A40 130The District--Heq.�-�h--Bepar#-men�:
CASWELL� �HATHAM - LEE - PERSON COUNTIES
A
Water Supply and Sewage 'sp�s I
IMPROVEMENTS PERD�.T I�I '"�
Owner:
Contractor: � � �
Pri
Public
Sewage Dis �osal �acilities: No. bedrooms —� Dishwas� r, �is o�s`�1,
ashing mac ' ther automatic appliances �
Size of tank: �r � Nitriflcation line: -- ,
,�,
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 an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PUT INTO USE.
Date approved: � Signe `
�f� San' ari
Well: "
_ . , T7
Sewage I)isposal: � '� ' � � Counter-
signed
BY� (Owner or his representative)
Cert�cate of Comple2ion ��
, � j, B : � �-.
Date Approved: �.2� Y
S nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, priyies, water
supplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located .
_�
WELL PERNZT
Casvell-Chatham-Lee-Person Counties
DATE ZS : DATE DRILLED�^ COUNTY: U"'�uW I��S
OWNER: �] ROAD/ST T•
ADDRESS: � WL� VOZ YEAR
DRILLING ONTRACTOR:
NAHE ADDRESS
ilELL CONSTRUCTION
Diatance from Nearesi Property Line ' Distance from Source of
Pollution___�
Total Depth. t. -Yield: � GPM Siatie Water 7.evel FL.
Water Bearin ones: � . Ft. Ft.
Casingz Depth: Fsom to Ft. D�ter: lnehes
TYPEs Steel Galvanized Steel
If Steel, does ovner apprqY� Yes No
iieight: Thiekness: IDU beigGt 11Dove Ground: Inehes
Drive SAoe: Yes: No:
Were Problems Encountared a.n SetLiaq ybe Casinq? Yea_ No
Zf •7ea' give reason: /
Grouts �pe: Heat 5 ement: Concrete
1►uaular Space 4ladth �Inches
Water i.n Aanular Space: Yes No �
lsethod: Pumped _e__ �e�nz�c poured
Depth: Froa to �.J pr.
Maiezials Useds No. Baqs Portlaad Ceaeat i�teiqht af
1 bag lbs.
Zf mixture (sand,�`iravel, eutiinqs) - Ratior to
ZD Plates: Yes o Chlorination: Yes No
4 Z 4 tlab Yes� No
�:3s7� ..
n
�m •
�'s�/i-il t/li� � ��1�7.1�7.��
tl�l'�i��.�, y���,�i-._.��ju�
�l�Uf►7�Y .. --
<�Z�<�LZ��L�
��
I�ItE87 CERTIi7 THAS T!� J180VE ZNFORlSJITION IS CORRELT 11itD Tiil1T IHZS
FiF.I.L iJAS COKSTRUCTED IH 11CCORDAHCE RE IOHS FORSH BY
CASFTELL-C3iASHJ1li-LEE-PERSON DIST. E
♦
, Signature of Con:ra Date
fOR HEALTH DEPAR2TSEtST USE ONLY
REASON FQF.' !10 ZItSPECTIONz
- SaniLarina's Signature Date
Sketeh vell locatinn oa revrsse side. Use established reiereaee
poinu.