A28 165� /'t��'oZ43 z
"�'"�` �erson County Heaiin Department �
S�e System Improvements Permit
Date• '� - ' Permit V id After 3 Years �
Owner• �, V � Y�.r � (y� ' �.S�Il�,l� % `S
Location/D'uections: t
�� �. . , .r r ,-� , _ _ _ _ .
Subdivision Name• Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: Public:
Semi Private: If not Private Tax Map#
Parcel # of Water Supply or Name of
Supplier#
Bedrooms: Garbage Disposal
Basement Basement Fixtures , , _
J8I11[aT18I1:(�c�+iF'E�y.�' -�6YY"�Z.j owAer or represe�uve I
REPAIR: V REEVALUATION: �" �
------ ----- �
----- �,
Size of Septic Tank: �� gallons � , �
Nitrification Line: �� �f� 1�3 v�/���- M�orr �F„
Depth of Stone: 12 inches =�- —'���'s��+r
Max Depth of Trenches:_ �D "
OPERATIONAL PERMIT: yes no
Remarks:
Date Well Approve %�� Wei? should be 100 ft from any sewer system
BY
Date Sewage S � Approved: _�_/'���f
B1' Sanitarian �
CERTIFICATE OF COMPLETION �
Contracto�� �¢�+,t�,��,`
------------------------ �
Sewage System location, installadon, and protection 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 manner as not to create a public health hazard.
Septic tank and ni�ification line must be inspected and approved by a member of
the Person County Health Department before any portion of the installation is �
covered and put into use.
�
Location of sewage disposal sewage system sketched on back. �
Q
(OVER)
,
OTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
'. `t�pplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
- � } � Person County �ealEh Department
Well Permit
DATE ISSUE : � � Q� DATE DRILLED:_���CO NTY: G S��
OWNER: .� ROAD/STREET:
ADDRESS: �j� �� '
DRILLING CONTRACTOR: � ns O PS
NAHE ADDRESS
WELL CONSTRUCTION
Distance fro Nearest Property Line ,�istance from Source of
Pollution Od 7/�t S
Total Depth:�Ft. Yie1d:�GPM Static Water Level Ft.
Water Bearing Zones: Depth�'_Ft�_Ft. Ft. Ft.
Casing: Depth: From�_to�Ft. Diameter: � Inches
TYPE: Steel Galv nized Steel v
If Steel does owner approve: Yes No
Weight:1�_Thickness:�'�Height Above Ground:�y�2nches
Drive Shoe: Yes � No �
Were Problems Encountered in Settinq the Casing? Yes_No�_
If 'yes' give reason:
Grouts Type: Neat � Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Annular Space: Yes No ✓ �
Method: Pumped Pressur Poured [�
Depth: From /� to_�. Ft.
Materials Used: No. Bags Portland Cement�_Weight of
1 bag��lbs.
If mixture (sand, gravel, cuttings) - Ratio:_�_to_�
ID Plates: Yes �� 'No
4 x 4 slab Yes L/ No
DRILLZNG LOG
De th
From To Formation Descri tion
� �_
��1� �
- 1`"''`' �
I tIEREBY CERTIFY THAT THE ABOVE INFORMATION ZS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PERMIT VOID AFTER THREE YEARS.
i c�
i u f ontractor. Date
s // �/
an tarian' zture Dat Is ued
Sanitarian's Signature Date Completed
Sketch well location on raverse side.
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