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� The Dist ., ealth Department
CASWELL - CHATAAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PEAMIT No.
, r Date %- ?�' � ? �
Owner: �_1 C�-rl.l�—�—� �!Y�-J-� C�v CT�
Location: • �
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Contractor: � � '� ��'�
Water Supplp: Private Public
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Sewage Disposal Facililies: No. bedrooms � Dishwasher, Disposal,
washing machine, other sutomatic appliances
Size oi tank: � ^ Nitriflcation line: �
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Other disposal fa i ity: - �
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Water supply and sewag 'sposal f�ities locat4dn, insCallatio �d
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 MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY POftTION OF THE INS�LLATION IS COV-
ERED AND PUT INTO USE. /
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Date approved: S �S - � � Signe i � � ' � �
Well:
s Z S�`� g ,� �- anitazian
Sewage Disposal: 9- /S -Y7
By
CerliBcate o� Completion
Date Approved:
By
Counter ��1►'uuc�
oigned �
( er or his representative)
��k �/O!p a� 3
Ye�«
Sanitarian
(OVEFi)
Location of well and sewage disposal facilities sketched on back.
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WELL PERMIT
Caswell-Chatham-Lee-Person Counties
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DATE ISSUED: � n DD DATE DRILI,� : ����� COUNTY•
OWNER: J� ROAD/STREET: _
ADDRES : � PERM T ID AF F�R O YEAR
DRILLING CONTRACTOR: r�����s b� �, N' T q j/
NAME A�tDD S-5�.,,� 1�.,[ ��C�
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WELL CONSTRUCTION �
Distance fro�m Nearg� Property Line Distance from Source of
Pollution �
Total Depth: Ft. Yield• � GPM Static Water Level: ' Ft.
Water Bearin ones: Depth:. Ft.�Ft. Ft. Ft.
Casing: Depth: From�to�"�'? t. Diameter: � Inches
TYPE: Steel Galvanized Steel `��
If Steel, does owner approve. es No
Weight: �_ Thickness:��eight Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountere in Se ting the Casing? Yes_ No �
If "yes" give r son:
Grout: Type: Neat � Sand/Cement: Concrete
Annular Space Width �_Inches
Water in Annular Space� Yes No �'1 . %
Method: Pumped Presqure Poured �'�
Depth: From to ,.�� Ft.
Materi Used: No. Bags Portland Cement�Weight of
1 bag �lbs.
If mixtu e(sand, $ravel, cuttings) - Ratio:�_to �
ID Plates: Yes V �io Chlorination: Yes No ��
4 x 4 slab Yes�� No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET-FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. H� LTH DEPT.
a�.� ?� `S � `�-��I
,' Signature of Cont actor Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO ZNSPECTION:
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S nitarian's Signature Date
Sketch well location on reverse si f1,�e establishec� re erence
points. ��� � � }�
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