A40 172.� !r
.�
s
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENT3 PERMIT No.
te
Owner: r
Location:
`�'—t`c •
Contractor: �� � �'�- � �� !S
Water Supplp: Private � Public
Sewage Disposal Facilities: No. bedrooms �_� Dishwasher, Disposal,
washing machine, other auto atic appliances
Size of tank: Nitriflcation 1�np� �� %�� �
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 INST LATION IS COV-
ERED AND PUT INTO USE.
Date approved: Signe
Sanitari
Well:
Sewage Disposal:
By:
Counter- �, ,
signed
(Owner or his representa ive)
Ceriificate of Completion
Date Approved: '�.� gy; a� 1
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
Y
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. Wrste in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
i 5 �
� � � .� (,� � � � 7_
t �� �; `,
�i�
'� �`���� '�
� i ""
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSUE �Q'S ( DATE DRILLED: COUNTY: "�V 6
OWNER:��� �r�t, ROAD/STREET: S�.
ADDRESS: PERMIT VOID AFTER ONE.Y AR
DRILLING CONTRACTOR:
NAME ADDRESS
WELL CONSTRUCTION
Distance from N/e�a�est Property Line "' � Distance from Source of
Pollution �'j ( / /�
Total Dept���/�� Ft. Yie1d:�GPM Static Water Level: � U Ft.
Water Bearing"Ztsfies: Depth:f. �� t. Ft. Ft. Ft.
Casing: Depth: From ,^�7 td�=Ft. Diameter: �Inches
TYPE: Steel Galvanized Steel _�_
If Steel, does owner approve,,, Yes No
Weight: Thickness: ,�; Height Above Ground:�Inches
Drive Shoe: Yes: r No:
Were Problems Encountered in Setting the Casing? Yes_ No�
If "yes" give reason:
Grout: Type: Neat Sand/Cement: � Concrete
Annular Space Width ��_Inches
^ Water in Annular Space: Yes No�
Method: Pumped Pressure Poured i�
Depth: From �! ) to � Ft.
Materials Used: No. Bags Portland Cement ,� Weight of
1 bag �_lbs. J
If mixture (sand, gravel, cuttings) - Ratio: ` to
ID Plates: Yes�_No Chlorination: Yes X No
4 x 4 slab Yes ,k• No
De th
From to Formation Descri tion
✓� G.. �' /' �
I HEREBY CERTZFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDAN �WITH REGULAT NS SST FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. HEALTH aEP�.� � G
i �e��t� -�y-
Signat of Contractor Date ���
NO
vU/� v �(/�w `" Sanitarian's Signature Date
Sketch well location on-reverse side. Use established reference
points.
� ���� �� . ,
u� �
I-ib ��
o�-
�
,. =�''_"
,;;,
lN-""'
�
[0��
J
/
�
_ h �! �
�alieatio� Date• o Zj
Amau_ d: � G .
�
�-�- � b �q �I—
. d 6,� �
�
jax Maa �k
Perso� Cou�rtv Hesith Deaartmeat
Emriroemerdai Heaith Ser.tion
. -. - T-�.:
� - �. � � �.u�_
'-' '�. C�n
�i �t,�a�ma �r: co�,e���. ow„�:. F�m� c.-s 4� �
� Ho� w,�« ; � ,v�� �4� �.�.,,..
9tninass phcn� ��- 5 q►.'1 � 5 5 3 B �� 3
Z� Nameandaddress�cwrsrttowrier: �►VG. �ox o� f�tuwJt� L%,�1�-l�
• 0 3 2�
� 75 7
3� Psoparty Daacrlptla� Lot�ixx ,,��s'ba+r�mdl� ��-R.�'r�e(C-
06n�ons ia 1he p�ty (lnciuding road tmmea and t�x _
� Trm�,s� St-e2.� u�
� I� ►►ll � ils �
r�, �
�w�i� �� il o,'�J � � ��
� PtoQosod Uae and 3tis�cttme DescriQt�a� � ead� af ihe fo0a�g q�testlons:
� Proposed � E�q �
b) S�c Buit 0, Moduiar 0. Si�ie 1Mde� Daubb Wid�e ❑
d Number ai 8edcoomx �, � Number af o�Ns� oc peopla to be sa[va� 2
e) 9asema� Yes �. Na�{i yea, #� b�aa�t tbducax
gj Q�6r�r�ons af Pno�Osed Struc�+e: V11�h: � Da� ��O
�1 � �PPhI'1�Ipe: � �((��� �9 Di� �4 �Y 4 S�inq � •
Ars atry waqs on a�oin�g ProP�Y? Yas�, No l] lt yes, tocafi�on
8j PMas� Indie� Deaii+ad SYs� �tPe= I� can !� r.u�iasd In ct�d� of Yotn' �i
�Ca�ventlo�i 1� Cotnruttlonai _ A�tlw _ jnno�rdlva
0ltt�t �[yj:
-s' � CLEARLY 3TAKE ALL CORHERs Al+� L1NE�S OF TNE PROP9iTY.
