A40 198, . i
The District Health Depart�ment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
� Date �– ���—
_�.� ,
Owner: v v r� u
Location: �� ��� � 1_
Water Supplp: Private
Sewage Disposal Facilities: No. beG
washing machine, o h �om i
Size of tank:
Other disposal facility:
. .�
Public
�
..,.,...y„�,_,— .�.�......�.. ., .,r.,.,...,
c appliances 3
NitriAcation line:
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 INS LLATION IS COV-
ERED ANB PUT INTO USE.
, Date approved�• � �� v �¢ Sign
`^ anitarian
��—�10 ,�L� ,,p�.c���_,
Sewage Disposal:
By:.
Counter-
aigned `
( wner or his representative)
Permit YOID after 3 Years
Certificata oi Completion -
Date Approved: �-�, �� By:
Sanitarian
(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.
c2�
��
�
1
WELL PERMIT
Caswell-Chatham-Lee-Person CoUnties
ATE ISSUED: S�/S'BiDATE DRILLED: COUNTY: �G�L1
WNER: � ROAD/STREET: /�IC
DDRESS: PERMIT VOID AFTER NE YEAR
DRILLING CONTRACTOR:
NAME ADDR
WELL CONSTR[JCTION
Distance from Nearest Property Line Distance from Source of
Pollution /�S
Total Depth:�Q�Ft. Yield:� GPM Static Water Level: � Ft.
Water Bearing Zones: Depth: Ft. �p�_Ft. ��Ft. ��_Ft.
Casing: Depth: From p to Ft. Diameter: 1�5/�-Inches
TYPE: Steel Galvanize Steel �_
If Steel, does owner approve: Yes� No
Weight:�� Thickness: Heigh Above Ground:�Inches
Drive Shoe: Yes: � No:
Were Problems Encountered in Setting the Casing? Yes_ No�(
If "yes' give reason:
Grout: Type: Neat Sand/Cement: Concrete
Annular Space Width 3�,�. Inches
Water in Annular Space: Yes No�_ `/
Method: Pumped Pressure Poured l�
Depth: From Q to ��_ Ft.
Materials Used: No. Bags Portland Cement 3 Weight of
1 bag �_lbs. '
If mixture (sand, ravel, cuttings) - Ratio: � to
ID Plates: Yes�No Chlorination: Yes No�
4 x 4 slab Yes�_ No
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. HEALTH DEPT.
��. �� //_S�O.� 1 �lL. .eGG,
gnaty�'� o�j Con�tractor Da
—/Yo - .�iQ�.l�!" /I/ // � 1.-. , r�
REASON FOR NO INSPECTION:
Sanitarian's Signature Date
Sketch well location on reverse side. Use established reference
points. �� _0__ „�l /.?�
Cxouf �O�
� � �� �