A30 93� PERSON COUNTY HEALTH DEPARTMENT
• WELL AND SEWAGE SITE, LOCATION INIPROVEMENT PERNIIT
Tax Iv�a� # � � (� Parcel # �'i�
Zo�ing Township v_ r� N�y/�
OwnedContractor y e W� �'�-�i"� �� Date � �
Location/Address �� ;.,.� � cl �`5�0 _-�- a+, Y-�— . a s--{- Da
Subdivision Name
�F� s,�►�.
�
(�r �•
��,��, � � S
��AO*75
�. � � .
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area .3'�%� ��,-�s Size of Tank
SFD Mobile Home ✓ Size of Pump Tank N �I�
Business # of Bedrooms�_ Nitrification Line y d a�}� 3`
Max Depth Trenches a � " _
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alteXed o' te de use c nged.
Well and Septic Layout by
Comments:
Date �-y-� 5' Installed by
Approved by.
Et� � � �Ia��� � err�+ri'WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab _
Public �eplacement Air Vent
Site Approved t� Required Well Lo�
Well Head Approved Well Tag
Grouting Approved .� �
Comment�:
n ,. � ►, .
Date u_ -� Installed by�� �. \( G���nt�, Approved by �
This report is based in part on infonnation provided the homeowner or his/her representative in the application su mitted for this permi The
environmental health specialist is not responsible for false or misleading infonnation 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 Person County nor the environmecrtal healih 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�pemutsam O1/95 rev.1.0
ORIGINAL
0
�
1'liK:iUN CUUN'1'1' liNV11tUNML•'N'1'AL UL•'AL'Cll
r�
• • WELL LOG
.�` ,��
nate,:— � �--� F'l �Li� � �
Owner: � SR# � �
Location/Directions: �
�'��}�r�:�rioir�Tl �T�lmn•. 1 � • � . �( , �.
. ., _.. . �v� rr
Drilling Contractor: 1li 1 1 _ ;_ .�.
WELL CONSTRUCT'ION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft. Yield: GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft� Ft. Ft.
Casing: Depth: From t� Ft. Di�neter: / In�hes
TYPE: Steel � Galvanized Steel ✓
IF Steel, does owner approve: Yes No
Weight: Thickness: � _ Height Above Ground: Inches
Drive Shoe: Yes No .
Were Problems Encountered in Setting the Casing? Yes No
If "ycs" �i��c :c:.�on:
Grout: Type: Neat Sand/Cement ✓ Coricrete
Annular Space Width � Z, Inches
Water in Annular Space: Yes No
. Method: Pu.mged Pressure � Fo � ed V .. .
Depth: From � to 20 Fc.
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes 1� No � �
4 x 4 slab Yes ✓ No
�
.ti
I HEREBY CERTIFY TH�T THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
. �
�_ '__ 4�- -Zq -�5
Signattire of Contra D1te
�
: P��.St�l�i �Cflt1Al'i"Y HEAL'� �]EPARTI4���I�'
� 32S S�t3_TJT� l�tO�t��l'�i. STRiET
. . ROX�OR�3;�P1��8T� Cr��.O�,III�IA Z7573�
I3.�C?'�Rt'OLOC;IC�! I. WATE�Z S'AM.AI:E �!N'AI. �'.5��
l�ame of �wner ar'I'�ant�en,n ��1r1 �►i�ip.ld
. Address 52� � .�pUYlfiy �.er��arn
. . . �..- _ .
' . � ' 4 .
�.Qu�� �� _ _ ��
:� Date �Qlle�tesi Io—�— o� �'ime Colle�ted_ �_ 3a
Sourc�: l� ��[ �� ❑ Spring ❑ Other ' � .
Lucatiom:• �o�as� Ta ❑�c�t 'T� ❑ , .
P �p Q��a�r
� Re- sa mP [�
L1Pio chargc C14:harg� � . � . '
. ��atat.lrtilil9t�t.ri.rCit3tSt..�*$.'1ti�3t�!*'.'1'.*3l�itst.lCat.t$.wtat5l'ai7:,k,.'��7h�1t�3bst9liCik�!*sbat�''2st7�aYRYcit?�YC.'4:k7C:t.rt7i�:t:9C�t:Gh�t
. . �.'��i7$2t3tlt�t:t�*.�}iitr�11C�'.'�'i�'i�$.'��it2�'.7tStit�t$�i��1Y7ti��'ili�it.'�'..'�.'tii�'.x�'.S��C1�9t."'�:t�,1ri11t7C.f.'�iY�i�311?t:�'.�iR.'±'.�:i.rtit.'�*.'i5't:t.�'ryi.'�7�:t
, . ' �
Total Colifae�nt
Fecal/E. �oli
� i2L'SllI�S
�..��
P•a�csen -
❑ ,
Reported � � / v �
-. �
�_ ,
bactreQort
. ! o/i o�0 7 —� �.�,y�,s,�� .
o�/ ��t. ��i✓�. ���99 ��° z�
: �- �!�'�� ��
�$3� �5S�S7