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B 3168
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # IT�JV Parcel # I"I
Zoning Township l_ U S i�,V Or'1�L.�
Owner/Contractor �-1�x �Ati—� ate '�7-- ) Z-943
Location/Address �q � �,
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Subdivision Name
Lot#
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S.R.#
Permits may be voided if '
Well and Septi Layout by�
Comments:
Date - 9 Installed by_
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Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual_��Semi-Public Required Slab
Public Replacement Air Vent ,
Site Approved_ Required Well Lo,���
Well Head Approved Well Tag �
Grouting Approved � K /�/�s
Comments:
Installed by.
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This report is based in part on i�formation provided the Komeowner or his/her
representative i� the applicatio� submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The enviror►mental 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 Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: ���2—q�1 Il�'ROVEMENT PERNIIT #: � �
TAX MAP #: �� PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: , �IP���i �
LOCATION/ADDRESS:
�� � i� c�r,-, ��-
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR CONS
AUTHORLZATION
:
LOT #:
1. The Wastewater system constcuction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #��. The
construction and installation must also meet all applicable rules and laws.
2. No portion ofthe Wastewater system shall be covered or placed into use until inspected and
approved by the Person Courny Heatth Depaztrnem.
3. Any aheratians in site or soil conditions (including structure loc,ations) or modification in use,
design wastewater flow, or wastewater characteristics as spe�ified in the associated
. improvemern pemut and application, may void �is audiorization and associated permits.
4. Conditions:
Schedule 40 solid QQe over dams Kee� seatic 100 feet from any well� 10 f�eet from anv
praperty line 15 feet from baseme�t wall 5 fed from anypart of the house. Keea well at
least 25 f�eet from anKfoundation and 10 feet from any.nronertv line
�" Person Requesting:
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE'LAYOUT
Tax Map #: ��O Parcel # � �
Township �� �'^.
Zoaing �
Applican�
Locatlon:
� �� ' ' �1 �
Subdivision• SecUon• �O�
Tvae of Water Suaqlv:
Re4uirements:
Well Permit
�dividual Community Public
Site Approved by ./
Grouting Approved by SK 11- s�99
Weil Log :�
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller:��,(��� � ��f� �t � , ��11
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Well Approved By:
Date: 3 '/ 3 -v v
**See Attached Site Sketch*'"`
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
. � � .
Date: �l '
Owner. C° �-1�
Loc�tion/Directions: _
T.r,_ ' .� .._._.-. , -,-
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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Sub ivision Name: _ __ Lot #
Drilling Contractor: -A�1, 1 �=.� �-� ( Q � ( �. ���-, � _-�,� r�,
WELL CONSTRUCTION �
Distance from Nearest Properry Line Distance from Source of
Pollution t ��C� '
Total Depth Z�� Ft. Yield: �C� �
G� M Static Water Level�� �=�
Water Bearing Zones: Depth ��=t._ Ft Ft� �t,
Casing: Depth: From C� to ��_Ft. Diame�er: ��� Inch�s
TYPE: Steel � Galvanized Steel .�'
If Steel, does owner app:ove: Yes No
� Weight: Thickness:�g Height Above Ground: 'i � jnches
Drive Shoe: Yes o �— .
Were Problems Encountere,d in Setting the Casing? Yes No �
If "ycs" give r�ason:
Grout: Type: Neat Sand/Cement Concrete -
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Me[hod: Pumped . . _ Pr�ssure � � - Poured � - �. .
Depth: From C� to Ft. . . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes_,�ITo � � :. �
�� 4 x 4 slab Yes�I�o �
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONS3'RUCTED TN ACCORDANCE WITH REGULATIONS SET
FORTH $y�THE PERSON C�ui1I'Y HEALTH DEPARTMENT.
, �� ��.
ignaturc of Contraccor Da