• STAKE THE CORNEi�S OF ALL P�OPOSED STRUGTURES.
P�F.A3E ATfACtI SURVEY PU1T OR SITE PlAN TO THIS APP�ICAT[ON
I tu�y rtieke app8catla� to q�e Pe�son Caunty Healtl� Dep�trna� ioc a a�s s+rapm�lon ibr ths on-sibs seawape disP�d ay�m �
tt'ts a6ove-descnbed pr+operty. t ag[ee tl�at �te �!s of ttds a�pp�loc� ate tnrs and t�epc�nt tt� meodrtuun � bo t
pFacad on the p�opesty. 1 w�das�nd � fhe s�e ts a�ced ac �s in0ended u�s c�.11te pem� strail bemme urira�d. l�
ft�at as ap�acrt. i�un tes�o�te fior fd�mg �ad rt� Prope�tY i�nes. �s and making tf�s ai�s a�is �r tl
personnd of the Peraan Cautdy Hea�h Dep�nent to � ttuair a�raN�atlona. i underatand th� t am r� ��g �
Heaith D , p�a cor�na anY � � � bY � �Y � � �-
2b
(�ue�a� nr 1 weal R�anhH�rw
A[Lf/IR! LEVEL
v�c�Hirr �w�P
I IM�) MssbY c.vrlitY that i as (r� ar�l tb� ovs�r�sl
o! tI� psopsrtr sl�ovn and d�scribd Au�oa vhieb vas
ooa�rid to ��wl blf dMd r�cord�d ia tb� hssoa
CouutY �qist�r o! D��da Oitici in sook
�y� , aed tha! I i��l 1wr�bY i• plan
o! s i� �ioa rith �Y (ourl fsM coas�at, utablish
tl� ■1Ai�ua baildiaq lin�s, ard d�dicat� all all�s ,
wlks, �aswata, parks, othsr op�a spao�s !o pablic
oe pri�at� ua� sa not�d. tustl��r i(w1 b�s�
o�rtitY that th� land as •hovn h�s�oa is ritbin tb•
snbdivi�ior� r�qulation jurisdictioa ot lusoa Couaty,
North Groliaa.
t
�►:
,
i;•ii aii MIaS t� °��°d � R'RS�T1� :.l
+�3 «(OfQG� It1 �tIS CKILs it � • . � �~
:'ti
c�`,�s:�t � �� `—�` -�-�— � ' �
rn��a�r d.��f--� i� �� � r' . �4 NNE F
:�
� . w
�� . •• -
j. �ij �p�ii ��C'Ya� 1.C7.' I.O�M,s-� �
��ti�.iS! Of �'!� .
. 1! 1
�' ,L l ' � L �.. ' : _ ` (
. • �
E�.«� w. t.. .� .�
OS /St. p, i7f `
�.f.00�
s-i�-»oo-E
it�.Is' hl�l
il�Ii' 1WN .- '
J�►r l� r���h►
a N� � .�.
I ltce6�sytlt� tl�i C�e wMi�laias
� t�. 1.�.. �ra.c.a: .
�� o� c!s llesro�
O�e� a�YCs..s:
3- - �
�easat
��++�
�
70
ao �9• � � � ;
:1�•
�1 :
,1 �: _
v,
�O' R/ ,
�
—
�
�
�
susAyt ForR Trp., P�.
A/ojr /9s7, � Ho!!
Sco% l
roo• o
r
N�o1 C. Homlef
�!e�� ���..
�r� �9Y Li!
''�``�'
:
. .
�� �oTA
_.
.,� ; p
;�'•. V81.
:�'o�.....