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A28 195Auolication Date• 10 ! di Amount Paid: • � Receipt #: Person Countv Health Department Environmentai Health Section APPLICATION FOR SERVICES Tax Map #: � 2 D Parcei #: � � S IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS ALTIERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested b:(Owner/agentlprospective owner): S a Y'Gt M 0 l' r D(.J Home Phone: - SQ7-3 � fCS Address: S 4� ��-k a� ►� �d . Business Phone: 3� - S 9 4-4�6 0 o v�c be ro . �1� z.� 5�,� 2) Name and address of current owner: f�K�%�Owc� S,$r Sct ra D,%'� p rr-r�� 14Z.r v►or.Gc �ai„, �.,ol. �2..o,c b o►.'� �, A1�- 2 7 s'1 3 3) Property Description: �ot size: Z'� Z Township: b� 1 V G �'i ( I Directions to the property (Including road nam� gs and numbers): '1"htt t1{S ft�— 2o�t,. 4) Proposed Use a d Strvcture Description: answer each of the following questions: a) Proposed q�� isting 0 b) Stick Built l�; Modular �, Single Wide ❑, Double Wide ❑ c) Number of Bedrooms: d) Number of occupants or people to be served: � e) Basement: Yes ❑, No s, # of basement fixtures: � � Garbage Disposal: Ye , No� g) Dimensions of Proposed Structure: Width: 7� Depth: � 5) Water Supply Type: Private �new 0 or existing �), Public 0, Community,F7, Spring ❑ . Are any wells on adjoining property? Yes ❑ No �f yes, location 6) Pl�ase Indicate Desired System Type: (systems can be ranked in order of your preference) / �Conventional _Modi�ed Conventional _Alternative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AfVD LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the Health Dep ment if my pro rty contains any wetlands as designated by the Army Corps of Engineers. . 1G-IS' 01 Owne or Legal Representative Date PCHD, rev. 10/12/99 TRACT � 2.72 ACRES . , ��'i° �� r � �`�� s �. �-s' - � ` � ' _ , � � \ � � � � E12 N 8�'4�' 38" E � � 213.17' � l.2 � � � � ., L3 E11 � � PR4POSED � o= .'��. H �U SE i � � � ) / L4 1 f E1 � B / / / � / � � � � � Tax Map �1: ApPitcar� , Locatlon:_' PE�2SOM COUNTV E�lVIRORlME�1TAL HEALTtd o Parcel �� 9� Township � r V�- %1 � I I PIN Su6divisfon PhaselSecffon Lot# �c�he�- hC�S�'"Y�'. otIERJ � 1 mt /�srdp tFdl�tfn � Imt�rovement Permit ��D'� ��a'� �� ```�s New V Addition Type of Stnacture ��%� -s � D Water Supply 1�r i�� # of Occuparrts �� # of Bedrooms� Other System Type� Projected Daily Flow: ? g.p.d. Permit Valid For. Q�Fi've Years ❑ No Expiration Proposed Wastewat rSystem: C-O,rl U?n�,`Dr�/ AlDu.n��t .h�r��,ra-, � Proposed Repair. ��/1 �{-rnn � .l ,, Permit Conditions: �-� � Zn S�Q.I%/ ,/��„�L/r�� }' �� etirl-S; �/�ri d r� i►'LS{�t llA.%tx� Owner or Legal Authorized StatE Date: � � '2- � oate: %D /7-fl! The issuance of this pertnit by the Health Department in no way guaraMees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeGng their requirements. This site is subject to revocation if the site plan, plat, or the irrtended use changes. The Improvemerrt Permit shail not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorizatio� % Construct Wastewater Svstem IReQuired for Buildin4 Permit) WastewaterSystem Description: `.l.z��i�-r�Qv�n � WastewaterFlow: .3,6a q.p.d. Type: � Facility Description: ��- S�� New � Repair 0 Expansion ❑ Basement? 