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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �o� � Parcel #� �
Zoning Township ' � � ► ` I
Owner/Contractor`T'o,,� n� C/'��,�,,.v�-��i �',��{S Date g� 2-9
Location/Address �Q 5"�I�_ P� I a1 o�i� �ct t n► Qa� . T��. I n; �� IQ r���
- ' l L 5 � ; �_�{ ;
Subdivision Name l n �h1n
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,� 0� Size of Tank �� ' �� e
SFD Mobile Home � Size of Pump Tank
Business # of Bedrooms_� Nitrification Line �16T� `X3 �
Max Depth Trenches � ��
Permits may be voided if
Well and Septic Layout by_
Comments: . � n,�.,�A
aitered or i
�� �y� .��I Ms�
changed. . A n
Date - -� Installed b}�'%�j((/�° Approved
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Sl '
Public Replacement Air Vent '
Site Approved� /U`- Required Well Lor
Well Head Approved �iP� Well Tag .
Grouting Approved �f ' J) + � .�� `� � J�J -/
Comments:
�
Date -� Installed by , Approved b
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for tnis permit. The enviro�mental
nealth specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the e�vironmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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Date: � l 1 ��1 '
Owner. _� �����u
Location/Directions: �
b�..i-a- i� i� � �-i� � v ot
Subdivision �Name:
Drilling Contractor:
_. _ ._ . . . _.__ __
._
PERSON COUNTY ENVIitO21MENTAL HEALTH
WELL LOG '
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Distance from Nearest Properry Line �C� Distance from Source of
Pollution (C� `
Total Dep.th: �� Ft. Yield:�_ GPM Static Water Level Z�-i Ft.
Water Bearing Zones: Depth7�� _Ft. � F� � F�, �t.
Casing: Depth: From � to�Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel /
If Steel, does owner approve: Y�s No
� Weight: � Thickness: /$k HeightAbove Ground: 6�i Inclies
Drive Shoe: Yes ✓ No •
Were Problems Encountered in Setting the Casing? Yes No ✓
II' "yes" gir•e r�ason:
Grout: Type: Neat Sand/Cement ,/ Coricre[e
Annular. Space Width Inches
Water in Arulular Space; Yes No.
_ .. Method: Pumped . . _ . �Pr�ssure � � Poured ✓ � �- �. � � • �; - : .
Depth: From O. to ��� Ft. . �
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
:ID Plates: Yes ✓� No � � � •-' .
�� 4 x 4 slab Yes�—No �
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�I C�Ui�1TY HEALTH DEPARTMENT. �
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�S gnature of Contractor ace
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