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A32 173Application Date: '7 � I� � t��1 � Tax Map: Amount Paid: a t�o •� Parcel #: Receipt#: �3 �b31 �k-� i-7�,� ��� �.� ��.�� �� �os7 � = =i-�^ � � �J' ��T�IC"l,`�( , �IE��r:l'R.4S�]L.]1�aC:D.1[T..IY"fYT..�I'..'.�':ILT.Q�.Y:IL.� I�TQ.7.GR.LL.�Q.%.3�. Application for Services (Seotic Svstems and Wells) �Improvement Permit (Site Evaluation) . $200.00/$300.00 (if> 600 gpd) C Mobile Home Replacement or Building Addition $150.00 (if site visit required) � ❑ Well Permit (New/Replacement) $225.00/$125.00 Services Re uested ❑ Construction Authorization (Fee is de endent on the e of sys ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Charge Important: If the information in tlie application for an Improvement Permil u incorrect, falsified, or the site is altered, tl:en tlie Imnroven:ent Permit mzd theAuthorization to Construct shall become invalid 1) Services Requested by: Name: � .c, � Address: Jtr� } : r�� Phone # (home): g(e Z -2C�R -b3 $s` (work/cell): 2)Name and addnress of current owner (if different than applicant): Name: Icil�i2�'� -� Y��v� >�c�%�_ Address: /t.�[, N, �. o�Q,,.e� 9�5=787-75$ f Z �`� A S division: 3) Property Description: Lot Size: 1. , Address and/or directions.to Property: i--'.y►T 4) Proposed Use and Type of Structure: Residential � Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes No �J _(with plumbing: Yes No _� Garbage disposal: Yes No �_ � 5) Water Supply: - Private Well � (Proposed Existing _� Community Well: Public Water System: Are there on the adjoining properties? No Yes #: �_ (please show location on site plan) Note: A completed application must also include: ➢ A pladsite plan of the property that shows property dimensions and tlze size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. � Signature (Owner/Lega1 Representative): � �� Date : 7-rT `av7 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) —,osu� � ..y..._.._.._.�..r... ...= �_�'_ �- ... �.. � � �..+5' � ".�� S� •�(u I�N �sfs �� tv wM1�Lfr �Le r N�icW Wa W �r �rrW [�rl �An W�Le1r.[Y !ar [e�tl fWl�adw ,�N"C4q�� s���G ;�,:��yiFo��. 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WOOD ' " ! i�N1 JNWI . • .�.«�r i�~� S� Mt �IMi�.�wl � �w . �NC�YI"i•i I�WIf n fl11 N�ipO MELONOWG D�T� TA+ WP S 8 w'�' 7.7� OG. sx //�� ,•L_ T • Y �,�l • � R 21.OB ec. � 7` �LJ/�__� � srr.y tor SAMUEL J. PARKER� �. �AVID MICHAEL PARKER. NELSON COOPER PARKER� & BARBARA PARKER WOOD ewn, w.k T„a,r�w,Kc s.pr., �895 Sea. P, 200� Emat & YMfoO�.k.� RLS-28�8� Ra�or0. N.C. hpL_ ��� �MiR ; �....� p, � '�°,�+yr a« �. wx.w a 'ir y�wi r.,. ( 4 �" a � 1.93 x. 8 B IS.73 oe. � «'.•' - � a s 3 ',.a g ; 2.69 x. d�e s 6.58 x. ..o.w g e p �� 278 ae. _ � �,�, 8 ..o.m g � �'ayy 2.4E OC. \ � �� \w. u�n �r� \ �s-ifa.tl.� \ � ` n � � �\��J _ Jt LSM[ !tl�tMi DIJI. tl !-1}INl-[ S].Y6 L2 YIYIJ�)-i l.n 1J FIS-��-ll-[ 'A.6T G bll-19-JS-[ .bl LS f-11-]l-tl-[ �t.M (.qlYi E6TI1 WNi 4iC �Olm TNI llMllq ib l-14]II-11-6 �6.03 Gl 90-06-0D �0.00 ll.Sl Tl.tl Y0.00 L�]J-0SN L'I l-1419-S6-t �1.60 C3 60-03-01 'A.00 53.tl f0.01 Il.90 4]FJ!