0 Yes �1�Qo Basement F'octures? ❑ Yes �lo Wastewater Svstem Requirements Tankage: Septic Tank size /� gal. Pump Tank size �'" fr gal. Grease Trap size ��' gai. Trenches: Totai tength � ft. Trench �dth � _ft. Totai Area oZ sq. ft. Max. Trench Depth: �, in. Aggregate Depth:� in. Soii Cover. � in. Trench Separation �ft. an center Permit Expiration Date: '��- - % Authorized State Ageni Date: �v ''� 7"'� � *See attached site plan and addendum pages for additional pertnit conditions. The type of system permitted a does G�does not differ from 4he iype specified on the application. t accept the specificatio�s of this permit OwnerlLegal Represerrtative Signature: Date: �� Z I � � Ot�eration Permit System Type (in accordance with Table Va) � This system has been instailed in compliance with applicable North Carolina General Sta�Ees, Laws and Rules for Sewage TreatmeM and Disposal, and all conditions of the Improvemerrt Permit arid Construction Authorization. Issuance of this permit implies no guararnee th t the system installed will function poopetly for aay given period of time. � /— �OO Z Autho at ent Date PCHD, rev. 03/07/Qi ■ `-��';,.).� ��`U'� � �� J��n.n:�vn.u-4D:n-nn-nn.a-untE.tn.� �Hl�-an.��.tL-��n. SITE SKETCH . � Name SCo�f-� E Sa� 1(�tOrr�� Tax Map # l�� Parcel # 1 q5� Subdivision Section/Lot# ID`l �-Ol Authorized tate Agent Date System co�nponents represent approximate contours only. The contractor mustflag the system przor to beginning the installation to insure that j�ro�iergrade is maintained _ _ _ -- ' 4 � _ �! � � �� T � '� I 30� �� ,� � � �C /, � � Q� ��`% �. �� _ _ �� -;�_ ,. _ a �. � �� X� �� '�'� . � ��► JfC�le > � � _��.s� ��I�.�� `"= ,� c� � �T�� a�-��.��.��.�.. ��.a��. WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: _�� Parcel # � � � Township �I i V � /7��I 1 Applicant• �CZ��'-i' � �� (\p �-c.J Subdivision: T�e of Water Su��ly: �ndividual Community Public Rec�uirements• Site Approved by �. � Grouting Ap oved by a2 t 3 o Z Well Log � o a D Well T ! .Air Vent � � D I � � Hose Bib � flr D� Concrete Slab _ � 1 '�, Well Driller. �l�X ��'� Well Approved By: Date: I�I C� �' O Z '�See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anq building foundation. Other conditions: PCI-ID, rev. 09/07/01 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant �Co'f-E NPI D2P�c.� Address r� �D . County �'..e r ot� �d�a �6oa.v Z %�� Collected By � � Date Collected 1 � ZZ O s Time Collected //-� 7v- � Source: L�'Well ❑ Spring � Other Location: �House Tap �Well Tap ❑ Other �Charge �Charge �f�t��,yy�� :��*�**�***�**�**�***��*��*�*�*��***�*�*��**�**��**��***�**��**********�*** ****�**�****��**�*��**�*�*�***��***��****�*�***�****�*�*�*****��*****�* Results Present Abse Total Coliform ❑ FecaUE. Coli ❑ � Reported By ��' \��, i�T bactreport North Cardlina �cate Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Scott Marrow Address: 1699 Thee Hester Rd Roxboro, NC County: PERSON A28-195 Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27523 Courier: 02-33-15 Zip: 27573 ATTN: ��, ��,. : 4-. � e, . �..