 1 IC,[-r�CC.S 1 1 l l �� ��' I
'I'y�e of Water Suvnlv:
Res�uirements•
�/ IndiPidnal
Site. Approved bp �/ 3 H [ 2�[ 2-0 2�
Gmuting App=oved by � 3� I 2-� Z-o2
Well Log
�1ell Tag,, .
Air Vent �
Hose Bib
Concrete Slab
Well Dri�ler.
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�aK C�rc�v� -(1'Lt �
lc � i� �t..-� �S5'
Well Approved By: �a��
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'�°5ee Attached Site Sketch'�*
Wells must be 14 feet from property lines.
Wells must be 100 feet from septic systems. �
Wells must be at least 25 feet from anp biu`lding foundation.
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C�C.D (ac.( f lOc7" ��M
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� L�-�i C, L� nL 5 1'1'1G�r1rC.� / P J'SPCE�, rev. 09/07/01
p; �K./ 61�.t 2� b�D�s �n�rK ��e�+S� aFs � p�'�
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:C z-�-�,; 7r•..cD71"R]tTTcF'+��.�,.]1 1L-3L�.�,.I1�1� �� ���
Owr.er: �'_
' oc�:tior: �
�ubc!ivision:
�
' Grout Log
Sm� lTh�
Lot #
Tax Map � ��Parcel # ��
Well Construction
�iscance From nearest Property Line (Minimum 10 feet) •
Dist �nce from Septic Sytitem (Minimum 60 feet)
"fot41 Depch: �c� fc Yield: 2- GPM Static Water Level: 3o ft
'�V1I?f Bearirg Zones: Depth ft ft ft ft
Casing:
Dep�h: From _ �__
'!'��p�: G�Ivanized Steel
�"ei`ht:
=)ri� � Shoe: Yes
`r "`�s" �ive reason:
_ to _ �5 _ ft. Diameter: � in
✓
Thickness: .(� Height above Ground: in
No Any problems encountered while setting casing? _Yes _ No
Grout:
�'eat: SandfCement ✓ Concrete Gravel/Cement
:�nnul�.r Space Width inches Water in Annular Space Yes No
��tethc�d �f Grout: Pumped Pressure Poured i� Depth � to �� Ft.
`Iaterials lised:
�o. B,.es Portland cement Weight of 1 Bag Pounds
'f mixture (sand, gravel, cuttings) — Ratio to
!D �la�es: __ Yes _ No 4 x 4 slab l� Yes _ No
Drilling Log Location Drawing
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rn
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I-7
I he-ehvi certify tha� !I�e above information is correct and that this well was constnicted in accordance with regulations
sct :�or�h by the Per���n County �-Iealth Dep�rtment. .
SiQnature of C�ntr;�ctr�r � ID #� �� Date � 2' 3— ��
� . PCHD rev 09/30/�?
���� �� ���.� �� �o� oo � 2309 ,
- - _- �-- .�� � �T �T'I� �Y" �'�'�� a� � � �s K�� � � ��1� � Lu � m�sa� �-
I.� n-n-�ii �r•�cDii�'�rnT.ce_ zrn�.tn�l IL'��.tn.�tL-Jia U�9JlK� IJUUDUlyl4J
Ce2LT� � Qa � c�� � L,Id n� $�
/�n /�n� 1 � . . . . _ _ e�. _ _ , Grout Log
Owner:
Location: ^
Subdivision:
Lot #
Tax Map �5 Parcel # � �J' (�
Well Construction
Distance From nearest Property Line (Minimum 10 feet) ��
Distance from Septic System (Minimum 60 feet)
Totai Depth: �QQ ft Yield: � GPM Static Water Level: �� ft
�Vater Bearina Zones: Depth 205 ft ft ft ft
Casing: � . . --
Depch: From _ � to �Q__ ft. Diameter: �_ in
Type: Galvanized Steel V'
Weight: Thickness: .�� Height above Ground: in
Drive Shoe: Yes No Any problems encountered while setting casing? _Yes _ No
If "yes" �ive reason:
Grout:
Neat: SandfCement ✓ Concrete Grave]/Cement
Annular Space Width inches Water in Annular Space Yes No
;�Iethod of Grout: Pumped Pressure Poured ✓ Depth � to �� Ft.
:�Ialerials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixtu►•e (s��nd, gravel, cuttings) — Ratio to
1D plates: � Yes _ No � 4 x 4 slab I� Yes _ No
Drilling Log Location Drawing
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From '1'o I'ormation w o
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I herehy certify that tl�c above information is correct and that this well was constnicted in accordance with regulations
set f�orth by the Per�c�n County Health Department.
Signature o(' Coi�tractor � ID #�^•��� Date ��'����Z.
. PCHD rev U9/30/0?