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Amount Pald• �
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� . AQpLlCATiON FOR SEiiVIC�S . •
1) Permit requested by: (Ownedagerrtlprospective owner): � 0 h n n ., 0
Home Phone: •��- S$� � Address:� ' S w e
8uslness Phone: �o4-`labg ..• � o o�o a'�S�l
. 2) Name and address of carneM ownec �IztM • .
3) -Property Description: Lot size: Township:
Dit�tto�s to the Property �duding road�amesAand
Lot #
4) Proposed Use and Structure Description: answer e�t� of the following questions:
._. 'a)- Pro� ,�, Existin9 _.+ TYPe of Structure: Width: Depth:
��' b) Number tl�f Bedrooms: . Number af oc�pants or people to be served: �
. �� c) Basemec� Yes .�No _ Will there be piumbing in the basement? _
' • . d) 6arbage Oisposal: `fes � No ____ �
5) Waber Supply Type: Prlvate �(new _ or existing_�, Pubiic . Communiiyy , Spring
. � Are any wdls on adjoining property't Yes_ No _ If yes, piease indicabe approximate tocatlori on the
'site pian. � �
6y Does yaur property cantaln previously tde�rtifled jwisdlctionai wetlands? Yes_ No�
PLE�SE NOTE THE FaLLOVY1NG:
➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MUST 8E SUBMITTED WfTH THIS APPLICATION.
➢ PROPEi2TY UNE3 AND CORNEitS MUST BE CLEARLY NIARKED. •,
➢ THE.PROPOSED LOCATI�N OF ALL STRUCTURES MUST BE STA(�D OR FLAGGED. �
➢ THE SITE MU8'fi �3E READILY ACCESSIBL.E FaR AN EVALUATION BY THE HEALTH DEPARTMEI�1'T
STAFF. ' .
I hereby make applicatton.to #he Person Cauniy Health �epartment for a siie evaivation for the on-site sawage dtsposat
system for the above-desctibed property. 1 agree that the contertts of this application are true and represent the maximum
facilities to be piac�d on the property. i understand ifi the siie is aitered or the intended use cl�anges, the permit shall
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Name .���,, �,,o�, Ta.g Ma.p #�34 Parcel # Z�
Subdivisi Sectiofl/Lot#
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� Au o�ize Sta.te Agent � Date .
System components represent a�iproximate �contours only: The contractor must, fTag the system prior to
beginning the installation to insure thatpro�ergrade is maintained
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Tax Map A�� Parcel # 2� Township: �,�,.,�.,,�,_
Applicant: �i�,,,..0 �, _ n -
Subdivision. ° Lot # .
Location: � 1'U�Y��� v�,;�� ?� � ...._ -- - - - �. . _
'Typ� of �a�er S�app�y: ✓lndividual
�teq�ia�eanen�s:
Site Approved By: _ Z ��
Grouting ApPr ed By: -Z -D
Well Log. � � �
Pump Tag: .
Well Tag:
Air Vent: � �
Hose Bib: � �
Gasing Height �
�Concrete Slab• � � �
Community Public
. �
Well Driller: �G7N �t ��/1 i �' � QYLI �b�-+�,
Well A�proved by:
�a�*see.��ched Site Sk�tch*���
Liner.
' 'Installed by: _
Depth set: _
Grouted:
Dafe:
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from s�ptic systems, �
. e must be at least ZS feet from any building foundation.
�-
Date:,
or�� �ana�tio�: �Ila� s� �kD ,k . lU(,�,crs� �er� e wel�
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Owner: l3
Location:
Subdivision:
Driller ID # •�
CornNany Na,me� � � /
Date Drilled i I.
Grout Log
Tax Map3� Parcel # 2�
Lot #
Well Construction
Distance From nearest Properry Line (Minimum 10 feet) �
Distance from Sepric System (Mini um 60 feet)
To�l Depth: � ft Yield: ,�_ GPM Static Water Level: �J� ft
�:'a:er Beanng Zones: Dep[h ft ft ft ft\�pRO^FQ(aCK
Casing: '
DepL�: From � to � 1 ft. " Diameter: � in
Type: Galvanized Steel L�— '
Weight: Thiclrness: �� Height above Ground: �2, in
Drive Shoe: Yes No Any problems encountered while setting casing? _Yes .�No
L "yes" give reason: ___ ____ _ _ _
Grout: -
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width �� inches Water in Annu�ar Space' . Yes �Ia�
Method of Grout: Pumped Pressure Poured �� Depth to Ft.
:�Iaterials Used:
� No. Bags Porcland cement Weight of 1 Bag Pounds
Lf mixture (sar , gravel, cuttings) — Ratio to �_ : +�_�
� �� pla;es: _ Yes _ No 4 x 4 slab _ Yes _ I�o �
Liner:
From
Depth: Date Installed:
Drilling Log
To I Formation
"Grour. lnstalled by:
1326
Location Drarving
�DI 1�l
I hereby cerrify that the above information is correct and that this well was constructed in accordance with regulaaor,s se: :or::-�
by the Person Counry He � De rtment. '�y'
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Signature of Contractor - ID.# 23 � � Date'
, . Pump Installment
PLmp Installation Cona-actor: State Registration Number: � _
PLmp Depth: ft Static Water Level: ft
Pump Make & Model: Pump Size and Rating: hp ;��r.
I hereby cenify that this pump was installed and the well head completed according to the Person County Well Rules in efie:t
on this date and that a copy of this record has been provided to the well owner.
Pump Installer Signature Date; PCHD rev Uli2�r0-: