A28 68The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No
�ermit VOtD aiter 3 Yearg �� - -� .� � `" _
Owner: '�
Location:
�� p / ' .'.,n .�= u.��1�1t l�.
-'" �'�� 1� , �� ? �� ��-�`�'
Contractor:
Water Supplp: Private Public -
_ , _ ,^.
r�
J �
}� /iL. �
Sewage Disposal Facilities: No. bedrooms Disfiwasher, Disposal�
washing machin � her suto� tic appliances �
Size o! tank: `� �'% "- Nitriflcation line: ��
Other disposal facility .
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBEft OF THE DISTRICT HEALTH DEPARTMENT
STAFF' BEFORE ANY PORTION OF THE INSTA�LATION IS COV-
ERED AND PUT INTO USE. �'// �
�'� �)(/ li i��� �'Jf �j.j�'
r^/ �
.». / � J�' � L"V .� �� �' /�/��_�µV
Date avAroved: �� _ Signed 'T_�_.;:� �' ,—.. _ _ '' `�
Well
0
5ew�ge t�isposai: Counter- � �
gY Gv,d , l—� ���'9' aigned
� (Ow e or his
Certifcate of Completion �
Date Approved: �—'���9 By:l�l���'�E: ��^.
Sanitarian
(OVEB)
Location of well and sewage disposal facilities sketched on bac.k.
� r
�o�-�.T
Person County
wel
DATE IS D•
OWNER:_����
ADDRESS:
DRILLING CONTRACTOR
rnoo� c,� T�c-ro�
Health Department
1 Permit
:oZ Z� —`�
IAD/STREET:
� � �1�►ASM
�
NAME ADii�i��" � "` —" - `���
WELL CONSTRUCTION � �, �
Distanca from Nearest Property Line Distance from Source of
Pollution c
Total Depth: Ft. Yield: ..7 GPM Static Water Level Ft.
Water Bearing Zones: D th F Ft. F Ft.
Casing: Depth: FrOm�to Ft. Diam.at�er: Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner appF��E�C Yes No
Weight: Thickness:._jcSltLHeight Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes_No_
If 'yes' give reason: /
Grout: Type: Neat San ment Concrete
Annular Space Width inches
Water.in Annular Space: Yes No
Method: Pumped Pre Poure9�
Depths From to Ft.
Mater3als Usad: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, c�yel, cuttings) - Ratio: to
ID Platesx Yes No
4 x 4 slab Yes_�� No
DRILLZNG LOG
De th
From To Form tion Descri tion
� � �, ���
� —
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH R GIIL�TIONS SET FO H BY THE
PERSON COUNTY BOARD UF HEALTH. PE I VO AFT HREE Y RS.
Signature of Contractor Date
\
� f -i�-�
Sa 'tari s Signztur Date Zssued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
,--
�r
�c
��-