-3'/-t U 4M#01-6 �'I.0] CJ lOD-3l-Il l0.00 h.6! ]p.�i yp.10 M-'IS-OSyI-� w e-mae-�i-s �i.n a mai-M 7s.ao �o.n xe.�> ».w s-eom-��-t ��/t,�, �'�. �,�,k f.b�� �s -�- -F'Lt�t Crt y Mc� ks 1 r�. `�L. � �►,t��t. ho�s� :j S��KS -�v S� • ,c%.,�/�e .►1. /�s �w� �+ l�,.ass �/• ��.ti an. 6.•css /l� sa ��oo�f %s''Mi��s dit �if�' f%�'s7 G�.�� .%✓.n an ,��ry L�c•��c �- -ti,c�t„ �,�/� II Sc. e T3S ��j f. f.� �✓�c ��C �•,►�• �''� � S �-f' • �+ �� a,✓ �.� k �. �l�S �i lw�..e. r� �• ,y,�u l�c«3 � � ��� ��G,��4,�,v�� �' y,t �, F.'tl•�� p6�-,��S-o3�s Application Date: 4 � �' Q � Amount Paid: Receipt#: �`�-,�. � IC�I��$.� ��T � � � ���� 1F�+�ca.vaic-.ra�rn.�ssa�n..c�r�nd:.r�.11. TE�r.e�.ra.� Q:..)�-n. Application for Services (Sentic Svstems and Wells) Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: Parcel #: ❑ Construction Authorization (Fee is dependent on the type of sys ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Char�e Important: If tlte information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then tlte Improvement Permit and theAuthorization to Construct shal[ become invalid 1) Services R uested by.: Name: o n n� L��� Phone #(home): ��� Address: �11� V1/l0 � �,�5a.�� {2 � (work/cell): �� � �- D � k�°r� N.,C� 2)Name and address of current ownej� (if different than applicant): Name: o � v �� �1C1- Address: ��5�.( L-a- 3) Property Description: Lot Size: Subdivision: Lo-t r#: Address and/or directions to Properiy: �rd ��\� � o-�v l�t�i' �'1 eyS �� `�l U �� O �5 a►�� v�1 uS d✓� Q 4) Proposed Use and Type of Structure: Residential ✓ Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): 2 / Basement: Yes No�(with plumbing: Yes _ No � Garbage disposaL• Yes _ No �/ Approximate size of building foundation: Length ��� Width � 5) Water Supply:� � Private Well ✓ (Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No es' (please show location on site plan) Note: A comnlefed apntication must also include: ➢ A platlsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing tl:at the property is ready to be evaluated. I am submitting this application to request services provided is accurate. I understand that if any site� invalid. // Signature (Owner/Legal Representative): a Person County Health Department. The information or th�intended use changes, all permits shall become Date: r! � �� 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) j �1��, �� � �.L:`L.i �' 9.. \L �J V .� `r` w � ' ' '`.J �' � / � Ji � ���.��-�„ ,�-, �e��.�.I1 I�-3L��.11� Applicant Locati.on: ���t �a�id fox� ✓�'ive �..� Type -of Fac�ity: - 1 1e � of Oc�upants g�,�c � of Bea P20j]OS� w25t8WdfET Sj7St�: � Proposed Repair:����2 Cf`Pn �x Map � ,. ' a!rc� / Su:p.d;ivis�ia:n • � I' , as�e S�cGia,n: � t :' I�prove�aent ��rmit - � _ �a �ir�tion � . � Neur LG Addition �ater �u�P�� �_ no ��I � Piojei;te3 Das3.y Flow O g.p.d. mD �fi�— D1td r�5°I� �edlici,'t7� L-Z �lo� �r C%C3tr�1e(�'ype: �%, o _c� [0'25°l� r�r�<<r-%iur-� CZ.�(o�,� �r ('{-�[1in�e�i �Type: -LZ—, '- •. •.. ..� �� � P �.