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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) • � • • • • • � -• • •• • .• • •.- . •- • •- � -• .. � � �. : � �. .�� ■■.■��■� ���������������■.� ���■■■■■ ■��r�����i��i��■��e� ��0����■ ■�i�'����� li ���1����� ■�■���A.■���� ���.� �'� �����■ ■■ ■■��■�� ���I� i�l �1��e ■■ ������� ��■I■■� i�e�■ ■�������f��������, ■ ���t���■��,,.- ■�■���Il����i�O�i��ii■ ��!':����!:.e ■��e����l�°��■����N�����"�ii�iii�li����� ■����������■����...��s���■���■ ■����������r�.��� �� ■�■�s��■ ���������r�r���� ■■ a■s�� ■ ����� ���� .� ��.s:.►.•s•.wr_::�■�r�rL, . .��y j; �� ���� �� �""' � "^ � `� �.1 l"! � �L � ��a-�,ro „-„-„ ,�m�.Il IE--����Il¢]� SITE SK�TCH e� d i c Z� m m c �nna n Ta.g Ma. # p" Parcel # �5�� . p 3�� ivi i n N 1� Section/Lot# ' �r I� I I-�3-aa � 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 . �'`=5� Sca1e. ��5���� k 3D E�st�,r�;cn PGHD, rev. 09/12/Ol ���' 7��� ���� �� `� ������ IEffi�a-�-n-„ -�-n ��¢.�.7l. I�ZL�.�.7L '� 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. �: �� _ �aK C�rc�v� -(1'Lt � lc � i� �t..-� �S5' Well Approved By: �a�� . �. .. . �� '. •_ K« '�°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. •,.� C�C.D (ac.( f lOc7" ��M �c�c. -- � � i � l� �l�c� � 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�'� ���, � f ���.� ��' DGaDUcaQ U� � 23�9 . ��`'= ��� � �l�T'II��Y �a�� �uK�►�•��1+��«u�m-sa��c.. :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 � rn � 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 c From '1'o I'ormation w o , ` � �„ r' � � - � • � 337 ry � I c�l'�+�- � ` r — - 1'"� � � �— — , -- ` ` /33( � , �- � 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?