�� S� (336) 597-2371 Source of Water: Ground Source of Sample: Type of Sample: Treated Type of Treatment: Filt., soft Type of Analysis Private ��`� Collected By: CASEY SLAGLE Date: �2/16/20�5 Time: 1 Location of sampling point: Faucet next to � rn Remarks: � �Q� �� . Parameters Or� �� f'�Q /'Results , �n�� Date Ana ,i ! r---� � �� ---,, r__ 00 AM Alkalinity as CaCO3 �152 � mg/1 �� '12/19%2005 I � Arsenic <0.001 ` � � � mg/I�� ° ' 1�12/19/2495 � � � a i I Calcium � �47.2 � ' � � mg%I°�� 12/19�20Q5 � Chloride IC �0 mg/I 12/19�200 Copper <0.05 mg/I 12/19/2005 Fluoride <0.20 mg/I 12/19/2005 Iron 0.22 mg/I ' ' 12/19/2005j,�r Hardness as CaCO3 (Ca,Mg) 144 mg/I 12/19/2005 Magnesium 6.4 mg/1 12/19/2005 Manganese - 0.13 y �� . � m9�� -- � _.�_ _.�. .,v. �.. _� �. . .R�. . .� ,�, 12L19/2005 Lead ` , � � `'�:OG� �� , : � �mg/I , ; 12/19/2005 pH ..�.. J { ,_� ��' � 6.�� +, � �:.___, '_.m.. �_ Std � unit � �° _. .�..,. _ _' ___1_2/19/2005 Sulfate 10 mg/I 12/19/2005 Zinc � � �.: �� '� 1.05 "� ` � � ; �mg/I,y � � � . � � k`.� ; �2/19/2005� �.. 3 T � �£ 4u ��...�' a � . 's � L.�` �a o §�� ,.,..� �, w �,.�., �.�� 5� � ��' ��r �<3' ,:.� „ � 3. � � � � � * t � � a "-_ E' � ._.v �� _ �p � � � � � - - . �t � ._ _ -,.. -` .i .. m tr -� . L . � �s -�.._' .. � -..,9' �..:., �, „ �� . ,i a.._y 1 Date Received: 12/19/2005 Report Date: 12/30/2005 Reported By: Today's Date: 1/3/2006 Ref: 17773 Login Batch Q��0041 4i Sample Number: AB36150 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not b� regarded as a complete report on the water supply. Inorganic Analysis: Recommended limits for d�water. Sample should not exceed levels listed below. Alkalinity Arsenic Calcium Chloride Copper Fluoride Hardness No established limits 0.01 mg/1 No established limits 250 mg/1 1.3 mg/1 4 mgll No established limits � Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 North Carolina State Laboratory of Public Health Department of Health and Human Services P. O. Box 28047 -- 306 N. Wiir�iingio� St. -- Raleigh, N. C. 27611-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM Name of System: Morrow, Scott Address: 1699 Thee Hester Rd. Roxboro, NC County: PERSON Report To: Person Co. Health Dept. 325 South Morgan Street Roxboro, NC 27523 Courier: 02-33-15 Zip: 27574 � �� . Source of Water: Ground � `r � � •` - ��Source of Sample: ATTN: (336) 597-2371 �___. , �= Collected By: HAROLD KELLY Date: 11/22/2005 Location of sampling point: Outside Tap Remarks: �"�� Parameters �"- � � /`Results ; � Units ! �---� �-�--� Type of Sample: Raw Type of Treatment: None Type of Analysis Private Time: � 11:30:00 AM Date Analyzed: -__-----_ �_._.__; ----._..._, Alkalinity as CaCO3 �162 � � mgll � � r---�� 11/23/2005 . �� Arsenic ' <0.001 � � : .