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PERSON CO�JNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERNIIT
Tax Map # f i 3 a Parcel # 3�
Zoning Township �,,�1� y F-o r K ` -
Owner/Contractor
Location/Address
--,� _ „ . � -
Subdivision Name
Lot#
Date
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �i, 0 j Size of Tank
SFD Mobile Home ✓ Size of Pump Tank f}
Business # of Bedrooms� Nitrification Line �/f,� )C 3
Max Depth Trenches
Pernut Void after 60 months.
Permits may be voided if s
Well and Septic Layout by
Comments:
Date
Permit Void if not in compliance with zoning regulations.
by.
Approved by,
WELL SYSTEM SPECIFICATIONS
Individual � Semi-Public
Public Replacement
Site Approved �/
Well Head Approved t/
Grouting Approved
Comments:
Required Slab ✓
Air Vent ✓
Required Well Loo �
Well Tag �/
Date � Installed by�✓�' ��� L/rpg''' Approved
'Ihis report is based in pazt on Wonnation provided the homeowner or his/her representative in the application submitted for this pennit The
envuonmental health 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 Petson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:4amipro�pemutsam O1/95 rev'1.0
ORIGINAL
P�RSON COUNTY ENVIRONPIENI'AL HEAL'I'll
tdELL I.OG
Ua �e: — a - �
Owner: �
Location/Directions:
Subdivision Nam�:
Drilling Contractor:
WELL CnNSTRUCTION
Distance from Nearest Propf;rry Line /�� Distance from Source of
Pollution � � (� �
�
Total Depth: ��� Ft. Yield;_�_ GPM Static Water Level � Ft.
Water Bearing Zones: Depth __�Ft. Ft. - Ft. Ft.
Casing: Depth: From��to��Ft. Diameter: Inches
TYPE: Steel � Galvanized Stecl 1� �
If Steel, does owner approve: Yes No
� Weight:��_ Thicl:ness: �'i ��,Heigh[ Above Gr�wicl: �� Iiiclie,
Drive Shoe: Yes No !� _ �
Were Problems Encountered in Setting the Casing? Yes No t� �
it "yes" give reason:
Grout: Type: Neat Sand/Cement Concrete �
Annular Space Widt�i Inches
Water in A.nnular Space: Yes No
Met�iod: Pumped Pressure po��
De��};: From io Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
Tf mixture (sand, gravel, cuttinas) - Ratio: to
ID Plates: Yes No � : �
� 4 x 4 slab Yes No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THTS WELL WAS CONSTRUCTED IN ACCORDANCE WITI-� REGULATIONS SET
FORTH $Y�T�-IE PERSON COUNTY HEALTH DEPARTh1ENT.
–� --- 1 `o��- �
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Sign�iture of Contractor � Date