A31 107z
`'r �i'erson County Health Department �
Sewage System Improvements Permit �
Date• This� P�ermitAVoi� ter Years
Owne���� ��t�`4 �'t !` f Z/ �-ztl SR# r ��
�i ' f I f � L� �Elv �w.
Subdivision Name: v Lot #
Lot Size: _�., j j�T� ,, Type of Dwelling:
Water Supply: Private: Public:
Semi Private: If not Private Tax Map#
Parcel # of Water Supply or Name of
Supplier#
Bedrooms: �a Garbage Disposal "� -�
Basement Basement Fixtures��„
$N11t8I'18i1: ,�. /�r� r.� , t��`'-C���� owner or aitadve �
REPAIR: �� Y ' REEVALUATION: ro
----- ------ �
Size of Sepdc Tank: ; r�; �� gallons � — — — — — — — — — `,
Nitri�cation Line: .-��'-�i r�7 �� � �
Depth of Stone: 12 inches f
Max Depth of Trenches:
OPERATIONAL PERNIIT: yes no
Remarks:
Date We( pp v g' � Wel' should be 100 fG from any sewer system
BY �anitarian
Date Se e S te proved:
BY Sanitarian �
CEK CATE OF COMPLETION �
Contracwr. ' �
------------------------ �
_ �
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be
maintained by owner in such manner as not to create a public health hazard.
Septic tank and nitrification line must be inspected and approved by a member of
the Person County Health Departmen[ before any portion of the installation is W
covered and put into use.
1
,
L.ocation of sewage disposal sewage system sketched on back. Q
(OVER)
. �
�" Person County Health Department
Well Permit
. � , ��LYS �
DATE ISSU .� AT DRILLED:�� :��OUNTY:
ON(NER: v ROAD/STREET:
ADDRESS:
DRILLING CONTRACTOR:
NA E ADDRESS �
WELL CONSTRUCTION
Distance from Nearest Property Line� c�Distance from Source of
Pollution O O �
Tota1 Depth: Ft. Yield ,,,..,�GPM Static Water Level � Ft.
Water Bearing Zones: Depth Ft Q(� Ft. Ft. Ft.
Casing: Depth: From�_to�_Tiameter: � Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner approve: Yes No
Weight:��Thickness•��eight Above Ground:_% LInches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No�_
if 'yes' give zeas n:
Grout: Type: Neat � Sand/Cement Concrete
Annular Space Width � Inches
Water in Annular Space: Yes No ��
Method: Pumped—[— Pressure Poured�__�
Depth: From �J to ��Ft.
MateriaQls� �Used: No. Bags Portland Cement�Weight of
1 bag / Y' lbs.
if mixture (sand, gravel, cuttings) - Ratio:�to�_
ID Plates: Yes L� No
4 x 4 slab Yes t/ No �
DRILLING LOG
De th
From To Formation Descri tion
�� � S Av;�.� �a
� r's-r � �
I HEREBY CERTIFY THAT THE ABOVE INEVRMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGIILATIONS SET FORTH BY THE
PERSON COUNTY BOARD OF HEALTH. PERMIT VOID AFTER THREE YEARS.
rw���`�t��C.[ �: .X �,> /_� cr�
S' ure f Con actor Date
1 ���
anitarian's natura Date Issued
Saaitarian's Signature Date Completed
Sketch vell location on reverse side.
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