The URL can be used to link to this page

A34 8/ N c, J�Address - � _T �- � � �(J X � C� CC� � . � i No. of persons to be serve� Bedrooms 1 2, 3, 4. Additional appliances to be used: Disposal, dishwasher, `ashing -_ machine Recommended: Septic ta � � `� Nitrification line: Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspec2ed and approved by a member of the Disfrict HealYh Deparfinen2 s2aff before any portion of the installation is covered. Date Approved: Countersigned �igne� Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer (Over) � • � � • � • • • -• • •• � .• • •.• • •• • •• • -• .. �v' � � �. � � � ��■�■�■��■�■ i�liTEf,�Jf��:,'J��I�� .. .��rr��ii�r.:�.r. �....�.r.�..�... ■�...�...�..�.... � ��0��l��■■i��■■��■ ►�ii��O��■�0��!! ■ i■��■�� . - ��■��r�� ■ �■�� ■■ � s��■■�■ ��■■ ■ � ■■■ ■■ ��s�� ■�� ■ i ��■�■ ■�■■■��■��■ ��e�■��■ ■��■■�� ■s�■■ ��■��i:ii i:ii��■��■ ��l�I ��ill��■O�■��■ ��■��!� ■ �� ■��■■��+�__� �i�i�°S�. ■ � ■ ■�� , a � �� `' � _. n� ., � .�; �oa � � Improvements PermiG(Fstablished/Recarded Lot) Impsovements Permit (Unrecorded Lot)�- provements Permit (Mobile Home Replace) Improvements Permit (Addition) � Reinspection of Existing System (Loan Closing) ✓Repair/�� existing Septic System • Permit for New Well , Replace Existing Well � � w U � a _ Permit requested by: . 7. Dimensions�or Proposed Stnicture: �wne rospective owner/agent�� C-f �Nidth: � �, dress: . J �v O/d � .�✓llJ�/.= �.D . Depth: � a Sl � U��- �� 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility tha� this sewage disposal system is intended to serve? Home Phone #: (-�l/D) 5�0.�-�5�3 . � Business Phone #:Mvn�[r'. �6�`�� 2. Name and address of curren[ owner: .�"�l�G 9. Water, su,pply c}'pe: � � private�public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes`L� No Q If so, identify tocation: 3, property Description: Lot size: a`� a3 �� 4. Tax Map#: a� �� 3�� Parce]#: 3 . - � Township: G✓UDpsj%�dGG'� - _ 5. Directions to property: State Road #& Road W ¢ z [ames,�tc. C"�t( Ddw,,,� C'� Tu�u ��:.� ►-�6,� �n �� - o S rP 5��! Number of occupants or people to be secved: of structurelfacility: Proposed: �,Existing: Q Type of dwel�ing: House:l� Mobile Home: L Business: ❑ Type of business: Number of Employees: • Number of bedrooms: 3 Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No�f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTX AND THE CORNERS OF ALL � PROPOSED STRUCTURES. I hereby make application to the PerSOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can b� issued, I must present a survey plat of the pcoperty to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. = ��►% _ _ Signc Ownec or Authorized Agent peCmit Issued ❑ Permit Denied ❑ Plat Observed❑ � Signature Datc 5� 13 3 `� 3'�`� �[� V �" . i � � r � J . '� RECOMMENDATI ONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, t�►� areas, wells, water bodies, slope palterns, etc.) C:V��tIPRO�DOCSUPPSEC.S�I FiNANCEP� PERSON COUNTY HEALTH DEPARTMENT � --� - ' WELL AND SEWAGE STTE, LOCATION IlViPRO�BMENT PERMIT �: U � � B 1441 Not for waste water system constru�tion. No permit(s) for Construction Location or Relocation Activity shall be issued untiI Authorization for waste water system construction has been issued. � Tax Map # � 3 �- Owner/Contractor 5ubdivision Name Parcel # �s Township - ��C�C� \ neS Date ? -'� �l'? � I 33 (l � ti2 �t /�3r � S2-,a� / � 3 �1, �- �- r x3o a� ��< � s.R.# �� SEWAGE SYSTEM:SPEC'ICICATIONS epair Lot Area ac-, Size of Tank SFD Mobile Home Size of Pump Tank usiness # of Bedrooms��r , Nitrification Line �Q� � v.� e � � �sre �r��,- ►J� �O � l�ii Depth Trench, ; ` U� N� r%► -SA^`P c� C�,�!/, so " ' rE �� p 1/`�,. Permits may be voided if site is alter i n e`� �cha� e. Well and Septic Layout by Comments: Date � �� (, -�j F[ Installed by Well Permit Paid ❑ WE] ell Head Approved � SYSTEM SPECII{'ICA Well Tag Well � � �- �Le -� �e �,� .Cv 3 5K. f'�,N,� ,+�•��Q.� %w,.,,� a � s-...,.e� C, d'�. Date This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permi� The environmental health specialist is not responsible for false or misleading information contained in the application. The eavironmental health specialist is also not respoasib�e for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wnrrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:lamipro\permiksam O1/95 rev.l.l � 0 �.. � r � . . . ._- � �� P ' .. . � - � ; �- _�z.