A40 159The District Health Deparfinent
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ond Sewage Disposal
IMPAOVEMENT3 PERMI�', ,�To,,,,��
Owner: _
Location:
Contractor: —
Water Supplp:
v
ro
� • � Public
Sewage Disposal Facililies: No. bedrooms � Dishwasher, Disposal�
washing machine, other utomatic appliances
Size of tank: � S� Nitriftcation line:'��v
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.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION I5 COV-
ERED AND PUT INTO USE.
Date approved:.
Weli:
Sewage Disposal• �� � 9- 8 S
By:
� �
Signe - �-�.--��3
Sanitari
Count - � .
aign
( Wner or his represe tive)
Certificale of Completion
+ ^ .i`
Date Approved: � a � �� By: ��'u'`' ��
Sanitarian �
-1_ (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, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
(1) (2)
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DATE ISS
OWNER:�
ADDRESS:
DRILLING
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
WELL CONSTRUCTION
Distance fro Nearest Property Line Distance from Source of
Pollution
Total Depth: t. Yie1d:�GPM Static Water Leve : Ft.
Water Bearin Zones: De Ft� Ft.
Casing: Depth: From p�to�Ft. D�fffeter: Inches
TYPE: Steel Galvanized Steel
If Steel, does owner appr Yes No
Weight: Thickness: � Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat San e ent: Concrete
Annular Space Width � Inches
Water in Annular Space: Yes No �
Method: Pumped�` � ssure Poured
Depth: From �1/ to Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand,/C3ravel, cuttings) - Ratio: to
ID Plates: Yes r/ No Chlorination: Yes No
4 x 4 slab YesZ No
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<�I����lyL�_S►��L_ �j�J��_
�r����►�����T�:
�a��� - - -
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WI RE ULATIONS S FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. HEAL H �
— Signature of Contract r Date
, �
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO INSPECTION:
S itari�'s Signa re - Date
Sketch well location on reverse sid 6fiFse�est�b i e�ence
points. J