� s � � - • y - • " �// Y. 11 � - !J! . ■ 1 ' . . - . � - , a. �� . . .a Date: The issuanca of this pemut by the Health Departmcnt in does not guaraates tfie ;sa�,a*+�.� of other pctmits. I# is the responsibility of the � aPPli�ProP�Y owner to in sure ti�at a11 Person Coimty Plaanmg and Z�niag and Bn�dmg Inspections req� are met 3his Iuaproveaae�t �'ermit is snbject to revoca4ion if the site p1aa, plat or t6e intended use ci�angcg. The Ymproveme�t �'�t is not a�e�#e� i�p a c3�nge in ow�ezsfup of the property. T7�is permit was issnesi in cm�pliance.with the provisions of the North Carolina `L�ws a�d iluies for Sewage Trentment mid ])isnosal Svstems' (15A NCAC 18A .1900). Neither Person �Cnnnty nor th� En�irvnffieatai �eaith Speeialist'w�rrants Wat the septic tank syst�ui w�i cmaati.nue ta fnnction, sati9ia�#only in the fu�e or'that the water supply w�71 remaim�potable. - —. . Ant�ori�ation �o �onstr�aci Wastew�ter Sysgem (a2es�resl for �ding ]Pex-muit) � * Ses siie plan and additional attachments i�- �z�1o..� �. . Praposed Wastewater System: �x C%�zrY, 1�pe�b,� Wastewater Flow4� -�:p.d. New �C Re�air Expausion _ . Soal LTAR: a5 g.p.d.! $ 2 � Type of Faciiity: �l l3 �, C i nc�� -�e�m ��a�P D 4�� rt o, Basement _ Y�No . . . �aste�ate� SgTstea�a� ���eageatts � '�ank Si�e: Sepiic Tank: 1�x� g� �p Tanic: 1 ou� gal �Grease Taap: — gai ��ai�elcfl: 'Tot�l Area: (4y �� sq i� ��otal I,eng#h �I�� gt � 14�a�aum Ti�rnch Depth /02 an Tr��cia �idt� �_ ft ��'in�u�a Soi1 Cnv�r. �9�• � 4in ��n1Ylfimmi.ffinm Treuch Se��ration: �'1 ft �istrs�mt�on: ��tribu�on �o� Serial �istn'bntaon �c Pressuse Manifoid - .SDEC1�Cd'�OIIS: _�iir�v�Q 9�n�li- d� rt-�� �:C� h1'inn ��r� 4�1-lO�r� c�'Sc>i�('c�t/PY (ArP✓ �hiiff' CYfCLiY��2�� Autho�esi State Ag�nt �� Permit Ex�siratian Date: �' Date: The type of system permitte3 is C�nveational ", Acc�tea Alternative. I a���t the spe�ificatians of the P�t- r' �ws�eil��i ��prrsa�iative: Date; �� � � -�7 ' —�� p� r�v. 11I10/�5 cb�.� - �b� �- ���a�l �"v� ian-µ�'� s���n �j ��a+ �r �a�U�1N a� �}ua ra� x�J 1 �o� � �� o� _ c�i �' ►. �b� �-snw � . 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Q�).�rn'l� :TYn':�.. : .�.'}:': 71���11� ;• •.. : .: �. � .,. . . • ... ... .... . . . ; ..; .; . .: •:: � •. � .:.. :;.: •.: :;,;;-�-^+ . . �1�.:L7l:' : �;a�'�3.1L.U� '. 9'�/ A'l9.�� %"J:�1YJL.4 8 �'1��YSA71L'i �1L'r� �� A t�'L. rA N�.� � n.t+' q 3�Jli Y7 S'1�� �8 JL 'L' . n'w.�� W$ Tax Map /� 3� Parcel # ��%� Totwnship: Applicant: �b, ,� �iQl�s Subdivision: Lot # `% Lacation: _ � tL�,�c�1Q Mi��S QC� �1 m� t�os� Qci ='� 'r-�� iS� � �3'pe mf ��ter 5�ng�p��: ' � individual _ Community �equfla�e�nen�s: Site Approved By: "�- 3 �� ��� Grauting Approved By:'� 3��� Well Log: � Pump Tag: _ Well Tag: .Air Vent• Hose Bib: Casing Height: Concrete Slab: Public Liner: �Installed by: Depth set: Grouted: I�ate: `JlTatea� Sample: Well Driller: ��rne.�ie � � Well Approved b • *�**9ee Attac�ed 5fte 5ketch***� Wells must be 10 feet from�property lines. (�Wells must be 100 feet from septic systems. �� Wells must be at least ZS feet from any building foundation. Other canditions: Date: s �/��o� PCHD rev Ol!?710� 0 � ���� �� ���� ��r ��� �'r- �. � ���� 7��.