A40 175The Dist�rict Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ond Sewage Disposal
IMPROVEMENTS PERMIT No.
Date .�� - -�---+' '�
Owner: _, A Y ,�_��/l.tn S
Location:
c� � � r, ��
Contractor: i � f ' Z
Water Supplp: Private
Public
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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
Hy:
: ': � 7
Signec� f�`Z�iZ'C�/�
Sanitarian
Counter-
oigned � �
Y ner o his representative)
Permit 1101D after 3 Years
CertiBcato o�f Completion �
4 �
Date Approved: 2 ��� By: - �
n tarian
(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
^t later date. Note location of water supplies on adjacent lots.
i) (2)
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WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSUED: �� Pj DATE DRILLED:
OWNER: M�Q, ��V A RLS
ADDRESS:
DRILLING CONTRACTOR: � d d� ».c
,
PERMIT
evso
'iZo�Cj o ie
—�1) Gt
WELL CONSTRUCTION
Distance from Nearest Property Line � y>�� S Distance from Source of
Po l l u t i o n__���� 3 T
Total Depth: t. Yield• GPM St�ic Water Level: Ft.
Water Bearing Zones: Depth:. Ft. %/,1 Ft. Ft. Ft.
Casing: Depth: From_Q_t �t. Diame er: 6%� Inches
TYPE: Steel Galvanized Steel
If Steel, oes owner approve. es No
Weight: � Thickness: �eight Above Ground:�%3Tiches
Drive Shoe: Yes: � SNo:
Were Problems Encountere in Setting the Casing? Yes No �i
If "yes" give reason:
Grout: Type: Neat ✓ Sand/Cement: Concrete
Annular Space Width �_Inches
Water in Annular Space:� Yes No �—
Method: Pum e Pressure Poured L—
Depth: FromP � to �O Ft.
Materials Used: No. Bags Portland Cement �' Weight of
1 bag �lbs.
If mixt r(sand, gravel, cuttings) - Ratio:_�to�
ID Plates: Yes `� Chlorination: Yes No ��
4 x 4 slab Yes� No
De th
From to F rmatio D scri tion
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. HE TH DEPT.
�/ � .rv • � -/9-Y�
S g— n'� ature of Con ractor Date
REASO FOR O INS C
Sketch well location
points.
ION:
vv� —W Sanitarian's Signature Date
on reverse side. Use established reference
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