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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�IPROVEMENT PERNIIT
Tax Map # �'?��p Parcel #
Zoning Township S
Date �/��-9
Owner/Contractor - Go r� a� vn loma n t�—
Location/Address ,-�''i 35(� T3 c. �/,` r7�o/1 2d _
Subdivision Name Lot#
1380
I SEWAGE SYSTEM SPECIFICATIONS �
Repair Lot Area Size of Tank
SFD Mo 'le ome 'ze of Puryap Tank
Business �# of roo itrification Line
ept Tren es
Pernut Voi 60 mo ths. Per it Voi if not in omplia ce with zoning
Pernuts may be voided i'te is altered or intended use changed.
Well and Septic Layo y ��
Comments:
Date / Installed� / Approved �
WELL SYSTEM SPECIFICATIONS
Individual � Semi-Public Required Slab (��� �
Public Replacement �/ Air Vent
Site Approved Required W 1 Lo� C
Well Head Approved Well Tag o�
Grouting Approved � �{ q�
Comments:
Date Installed by . Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pennit The
environmental health specialist is not responsible for false or misleading infortnation 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 liave resulted from false or misleading
statements provided to him in the application. Neither Person County nor the envuonmental health specialist watrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potab(e. c:�amipro�permit.sam O1/95 rev.1.0
ORIGINAL
� • P�RSON COUNTY ENVIRONMENTAL H�ALTH �
� .• WELL LOG
� Date:.L'2"� � ...".
Owne:: �— '�� SR# . .
Lflcation/Directions: .
Subdiwision Namc: i'`�t �
Drilling Contractor� ����N w��� �M s+ ��
. WFL,�. CON-�'�'RL� -
Distancc from Nearest Property Line _ Distance from Source of
Pollution
T�tal �ep�: FG Yield: GPM Static Watet Level Ft.
Water Bearing Zones: Depth _Ft. _ Ft. F�_ �t.
C��g: Depth: From d._to____.�_Ft. Diameter: � Ynches
.—_. �
'T'YPE: Steel � _ Galvanized Steel_ __
If Steel, does owner approve: Y�s _.No_______
Weight:_ Thickness: •.��Height Above Ground:______ Inches
Drivc Shoe: Ycs______. No _ ______
Were Problems Encountered in Setting the Casing? Yes�,_. No______._
Ii "ycs" givc rcasor,: .
Grout: Type: Neat _ SandJCement Concrete
A,nnular. Space Width 1 �___�nches
Water in Annular Spacc: Yes_,_,.r. No`
4 Method: Puinped �-- Pressure_..._ Poured ��.,_ �
Depth: From O to 20 Ft.
Materials Usai: No. Bags Portland Cement_____.. Weight of .1 bag___r..lbs.
Yf mixture (sand, gravel; cuttings) - Ratio: to ' .
TD Platcs: Ycs !� No�_.. �� �
4 x 4 slab Yes ✓ No_. �:.. ,-
T HEREBY CERTIFY THAT THE ABOVE YNFORMATION TS CORRECT AND THAT
THTS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULA'TIONS SET
FOR'1'I-I $y•^CHE pERSON COUNTY HEALTH DEPARTMEN'�'.
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Signarirc of Convact � Dacc