A40 164The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
� IMPROVEMENT3 PERMIT No.
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Owner: ���„1L�-'�Y S'
Lacation: ''
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Contractor:. � �o���� ��'��
Wates Supplg: Private � Public
ivosal Facililies: No. bedrooms
in�t�i�l other sutor�atic appliances : -�
of� tank� C_ NitriAcation line:
Disposal.
Other disposal�i acility: — . .
�l'� � �j 0. J�C rN.c'..�- �Sc�cvf k. f�C:-�
�ater supply and sewage disposal faciliL4�s location� installat�q� $1Rd
protection must meet state and local regulations. -
Seplic tank should b¢ umpecl out every 3 40 5 years and s6a11 be maita-
tained by owner in suc�i a manner as not to create a publie health hazard.
Septic tank and nitri8cation line MUST BE INSPECTED AND AP-
PROVED BY A MEMBEft OF THE DISTftICT HEAL DEPARTMENT
STAFF BEFOAE ANY POATION OF THE . IN A O IS COV-
ERED AND PUT INTO USE.
Date approved: Sig
Sanitarian
Well: C.�"�
Sewage Disposal: Counter-
aigne ��
BY� (Owner or his representative)
Ceslilieate of Completion
.
Date Approved: g��q��7 By: a
a itaria �
(OVER)
Location of well and sewage disposal facilities sketched on back.
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DATE ISSUED:
OWNER: �
ADDRESS e��"�
_. _ - ----- . �.�..�.-�
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_ _-_ - - -- ,
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
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DRILLING CONTR7{CTOR: ' ' �!!!'wl�' ' � • �y�_� ""�� �'� i
NAME - • � -� -.- ADDRESS i
� WELL CONSTRUCTION '
Distance from Nearest Property Line Distance from Source of
Pollution ♦ : �
Total Deoth: . Yield: {�GPM `S�tatic Water I�evel: Ft.
Water Bearing Zones;: D�p�.h: ' i Ft. . l t. ` Ft.
Casing: Depth: From�LJ to .�tr Dia�er: Inches
TYPE: Steel Galvanized Steel �"-
If Steel, does owner appr Yes -�'"" No
Weight: Thickness: �yHeight Above Ground: Inches
Drive Shoe: Yes: _ No:
Were Problems Encountered in,Setting t Casing? Yes_ No_
If "yes" give reason:
Grout: Type: Neat San it�ment: � Concrete
Annular Space Width . ��� Inches
Water in Annular Space: Yes No y�
Method: Pumped sure Poured
Depth: From to � Ft•
Materials Used: No. Bags Portland Cement Weight of ,
1 bag lbs.
If mixture (sand�avel, cuttings) - Ratio: to
ID Plates: Yes _ Dlo Chlorination: Yes No
4 x 4 slab Yes i7 No
De th
From to F r ti n De ri tion
I HEREBY CERTIFY THAT THE ABOVE INFO IO IS CORRECT D THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W RE LATI SE FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. HE E
Signature of Contracto Date
REASON FOR NO
Sketch well locatinn on reverse s
points.
.� -/�-�.
ature Date
ished reference
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �r�Id�`P �Uv-�h
Address Cou ua �. . County PERSON
Collected By � S
Date Collected /�(���`f Time Collected /�: �S
Source: �ell ❑ Spring ❑ Other
Location: C�Iouse Tap ❑ Well Tap ❑ Other
❑ No Charge f�L:harge
........................................................................�
*************************�******�***************************************
Total Coliform
FecaUE. Coli
Present
❑
�■7
Reported By ` h
Date Reported � � �� I � �"
Report Called ❑ YES �NO
Called To•
Results
Absent
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