� S �'� , A 3 I ` a� Amount paid � �� •0� R.eceipt .�� ' �a0 ; � . � � Q�` � H O � � a w U � a � � Dat ts Permit. (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing) Imt�ovements Permit (Unrecorded Lot) improvements Permit (Mobile Home Replace) Improvements Permit (Addition) _ Repair/Replace existing Septic System _ Permit for New Well ,_ Replace Existing Well z l. Permit requested by: . owner/prospective ownec ome Phone #: �-7� usiness Phone #: I�Iar�e and addreSs of,current owner: 3. Property D Tax Ma� Parcel#: ion: Lot size: . Dimension� or Proposed Structure: Vidth: - �� 8. What type (if any, additions, expansions, or I replacement is anticipated to the structure or facility that, this sewage disposal system is intended to serve? /l/.�j,rt/�' . 9. Water �pply ty pe: D>' O.i private �j public ❑ community ❑ sprin�g ❑� Are any wells on adjoining property?Yes LyJ�No Q. If so, identify location: ��/��/� I-�,.c �1' -ro "` c'�} .r o u- 5. Directions to propercy: State Road #& Raad Names,�tc. � �i<<.n � .�yr ,�n � s�� >f'�/_ l�%C7d,�/ o /'1� , i�� . Number of occupants or people to be served: �_ 10. Type of structurelfacility: Proposed: C�Existing: Q Type of dwelling: �/ House: 0 Mobile Home:11L1 Business: ❑ Type of business: Number of Employees: Number of bedrooms: �_ � Garbage Disposal? Yes ❑ N � Basement? Yes ❑ No so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED ST�tUCTURES. I hereby make application to the Pet'SOn COunty T.�ealth Depat'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. G Owner or(�{uthorized Agent v, � v� � � Soa�ouHncoyG a`'o- ,.ti y+. � � � �.. • . * r : �ZC � wf,vJ S`aGt PERSON COUNTY °"`°�" PERSON COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH PROGRAM 325 South Morgan Street Roxboro, North Carolina 27573 (33G) 597-2371 Date: q - a � - � g Re: � � � l`� C�Ce � � Dear � ��('k N , �or� The above referenced lot has been evaluated by the Person County Environmental Health Department. The results of the evaluation, a copy of which is attached, indicate that the site is unsuitable for installation of a ground absorption sewage system for the following reasons: Due to the limitations on your site, this Department is not aware of any modifications or altemative measures that can be implemented to upgrade the classification from "unsuitable" to °provisionally suitable." Your application for an improvement permit must, therefore, be denied. You have the right to an informal review of this decision by the environmental health supervisor of this health department and also by the regional staff of the Department of Environment, Health, and Natural Resources. You should contact the health department to arrange for this further review. You may also wish to obtain the services of a private consultant to collect site-specific data and submit such data and a system design to the health department for technical review. A site may be reclassified to provisionally suitable provided written documentation, including engineering, hydrogeologic, geologic, or soil studies indicates to the local health department that a proposed septic tank system or a proposed alternative system can reasonably be expected to function satisfactorily. Page 2 The substantiating data from these studies must indicate that: A. The effluent (wastewater) will receive adequate treatment; B. The effluent (wastewater) will not contaminate any ground water or surface water; and C. The effluent (wastewater) will not be exposed on the ground surface or be discharged to surface waters where it could come into contact with people, animals, or vectors. Finally, you have the right to a formal appeal of this decision if you file a petition for a contested case hearing with the Office of Administrative Hearings, P. O. Drawer 27447, Raleigh, NC 27611-7447. A copy of a petition form will be provided to you upon request. The petition must be received by the Office of Administrative hearings within 60 days after the date of this notice. The hearing will be held in the county in which your property is located. If you file a petition for a hearing, you must send a copy of the petition to Mr. John C. Hunter, Office of General Counsel, P. O. Box 27687, Raleigh, NC 27611-7687. Please call or write this office if you have questions or need additional assistance. •�� / ' / /� ' � � Environmental Health Specialist Environmental Health Division Person County Health Department Enclosure .