A32 197Person County HealEh Department
Well Permit
DATE ISSUED:�; � �.
OWNER:
ADDRESS:
DRILLING CONTRACTOR:
i. �
LED: COUNTY: �`i+
ROAD/STREETs Cjl.� ��/� 1
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Nr,� ADDRESS � r � go,� 3G 4�
WELL CONSTRUCTION �' d V� d'e- "G e, /VG
Distance from Nearest Property Line -,�<$ F�T Distance from Source of
Pollution a o a F i �7
Total Depth:l[� S Ft. Yield: J GPM Static Water Level�Ft.
Water Bearing 2ones: Depth ( 5 Ft�Ft. Ft. Ft.
Casing: Depth: From a to c�Ft. Diameters 'S Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner approve: Yes No
Weight:l.�` 1$�ickness:� g� Height Above Ground: N r Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No��
If 'yes' give reason:
Grout: Type: Neat Sand/Cement � Concrete
Annular Space Width c�- Inches
Water in Annular Space: Yes No �
Hethod: Pumped Pressuze Poured �
Depth: From e to a C� Ft.
Materials,�]sed: No. Sags Portland Cement_�Weight of
1 bag �j `/� lbs.
if mixture (sand, gravel, cuttings) - Ratio:�_to_�
ID Plates: Yes ✓ No
4 x 4 slab Yes �� No
DRILLZNG LOG
De th •
From To Formation Description
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTii. PERMIT VOID AFTER THREE YEARS.
Sketch vell locatioa on reverse side.
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Tax Map #: �`�� Pareel #�„� Township I'Mrd (e � � l► ��$ PIN
Appiica� � f3ea51 �N lsud�e ��on � Phase/8ectlon LotS
L.ocaUon: �
New ✓Addition
# of Ocxupants 3
Projected Daily Fiow _
Propased Wastewater
Proposed Repair. 5
improvement Permit
TypeofStructure'� ,3 6�. ��s;�P.M7I�'�., WaterSuPPijr P�Va�e �V���
Bedrooms 3 Other
) g.p.d. , ,, Per�nit Vali
ntr
Years ❑ No
System Type � �
Permit Conditions: i'%U��� m���5 t� � Wo.l�u�� �1r�Ve �n. �cd• �,o'�" or. �>►�si' n S�'
�Ica _ � Lfl I�ouse s;l-e . ; u s � �E��-e ��'�5 W�I hk� Cm�e ('.� , � . —�—
Owner or Legai Representative Signature: �\��� Date: �-- I� o I
Authorized State Agent: Date: �� ��� �
The issuance af this permit by the Health Department in no way guarantees #he issuance of other pertnits. The permit hoider is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subjeat to r+evocation if
the site plan, plat, or the intended use changes. The improvement Permit shall not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatmerrt and
Disposal Systems of the North Carolina Adeninistrative Code.
WastewaterSystem DesCription: ��DW �OnVP��'ol�� , WastewaterFiow: �o� s�.p.d. Type:�
Facility Description: f-�r� �S`� e�'���`� New O� Repair ❑ Expansion ❑
Basement? O Yes o Basement F uctures? � Yes o
Wastewater Svstem Requirements
Tankage: Septic Tank size (Ooc°7 gal. Pump Tank size ��` gat. Grease Trap size �� gal.
Trenches: Total length � ft. Tren�a'Mdth � ft. Total Area �� sq. ft.
Max. Trench Depth: � in. Aggregate Ge��h: %� in. Soii Cover. � in. Trench Separation / ft. on center
Perrnit Expiration Date: �— %— O 6
Authorized State Agent Qate: /— I�
'See attached site plan and addendum pagss for additional permit conditions.
The type of system permitted a does ❑ d�es not differ from the type spec�ed on the application. I accept the
specifications of this permit
OwnedLega! Represerrtative Signature: � Date; �-�-0 I
Operation Penr�it
Sjrstem Type (in acxordance with Tabfe Va) �
This system has been installed in compliance wifh applicabie �lorth Carolirta (3eneral Stah�tes, Laws and RuFes for Sewage Treatrnent
and Disposal, and al! conditions of the Improvemerrt Permit and Construction Aufhorization. Issuance of U�is permit implies no
guaraMee that the system install�d will functton propedy for any giveo period of time.
Authorized State Agent
Date
PCHD, rev. 03f07/01
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PEF2SON COUNTY ENVIRONMEiVTAL HEALTH
PLEASE SE�E A�'i'ACFiE� PLAN F�DR WELL SITE LAYOUT
Tax MaP iF. � � � Parcel # � � �
7ownah(p �ur�l l, � ( I �
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n ng _ , . _ .._. . . ..
/►PPlican�
LocaUon:
Subdivision. Section• �O�
Weli Permit '
T e of Water Su I: ��ndividuai Community Public
Reauirements:
Site Approved by
Grouting Approveci by
Well Log
Weii Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller•
Well Approved By: � Date:
**See Attached Site Sketch**
WellS must be 10�from property lines. f'
Wells must be et from septic systems. —�� v'"�� •n -
Wel(s must be �at least 25 feet from any buiiding foun ad tion.
Other conditions:
PCHD, rev. 11/29/99