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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
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Owner: _
Location:
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Contractor:
Water 3upplp: Private Public
Sewage Disposal Facilities: No. bedrooms
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Dishwasher, Disposal,
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 an3 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IN LLATI Id IS COV-
ERED AND PUT INTO USE.
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Date approved: ' � Signe
�,� Sanitari
Well: T-
Sewage Disposal: '
Counter- %I'"_ �i�JQl � � ��%.,,
oigned " �L1�''� `�'
(Owner or his representative)
Permit YOIp efter 3 .Years
CeztiSeale o� Com�pletion
Date Approved: �_.���,�_ " I By.
Sanitarian
(OVEA)
Location oi well and sewage disposal facilities sketched on bacls.
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
` supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Caswell-Chatham-Lee-Person Counties
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DATE ISSUEa: DATE DRILLED: COUNTY:
OWNER: �1��� ' r O /STREET: p i
ADDRESS: ' �i- �� P T A YEA`—.�
DRILLING CON AC OR: '
NAME ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: t. Yield: � GPM Static Water Level: Ft.
Water Bearing Zones: qp�th:�T�. Ft. Ft. Ft.
Casing: Depth: From t� to l Ft. Diart�ter: Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner ap Yes No
Weight: Thickness: Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting the Casing? Yes_ No_
If "yes" give reason:
Grout: Type: Neat S Cement: Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
Method: Pum ed sure Poure�
Depth: Fromp to � Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand� avel, cuttings) - Ratio: to
ID Plates: Yes No Chlorination: Yes No
4 x 4 slab Yes No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORR T AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANC T E U IONS ET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. E T
Signature of Contr c or Date
REASON FOR NO INS
San�ta�ian's �igna�tux'"e , Dat
Sketch well location on reverse sid . Use established reference
points.
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