�� mg/I � -. � — � ; � 1 �/23/2005 ; ? . _._._, Calcium� � <0.5� � � mg11= � �-�� 1(1/23/2005 ! �` � � ; � Chloride IC �11�� ` � mg/I - � 11/23/2005 ' � Copper <0.05 mg/I 11/23/2005 ' ; Fluoride <0.20 mg/I 11/23/2005 ' Iron 0.05 mg/1 11/23/2005 � Hardness as CaCO3 (Ca,Mg) <2 , mg/I 11/23/2005 Magnesium <0.10 � mg/I 11/23/2005 Manganese �. <0.03 mg/I 11/23/2005 _�.. �a_.< <��. . . � _.. , .� s _, Lead T � '_ . <0.005 mg/f 11 /23/2005 pH � � � �. � 7.7`� ° ' f ` ` " Std. ��unit° '��- ' 11/23/2005 ��,� . _ �. u_..��_�, � � Sulfate 10�� riig%I - �. �� 11/23/2005 Zinc ��; �� -0.05 ,-,� � � �� :� m%I: : 11/23/2005 � � ; _� , .. 9 � . � .wz � � � . ;� � ��. �� . , R �� y . K � _.� _�. �.. � .� s � �.w � . � x � ..� � . .. � � a ` ,, ; ; �. ., � � �, � ;: �' ;; ; �t , ,. , _. . . s _, .� �-•� , .��,.�.v �: �. .�.,� .� � _ � � �_ . . � . _ , . . _. _ ._ _ _ . =_z � _ , _ �� ;_ . �N - �. � Date Received: 11/23/2005 Report Date: 12/9/2005 Reported By: Today's Date: 12/9/2005 Ref: 16442 Login Batch �05e110Q52 °�l Sample Number: AB35288 Explanations Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purposes. If coliform bacteria are Present, the water is considered unsafe for drinking purposes. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. Inorganic Analysis: Recommended limits for drinking water. Sample should not exceed levels listed below. Alkalinity No established limit�, Arsenic 0.01 mg/1 Calcium No established limits Chloride 250 mg/1 Copper 1.3 mg/1 Fluoride 4 mg/1 Hardness No established limits , Iron Lead Magnesium Manganese Nitrate Nitrite pH Zinc 0.30 mg/1 0.015 mg/1 No established limits 0.05 mg/1 10 mg/1(as N) 1.0 mg/1(as N) Not less than 6.5 units 5.0 mg/1 iJOP.TH CAROLIi�IA DL P.ti1ZT1�•1L-NT OF HEP.LTH A1��1.> HCrr�1A11 �Er:l�ICrS I�;\�I�1GII UF F'[J�.L.1C HEALTH OCCL�I'P.TIONAI_ A1��L� F11VIF.Oi�?ti�tLf`I�F,L EYi])Lt��IULU�:tY BRAt•�C13 DRINItING \�'ATEP. HEAL"TI� Ft-ISK EVALUATION �- Gr NEIZAI� DATE b l� °� COUN1'�' ILVI° LABORATURY # )� Based on tliese analytical results, this �vater st�ould be considered safe for nonnal usage. O Ct�emical analysis did not sho�i� any contamination. 1�Vater should be resampled if odor ur taste persists. p The water should not he used for drinking or cookin� purposes; avoid prolonged batt�ing/showenng. p Ba:ed on these analytical results, this water is highly contaminated ��d should not �e t�sed for drin}�ing, cool�:ing, or Uathin�lshowering_ O T'ne laboratory•results are not conclusive, please resample. PLEASE ].NDICATE ON LAB SHEET THAT IT IS A 1ZESAMPL� AND PROVID� PIZEVIOUS SAMPLE NUMBER(S). COA'IM�N7'S: For fiirtller information, contact �3r. Ken R��do `vitii tt�e Oceu�zation�i an�� nviran�ne�tal �pidemio[o��' I3ranct; at ('��°') 707-5911. Temporap� Draft Form T�22i05 . N. C. Department of Health and Human Services State Laboratory of Public Health �.�;e he��' "" �''i j�C,�. P.O.Box 28047� Raleigh� N.C. 27611 �o� �k conh , Environmental Sciences Analysis Report ��Rp�;�l�"� �R''y'''L�� Name of Owner, Patient or Supply: JCa� Morrn� � l Telephone #��pj __�,'1- �� • � � :, .' ' la.