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WELL AND SEWA�E SITE, LOCATION Il1iIP�9 VEMENT PERMIT _
Tax Map # �' ?Z� Parcel # y S
Zoning T wnship '
-' " � Owner/Contractor � r� Date � _%/T��%
Location/Address
� S.R.#
Subdivision Name Lot#
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as �u�
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5� (336 �?�' .�3G
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � Size of Tank �
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line
Max Depth Trenches
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered i e e use anged.
Well Layout by
Comments:
Installed by
by
WELL SYSTEM SPECIFICATIONS
Indi{�dual ✓Semi-Public
Public Replacement
Site Approved . ✓/
Well Head Approved �/ _
Grouting Approved
Comments:
Date
by
Required Slab `�
Air Vent `�
Required Well Lo� ✓
Well Tag ��
Approved by,
This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for ihis pennit The
environmental health specialist is not responsible for false or misleading infortnation contained in the application. 'Ihe environmental health specialist
is also not responsible for concealed conditions on the pcopwty or for statements in this repoR that may have resulted from false ot misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank system will
continue to fundion satisfadorily in the future or that the water supply will ranain potable. c:�amipro�pecnritsam 01/95 rev.1.0
ORIGINAL
�i
PERSON COIIN'I'Y 1�:NV:I:KON��`:N1'!�L 11L•'ALTI-1
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Date: L : � � �
Owner: r� ' �'
�- � SR# � �
Location/Dire tions: _._1/..�c G.�,� -_-_�yl• �-�-���_ _--- � . � :'
�ub��vision Name: __ _—_ - -__ __ _ __._ Lot # ` .
� Drilling Contractor: --.�.q- (,J�_//__.,Q_,-.1�_ � � '
�._S_- �L s � �,
wrl..►_._ c��rvs���zucr�o�r . �
Distance from Nearest Pro �c��i Linc__ � `' �'
1 Y ��4��� cws llistance .from Source of ' k��r�
Pollution_ .Tp /� . ;�
,
Total D �� ' • ,: ��
...�p.�:� � o z Ft. Yicld: S G1�M Static Water Level
�Fc = =�
;Water B�earing Zones: Depth Ft. �t. - � � . '�
-,L�-�--- F�. ��t. u.,
Casing: Depth: � From t� ���
TYPE: Steel �_ �zf�.__ Ft' Diarncter: .,; � Inches ,�
. Galvanizccl Stec:l � -- • ' :
Xf Steel, does owncr approv��: ycs No � *' �
�
' Wei h[�. — � '�
.g '�_ Thickncss:_ l�� , Height Above Ground: _,L� ���hes a�
Drive Shoc: Xes ✓�� N�� � ' . , �„_
x :,::
Were �'z-oblems Encoti�iterccl in Sctuilb t�1c Casing? Yes �� � No �— �" _,;; j� :
„ „ 1'
I[' yes give reason: :a;,��
I t.�yy-
Grout: Type: Neat Saricl/Ccment � • • � '¢
'—' Coricre[e , '.��.' °r,
Aluiular. Spacc Wi�ltli 3 Tnchcs � `"'
r
�p
Water in Annular Spacc: Yc::._ No � �. ��
Metho.d: PumFx;cl�----- I'rc;.tisurc I'ourc:cl � -� . . �. . '"
,;
Dcpth: From �_---- tu. .__� a I�t. . ;. :��
Materials Usecl: No. Bags .f'c�rtl.u-id Ccmcnt ' `F�
_�._ Wei�t of .1�ba��_lbsr� ��� ��
If mixtuic (sand, gravcl; cuttinGs) - 1Zatio:__� �� /
r r.
ID Plates: Yes � No � � . � .. • �'"
;,
� 4 x 4 slab Yes `� y'�
No � �.:
_ " ";;:�
— ���
x,HEREBY CER7TFY THAT TI-IE ABOVL INFORMATION IS CORRECT AN
:T�S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIC
FORTH �y�T�-IE PERSON COUN�'X I-ILALTEI DEPARTMENrr. �
,, ..
---�� �._.,�_—
.Sibnaturc of Contractor
Date. J