A31 105�
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B 131�5
PERSON C(JUNTY HEALTH DEPARTMEN'd'
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Retocation Activity shall be issued until Authorization for waste water system construction
6as been issued.
Tax Map #
�i 31
Zoning
Ovmer/Contractor 3a�,e5 �&
ion/Address fic�� �'7 70
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Parcel #_
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SEWAGE SYSTEM SPECIFICATION3
Repair Lot Area 5. 3-s' fICC� Size of Tank /OUD
SFD Mobile Home � Size of Pump Tank
Business # of Bedrooms � Nitrification Line o' x 3
Max Depth Trenches �?(� %�1 •
Permits may be voided ii
Well and Septic Layout by
Comments:
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Well Permit Paid L� WELL SYSTEM SPECIFICATIONS
Individual a/ Semi-Public Required Slab � P� C-
blic Reglacement Air Vent (�Pc
Site Approved `� Required Well Log, �13�
Well Head Approved � �� Well Tag �� «
Grouting Approved G C.�
Comments:
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permi� The environmental
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 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:lamipro\permit.sam O1/95 rev.l.l
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Date: la -o� � �9�- '
Owner: ..sc'�.mu.�
Location/Directions:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEA�,TH � � � � ��
WELL LOG
SR# /Iv� ' � ,
Lot #
. . WELL CONSTRUCTION �J
Distance from Nearest Properry Line /C�' � Distance from Source of
Pollution / �°v' �
Total.Dep.th:� � C� Ft. Yield: /c� U GPM . Static Water Level � 5`" Ft.
Wa[er Bearing Zones: Depth ,3, Ft.�ZFt� Ft� �t.
Casing: Depth: From_�to�Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Y�s No
� Weight: � Thickness:� Height�Above Ground: %�% Inches
I?rive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ...�
If "yes" give reason:
Grout: Type: Neat SandJCement ,/ Concrete
Annular Space Width Inches
Water in A.nnular Space; Yes No
_ .. Me.thod: Pumped . . _ Pr�ssure . Poured � . _ . - - _ -
Depth: From d ;o �,�c� Ft.
MateriaLs Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes� No � � � �
� 4 x 4 slab Yes_� No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�'Ji1TY HEALTH DEPARTMENT.
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Signature of Contractor Datc