- - .�� • �. , � �� •. � � ro r�1C z�p:�� ************�*************************************************************** Report to: Telephone # �) erson oun ntat-Health Address• 20-B Court Street 0 , Laboratory Number Collected By�lttin�P_ }�i}- Telephone # (��tnl�q'7- ��q� Date Collected: �' i2� �O� Analysis Desired: �t�i�b � u rh Sample ti I Sample Description or Remarks �' k �� DIViS10N OF HEALTH AND HUMAN SERVICES STATE LABORATORY OF PUBLIC HEALTH � PO BOX 28047 -306 N. WILMINGTON ST., RALEICH, NC 27611 Purgeable Organ(c Compounds by Gss Chromatography/Mass Spectrometry C0111POUND Chloromethane Vinyl Chloride Bromomethane Chloroethane Trichlorofluoromethane 1,1-Diehloroethenc Acetone lodomethane Carbon Disultide Methylene Chloride Acrylonitrile trans-l.2-Dichloroethene M1I et hyl-t-B u ty I-E t h e r 1,!-Dichloroethane Isopropyl Ether cis-1,2-Dichloroethene 2-Butanone Tetrahydrofuran Chloroform 1,1,1-Triehloroethane Carbon Tetrachio�ide Benzene 1,2-Dichloroethane Trichloroethene hIDL 2.0 µg/L 2.0 pg/L 2.0 µg/L 2.0 µg/L 2.0 µg/L 0.5 µg/L 2.0 µg/1. 0.5 pg/L 0.5 pg/L 0.5 pg/L 0.5 µg/L O.S P81L OS µg/L O.S pg/L 0.5 pg/L 0.5 µg/L 2.0 µg/L 2.0 µg/L 0.5 µg/L 0..5 pg/L 0.5 pg/L 0.5 µg/L 0.5 µgJL 0.5 pg/L µg/L �J LABORATORY k O��Sd V COMPOUND 1,2-Dichloroprop�ne Ditiromomethane Bromodichloromethane ei s-1,3-Dichlo ropropene 4-Met hyl-2-Pentano ne Toluene trans-1,3-Dichloropropene 1,1,2-Trichloroethane Tetrachloroethene 2-He:anone Dibromoehloromethane Ethylene Dibromide Chlorobenzene 1�1,1,2-Tetnchloroethane Ethyi Be�zene Xylenes Sryrene Bromoform 1,1,2,2-Tetrac hloroethane 1,2,3-Trichlo ropropa ne 1,4-Dichlorobenzene !.2-Dichlorobenzene l.2-Dibro mo-3-Chlo ropropa ne trace - detected, but less than MDL MDL-Minimum Detation Limit C- Pos�{bk tab eontaminallon or backerouad J - EsNmated Value • K- Actual value b known to be ks� thas rdue gfveo. L- Actud value b Icnowa to be �re�ter Ihao value �iven. U- Matetial vra� andyud for but oot detated. T6e aumber 1� the Minimum Uctatloa I.imit. j/ - TeaqHve Ideatl0eadoo. D-Sample dtluted. MDLt do oot apply. 0 h1DL �� p�L 0.5 µg/L 0.5 µg/L. OS pg/L 0.5 pg/L 0.5 pg/L OS µg/L 0.5 Ng/L 0.5 µgJL 0.5 µg/L 05pg/L 0.5 µg/L O.S PSl� OS µg/L 0.5 µg/L 0.5 µg/L 0.5 µQ/L 0.5 µgJL 0.5 µg/L 0.5 pg/L 0.5 pg/L 0.5 µg/L 0.5 µg/L 2.0 pg/L �° a � ��CS OCCUP� �MA�� YNS CTI�O(d f�TF,I a:�aaney.frm (3/01) DIVISION OF NEALTH AND HUMAN SERVICES STATE LABORATORY OF PUBLIC HEALTH PO BOX 28047 - 306 N. WILMINGTON ST., RALEIGH, NC 27611 Purgeable Organic Compo��nds by Gas Chromatography/Mass Spectrometry LABORATORY M O5 � O a L COMPOUND M1iDL µg/L COMPOUND MDL Np/L � Chloromethane 2.0 pg/L 1,2-Dichloropropane 0.5 pg/L Vinyl Chloride 2.0 pg/L Ditiromomethane 0.5 µg/L Bromomethane 2.0 µg/L Bromodichloromethane 0.5 µg/L Chloroethane Z•� µ�� eis-1,3-Dichloropropene OS pg/L Trichlorotluoromethane 2•0 PB�L 4-Methyl-2-Pentanone 0.5 pg/L 1,1-Dichloroethene 0.5 pg/L Toluene 0.5 µg/L Acetone 2.0 pg/1. trans-l.3-Dichloropropene 