A28 129�-� �
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PERSON COUNTY HEf�LTH bEPARTMENT
SEWAGE DISPOSAL
IMPROVEMENTS PERMIT N0.
Issue Date: �
Owner: ��f�"�-' � / � U tJ � %1�
Location: �
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Septic Tan c Con acto : •// ., �{Y� Q
Building Contractor: �l��r��-�� ���
Water Supply:' Private Public
All wells should be 100 ft. from sewer system.
Lot Size: .�'`'1"
Sewage Disposal Facilities:
Size of tank: 1 f�f]l�_��
G; lY��
Nitrification line:
!
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line MUST SE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON C0. HEALTH DEPARTMENT STAFF $EFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PIIT TO USE. HZ
PERMZT VOID AFTER 3 YEARS. i' �
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Date Well Approved: Signed l fal/� �
gY; � Sani ar n
Date Sewage Dis osal Approved:_
Counter-
gy; signe
(Ow is presentative)
Certificate of Completion `
Date Approved: � � BY
nitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
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Person County Health Department
Well Permit
DATE ISSUED: DATE DRILLED: �_I y��OUNTY: I� o
OWNER: ROAD/ST T:
ADDRESS: ��t, J�fj �
DRILLING CONTRACTORs I �S�.ON r
NAME ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft. Yield:� GPM Static Water Level Ft.
Water Bearing Zones: D th—� ��Ft. �Ft.
Casing: Depth: From � to V Ft. Diam_e,L�er: Inches
TYPE: Steel Galvanized Steel r
If Steel, does owner app 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 Sand/Cement � Concrete
Annular Space Width Inches
Water in Annular Space: Yes No �
Method: Pumped P re Poured
Depth: From tor�Ft.
Materials Used: No. Sags Portland Cement Weight of
1 bag lbs. / -r
If mixture (sand „ g�lavel, cuttings) - Ratio: to �
ID Plates: Yes� No '
4 x 4 slab Yes No `
DRILLING LOG
De th
From To Formation Descri tion
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS
WELL WAS CONSTRUCTED IN ACCORDANCE H GULA
PERSON COUNTY BOARD OF HEALTH. PE M ��.AF
of
AND THAT THIS
' FORTH BY THE
� YEARS.
Date
Sanitarian's Signatura Date Completed
Sketch well location on revezse side.
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