��-�� � ���.II I�L��.11� Applicant: Location:_ 0 , �f� ��(� Y � 7�- f�° �C�Q % � 1 ! � � � o ��or� � ` cws Pf�1�o�a�t� � � o� Dca�l � � - : r i� n r �� �o�,. � System Type (In Accordance Wifih Taiale Va): �� THIS SYSTE�lI 1-3.�5 �E�ii� INST,�LLED IN CO�tIP�lANCE l�i'iH A►PPLlC�.BLE . AfORTH G'AROLI➢�lA GENE€�►L S?�TUTES, RL1�.ES F'OR SE14V�►GE TR�TNtEi�T AND DISPOSAL, � AND - ALL � TiONS �F � THE 9[VDPROVEMENT PERIVIIT AND CONSTRUCTIO�t AUTHO TIO . - � . , . �=--�� og - . , A orized State Agent Date � �. ,n e/ �lnstalled By: �� v��� Date: � � Z o 0 � � � � S � 4k.4" . - � a� �cs' 2—Z I-o `�' 17t-z [� �ac . �-/--g5r � . 'f�' �'� � v�� s�P?'�-J S �� G'6" .���� 6i �' S'�'/�r" 16 �/v'' s'°".�---' 5,;�, $, � s' s-�P /�u� s � �J (� ��� �a� va�� �� FCHD, rev. C7I29/G�? � ����c °Q°�� ��s�����o� �����..�s� �'��� �9 � i� Ta; IVia� ��� Z Fares! ��'7 3 Sysiterra Type (Tabie Va) Owner/Appiicant Subdivisior� AddresslLoca�ion Sec/Phas� Lofi # � Se��c. Tanls iniigaU�a� Ni�a ���on en�s ln��� c�at� � State-(D/date S�e�'� S�/ Trencf� 11Vidih 3 ft. s. Ca aci ovv al. :/� � Tre�ct� De th /2 in: Tee and Fiiier � � ./' Trenci� Len � b� �t. � Baffle � Trencfi Gtade � � Sealant � Trench S ac9n �.. � Riser ifi a iicable � � Roc� De th and Quai' � • -�''ank Outiet Seal Dams/Ste dowr�� etc. -'— Permanent Nlari�er Pressure Laterals � � . �'ump T�nk � � Hole Spacing - ---- � State Dl ate o e tzs - - Ca aci drJo al. ✓� Pi e. Sie�ve � Wate roof /Sealan# � Turn-u s/Protectors — � Riser Requi�d� �etba�� Water Ti ht � c� �'�r� From� Wells Pue�ap From Property Iines Checic ValvelGate Va(ve S$n.ictures/Basemenis �� Anti-si on o e c es / rama e.a s Fioats/Switches � � Surface Waters . �-11arm visable and audibie Public iNaier Su iies �- � Elecfrical Cam onents � Verticai Cuts >2 ft. � � Rate m VVater Lines � A roved Pum ii�ode! " Vehicle �Traffic �� Blocic Under Pum � Ad'ac�nt siems � - � Pum Removal Ro elChain � .�Easements/Ri hf ofi V1/a s . � Dis�ibu�aon; Sy��an O�e� � Se�ial Distribution .. Eas�menis Recorded � Pressure f�ani oi e e erator ontract �.ow Pressure Pi e � Tri-Pariate A res�nes�t A r. Pi e I�rlate�iai and Grad� � � Valves �' � C��s�ten� . . . � � � la � . (tMC', t I �Ve�� ���8`3�'S pc7d rev. 3113/4'1 PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER S�'STEM MOrTITORING REPORT g-�� -� 3 LI-��--ng 3Z JZ Date of Inspection System Installatian Date Tax Map PazceI # � Property Instructions: Chec:c yes or no for appropF�iate items and explain in space provided for rerrnrks and comments. If an item is not applicable, indicate by "NA". If an item is uot or cannut be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and rsonitoring items specified in the permit are to be camied out. IIVSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks 7 Tank risers accessible, free of infiltration and surface water div�rted ? Septic tank nee3s pumping ? Inches of solids: � Septic tank filter cteaned ? �YE-S / �N