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PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISPUSAL
MPROVEMENTS P/gRMIT NO.
SV%�he�ssue Date: / � � —
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.
Owner. �
Location: �
✓
Septic Ta Contractor:
Building Contractor:
Water Supply: Private �/ Public
All wells should be 100 ft. from sewer system.
Lot Size: � l� G(�
Sewage Disposal lFacilities: No. bedrooms
Size of tank: / ���Nitrific
Other disposal facility:
line:
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 BE INSPECTED AND
APPROVED SY A MEMBER OF �'fiE PERSON C0. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS.
Date Well Approved:
By:
Date Sewage isposal Approved:_
� 3 �..�i
By:
Signed `
a ari
Counter- �°-
signed
(Own r his representative)
Certificate of Completion
Date Approved: / �`' �� gy.
anitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
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1 \.� T _� �-� � � � ( � �1
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Person County Health Department
Well Permit
DATE ISSU•D:/ � DATE DRILLED: �.2 _ OUNTY: �
OWNER: -� ROAD/STREET:
ADDRESSs � Ib�� , ���}� �j{� q
DRILLING CONTRACTOR: �. /�� �
NAME ADDRESS
W£LL CONSTRUCTION
Distance from Nearest Property Linel,rTDistance from Source of
Pollution�/� d � /u. S z
Total Depth:/ �_� Ft. Yie1d�GPM Static Water Level J� Ft.
Water Bearing Zones: De th / O Ft �J (� Ft. Ft. Ft.
Casing: Depth: From � to��Ft. Diameter: 6� Inches
TYPE: Steel Galvanized Steel Li �
If Steel, does owner approve• Yes No
Weight:��Thickness:�Height Above Ground: /•11nches
Drive Shoe: Yes Cu .v� ��,. yNo
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 Spacez Yes No �—�'
Method: Pumped Pressurg Poured � -
Depth: From �—to �0 Ft.
Materials Used: No. Bags Portlan�d Cement_�Weight of
1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio:_�to�
ID Plates: Yes �� No
4 x 4 slab Yes L� No
DRILLING LOG
DA th
Frqm To Formation Desc i tion
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/Z Y --- G'rT � �-._
I HEREBY CERTIFY THAT THE ABOVE INFORMATZON IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COQNTY BOARD UF HEALTH. PERMIT VOZD AFTER THREE YEARS.
�/�- �/� �. �- �. �`'i
Signature of Contractor Date
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Sa ta an's Sig ture te ssued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.