0.5 pg/L lodomethane 0.5 pg/L 1,1,2-Trichloroethane 0.5 µg/L Carbon Disulfide 0.5 pg/L Tetrachloroethene 0.5 µg/L M1lethylene Chloride 0.5 µgJL 2-Heianone p S pg/(, Acrylonitrile 0.5 Ng/L Dibromochloromethane 0.5 pg/L trans-l.2-Dichloroethene 0.5 pg/L Ethylene Dibromide O.S pg/L hlethyl-t-Butyl•Ether 0.5 µg/L Chlorobenzene 0.5 µg/L 1,1-Dichloroethane 0.5 µg/L 1,1,1�2-Tetnchloroethane 0.5 pg/L Isopropyl Ether 0.5 µg/L Ethyl Benzene 0.5 µg/L cis-1.2-Dichloroethene 0.5 pg/L Xy�lenes 0.5 µR/L 2-Butanone 2.0 µg/L Styrene 0.5 µg/L Tetrahydrofuran 2.0 pg/L Bromoform 0.5 µg/L Chloroform 0.5 µg/L 1,1,2,2-Tetrachloroethane 0.5 pg/L 1,1,1-Trichloroethane 0.5 pg/L 1,2,3-Trichloropropane 0.5 µg/L Carbon Tetrachloride 0.5 µg/L 1,4-Dichlorobenzene 0.5 µg/L Benzene OS pg/L I,2-Dichiorobeazene 0.5 µg/L 1,2-Dichloroethane 0.5 Ng/L 1,2-Dibromo-3-Chloropropane 2.0 µpJL Trichloroethene 0.5 µg/L trace - detected. but leu thxn MDL MDL=Minimum Detection Limit C- Pasible Iab eoauminaHon or bac�eround J - EsNmated Value . K- Aetual value k Icnowo to be ks� than ralue given. L- Aetual value b kaown to be gnaler thas value given. U- Material was aaalyzed for but aot detated. The number h the Minimum Uelection I.imit. 1� -TcntaNve Ideotl6cation. D-Sample diluted. M11DLf do oot appiy. TRIP BLA�lK (DA�E: e3 -:Z3 --eS .� p �C�C�D�I� �1 � Te;`:' n� `� ('ir i:la�ncylfrm (3/01) c ��, � �- :,, �CU� lJ ;�, OCCUPATIO�J,�L & EtJVIRON",1ENTA.! �` `�. �.� �I��.� �� o � � '�' -�-�- ,� � �'�� l-�u.��n�t,t-��G ..C, C� IF' ��an-ca��rncA��ra.�eaIl ��m�� lAA9.�► vuU�Rll+�i�tRl � ` �,�- �) a. V6�ell Log � U ' � � dwn�r: �S C,cS-'r•k -.�- �-{�t'0.. I�-t or � Tax Map Parcel # L�catiozt: y-q 5`�/r� �-�J ke.v- '�-Fcxe ' 2� i h�� i-�e. �e � F.� f u o� Gn ,��e s� d� 2ed iBQ,e.�li S�1V131U1I. �.OL # .��.,. W�� COIIS�'11Ct10II Distance firam nearest Prope�rty Line (Minimum 10 feet) � V . Dist�nce frv�n Segtic Syst�m (Minianum 60 �eeit) ,(�j __u_�, Totat D�pth: � C� 5 ft Yield: � GPM Sta#ic Water LeveI: � �V�ter B�axiag Zones: D�pth i�� ft t�UGft ft ft Cag�g: $ �-! I�epth: From —�-i Type: Galvanize� Steel Weight:�i� ��`, Drive 5hoe: Ye If "yes>, give reason• + � .� -,`'� ft. Dia2neter• ��' in r/ �Thic�ess: �j�� Height abav� Ground: �� in s No Any problems encountered whil� s�tting casing? ye, No G�out: Neat: Saud/Cement Concrete GraveUCemcnt Annular Sp�ce Width 'vnch�s Water i.n Annular Space Yes No Metho�i of Grout: Pumped Pressure `� Poured Depth to Ft. Materisls Used: Na. Bags Port2and cement Weight of 1 Bag Pouuds rf mixt►ue (sand, gravel, cuttengs} - Ratio t� ID plates: � Yes ____ No 4 x 4 slab � Yes _ No Drilli�g L�g Location Drawin� From To � Farmation O�t� �5 "� z�2 ZZ t��. "Z" i2� i� i � � Z. �n � (� ��s — a Rb � n rf� � � cs�`� w� r---- - � � �� I hereby certify that the above infarmation is correct and that this well was constructerl in accordance with regulations set forth l�y the Persc�n County Health Depaztment. Si�uature of Ca�ntractor ��IZlv1 L% ��-�� iD # aU`�o� Date o�r �� -d o� PCHD rev Ol/16/U2