REMARKS LJ / Lb d � l . � � � �,� �� �o �, neK-% � fa� I� � Dn ��F RecoMme,�C� ptAM��n� f �261$) � d �/ ❑ ��i��er WaS Q�mo�l' Como��P�e�ll ��n4q2 _ EFFLUENT UOSII`TG SYSTEn�: Requ;red pumps present & functi�nal ? High water alarm operating properly 7 Pleats, valves, etc. in good condition ? Control panel & components in good condition ? Bffluent free of ex�ess soli�s ? „ Inet+es of setids(pum.p!dose t:n.k}: 2 Elansed time r�adings ? Countcr readings ? Drawdown mte:�� DISPOSAL FIELD: Eridence of effluent sarfacing ? Evidence of effluen! por.ding in trenches ? Surface water effecdvely diverted ? Diversioas/swales properly maiat3ined ? Vegetative cover maintained '? Protected from traffc/unauthcrized uses ? Dutribution devi��Es in good coadition i� rield free of settled or low areas ? / / / / / / / � � ■ ■i ■ �^/ I� ❑ �!� ❑ ❑ ❑ ❑ PRESSUR� llISTRIBUTION SYSTEM: Turriups�cleanouts;valve�itaps nitact c�C �,/ accessible 7 L�y,/� ❑ Pressure head properly adjusted ? L�d" / ❑ COMPLIANCE: / Compliar►t [�� NUn-compiiant ❑ Needs Maintenancz ❑ EHS ���`�.�� ���.���� ^ ������ ?E�-�-�..�.-.,.,.���.1t ��,�.�� Owner: J�io �–ietc�5 Tax iYia�: Parcei #: I �� Date: l�ly) �� �.a�ae ��� �a� (Sc�a) ��p �Io� �e ��� �ow 1 �oot # �i�e��(aa�) . ( �� �. {i�} , 3. ►� _. J. :J .� � '�z u �� 9 n.c� � ��Z , � ..� 4 ��Z ' ..`SM.� , � 5 �tz c� 5.5 t� � o•�� 6 7 8 9 10 � ' `l� ft of Iine x 65 gal. per 100 ft =3i a� �; 1t�0 =�._ gal 75% x�� ga1= � g� per �ose �_. ga� Per minute (gpm) _�+'iow �-� �'riction �eead Loss: ���l ft per 100 ft of supply line x�l � ft of supply. li�e =100 =`7 •� ft ,.\ ft x 1.2 = � ft of friction head . - ��Iani�Fold Si�e: �„ Force i�in Sia�: c�" PYC �otal Dyn�ic �eaa� _.�O ft of Elevation head +�_ft of Pressnre head + 9� ft of Friction Head = � � TDH Pu�p ���a�e��: . 3l7 GP14I @ ��1 . ft of Head �3rraawalowa�: � 3� pex dose ; 21 ga1 per inch = 1 I inci� drawdown per dose .:.,:, � �:.:.� �.� : �, , .,� :�,�� �. �: .., �t�����t0 — - . . � � ,. ■!� � t� �[ti)����00! ... : �-�-o-�-�. o-�-�-� o-o-�-�-�-�-�.-,-o-<.-�_..-�-<.-e-. (�► 1�1 i! I�r ..�a*.....���.�,..�...+►� ..... :.... .. ... r*�i�i!l+iil���N�Ni�i!!�� ' ' , � �. ,- �.'. .. _ : • a : :� : : � •e: ��� � "�s � 3" �:. . . ..t .. 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' ' . • ' � ' � - � �• f �. • '��'. ��� I � KDOIS � �ISddOSE<K�az}Sleua}ryy� �;•' _ _ a}az�uo� „tr �[ue,L a}axnxo� }noazd . :� . d� � � �� .�30 d'und' IanBT ^"''I . , ' , ��� �� , t�x dn� ,�,��Q : c}eot,; � , xooZ zodrA,� � •� , , r up dua� -janaT �H �uoi}esedaS „9) ' ' • janaZ uuejy za}eL�A �H � ; � saxt�y(� }eo� adog �jen , adtd �AdOtrH�S ��Z d._— uoz}aq,u}nQ oy }aj}np . • + �"I �nauJ;uauza�p�e[3xod �cTddns K�?I�A paII.T3 �utivadp . : _ , n}sey� • }ncu� e}ezauo� pueT�zod—�"r''', _ .r%rrs",� ' • . . . ua[}Exsdas ��Q ,• zass� a}azotxo� u°jd�,j-�' ��a�j� adzd �Ad Oti H�S ��V ' �IIiH �Q) uauza o ��.L i S 3��I 3nO�J � � P�Iu d n da tuoz � caiy ' �og uo�atg c}u� K�T.1�A PaIIT.i �uLuadp '�� ' Pio� diZ _ . = ' .:.• . �.'. � , = ,+ .� •� ..' ' � � ' : ' •sano� ssao�y � �• zaao� ��9 ---- � , . . . • . ' - 1 # �o� uoi�����S. a�s'���Id uoisini���c�nS # la�.r�d — ` ci�W x�� . .•, �' -- i?nF,u°� i��3��I3 ua�}rsedaS pZT � ;sod pa}Yaz,I, amstazd ��tr X ��t+ i I L � T�d t°xluo� xatduxcS Xb jii^I3t1 sa}a� paKg oy padoig ����ag"� '�-a�����uac�¢x.icZc..ca '¢�� �..��� � � �`_' - -,`� �� ���� �� �� . \1��� � � \ � 1 1 � �1 ` � �L./ � UJ -� 11 .11 I�:�.�a.��,�.�.��.�.�.11 ��--It�.�,I1�:�. �aailcia�a� Add��ons/ l�o�ile �ome Re�l��e�ents Tax Map #:�_ Parcel#: I%3 Approval� Requested for: 1Vlobile Home Replacement Building Addition Applicant Name: � O�h�. o, '�� el ��- Address: i M ` � 7 4- Phone #'s: Pernut Located: ✓ Yes No Installation Date: �{�[la�, Design flow: '��� (gpd) Current Contract with Certified Operator on file (if required): N�- Water Supply: � Well Public or Community � `,I ��� Wastewater system shows no visual evidence of failure on: �l (date) �P � (Applicant's signature if site visit is not required) • -- r t� '� � • .c•. ' s� � • . �. a� " A�di4ao��plac�ment Approve� ��� �- Environmental Health Specialist 11/15/OS �laa (�� Date :� -_ .:'•.. ..•.�_. w��Y}'��n.A -�� .. �Y�.•�ti'y: l�$i�.:�; �.' v4• . ��M `'-'"_ tiC _ ..Z� �� - y:`�� � � 'f����'�„�J •���� • �� • µ � r� � � � - % � � _ h h��1'-•Y _� •_:��•�� •.���`���`�` - - -� . �: :.:..:--- -= �...... .. . . . ]�m.==��.� ��---�.�._._�-s-�-:�,;.�.�:-��€���:.: •..�:. � , / , W . . � ���.����li�/1 � , , ,,, Dr�iller !:D » Com���n;; N��m� � � , /;, Dat�e �riileci � Grout Log . - wea co��n Dist�ance From n� Frb�tty L'me (14linimum 10 feet D;sfiance from Septic syste�n 6o feet) Totai Depth: ��_ ft Yeld: GPM • Static Water I,eveL• Z O & Watex Beariug Zone� Depth�� ft � ft �`ia ft f� � 4 Depih: From �_ to Z J ft. Diam�e�x: _�,�_ in . 1�+pe,: Galvan�ed Steel 2/ � Weig� Thiclmess: r�� Height above Gr�otmd: _� Z_- m� �- Driv+e Shoe: � No Any problems encountered wh�e se�tmg casingi _Yes �lQ'o If `�e,s" give reason: _ _ _ _ _ - _ . . Gcoui: - _ /. : - _ � ' - . Nea� SandJC�t C/ Conc�e GraveUCement . -•- i�u�r Space Wi�th • inches Water in Affiular Space Yes - No .. Metl�oci of Grau� Pumped Pre�u�e � Poureci Depii� ' to Ft 11Zatc;ri.�is IIseiL- - . No. Bags Pordaud cemeut ' Weiglrt o� 1 Bag � Po�mds . _ If mnd�u�e (sand, gravel, �) — Ratio to ID pla.te� Yes _, No 4 a 4 slab Yes No I:�ner. — — - .�. Depth: Dat,e Instatled Grou� Installed by:- - DriBing Log . Location Drawing I�om To Rerms�on � . 6 t7�ey . c, .�O � �� �` � , . - � : . �ov�e �i . [ h�ereby ccx�fy that t�e above• iuf� is comect an�d t�at t#�is well was c�d in a�ce wi@� regulati�s set f� by ti�e Persan CouniyHealih Dei�t �' � - �gaatnre of C.amh�ar _ __ , ID # Z� Daie _ PiamP In�limeat ' . ��n�u�on con�r: Gt �(c �i� e sra�e xe�on x�m�: � � P�mP �P� � � ft S'iatic wat�s Level: $ Pamp Maloe 8c ModeL• _ �.ak:lG� Pump S'rr.e sn,d Ratin� �Z hP � gpm [ herebY cemfY t�at ti�is pump was instatled an�d the well h�d co�le�ad acco�ding to ti�e Persan Cam�ty Well Rules in effe�t xi ti�is date and ffiat a cxipy of ' record �vi�d to� wdl owner . �P � � - - - - Dat� � � a � P(� rev Ol/27/Q4