� ��_�., �- �,: �• �.ti •��i� �c'_� - / / • ;�� i - � � � � ��ao� �3�/ �� Person Cou� Hesith Deaardnent Environmerdai Heaith 3eclion - � • � • - �:u �_ p; r�estied �.(own,dage�,tfpe+oapec�ve awne�: •l' so al 5,+�,ee.� Homs Phon� 3�-0�5 3 � Add�+es� �' �� Bt� Phon� �i►S/ � oK� r L �73 Name anc! add�ess � eumsat awner �� S i. %ji `t.. "l4- . � q��. c 7573 fi ��2rs �UvDs�i� � o�� n �, a�� and n�u�ersY .S 2_/ 3 3 3 Ta S� / 33 7 �a -- q � �_ �q�a� 6 �a 9 . uPS � u � � c,�nc�3..w— �- ro ve � P�opas'd Usa and � Descriptia� sinswer eac� af ffte folbwing qt�iiocm: � ProPosed �. Ex�n9 b) SOdc 8ui� Q Nodt�ar 0. S�ie W(de Q �a�6b Wi�e � e9asen�e� Y�81�—j�ea. # of b�aa�nt iGduce� �� ar people to be se�vec� •� Garbage Dtspasa� Yes �, No B� � ' g� q&ne,�cnsctProp�sa�,ra:wf�h: a� oe� �� s1 �' �PPhI '�IP� PrEvate � � cr mdsHng E��c 4�I� ❑. Ara any w�s an a�oin�ng PrcPa►�1 Yas 0 No 8'�yes, gtoc�ion � � Indicad De�ii+ad Slfs� �"YP4= (� can � raRdaad In o�+di� of YaR �) t/C�octventlonai 1� C�onv�tonai _Alb�nait+r� _„Jnnova#tve � �. CLEARLY 3TAKE ALL CORNERg A1r0 � 0� THE PROP�RiY. STAKE THE CORNEi�S OF ALL �OPOSED STRUCTUREB. P�.F.ASE ATTAqi SURYEY PtAT OR SITE PU1N TO THl3 APPLiCATtCN � I hatiby malce ap�at to the Pe�an Camty Haaith Depactms�u � a s�s evaam�on tbr U�s cn-site sewaqe dts�l sY� � tha above�deacxbad prcpedy. t� tl�at U�e co�enta of this app�ton a�e fn� and t� tlm tne�dmum � to t piaced on the pca�ty. 1 iu�d�d �ths s�e ts a�eced ccthe ir�nded usa d�.lite pem�it sfiat bemtns �v�d. l� tt�t as am tespo�ia far id�ng aad n�ari�g p�opect�l Qnes. �m�a and maldt�g t�e a�s a�a �oc tl Caurrty H�Ih Oepa�tent to � iheir svaNmtlons. l tau�nd tlt� i am r�apor� ��9 ti eith D e it properly c�a any w�nds as d�bed by the Amry Corps ot �cs. ,� . �' 021-00 [hw�nr nr 1 weal R�.w �-�+-� Gp�NTY Gp�, 7 `'0� �P�'%1 `Wo- � �i * ` * � * a � w PERSON COUNTY ycpERs°"`°°'�s\a`� PERSON COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH PROGRAM 20-B Court Street Roxboro, North Carolina 27573 (336)597-1790 July 19, 2000 Jason Sharer 1830 Oak Grove Rd. Roxboro, NC 27573 Re: Application for improvement permit for Wasteuvater system for property at 1830 Oak Grove Rd. Person County Health Department File: Tax Map #A34, Parcel 8 Dear Mr. Sharer: The Person County Health Department, Environmental Health Division on June 30, 2000 and July 18, 2000 evaluated the above-referenced property at the site designated on the plat/site plan that accompanied your improvement permit application. According to your application the site is to serve a two-bedroom residence with a design wastewater flow of 240 gallons per day. The evaluation was done in accordar�ce with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of North Carolina Administrative Code, Rule .1900 and related rules. Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the following: 1. Soil depths to saprolite unsuitable (Rule .1943). 2. Unsuitable soil characteristics (Morphology) (Rule.1941) These severe soil or site limitations could cause premature system failure, teading to the discharge of untreated sewage on the ground surface, in surtace waters, directly into ground water or inside your structure. . The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, the Health Department has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall not be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assisst you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an informal review of this decision. You may request an informal review by the soil scientist or environmental health supervisor at the local health department. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for an informal review must be made in writing to the local health department. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition from a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 140A-24 and 150B- 23 and all other applicable provisions of Chapter 1506. N.C. General Statue 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to your local health department. Sending a copy of your petition to the local health department will NOT satisfy the legal requirement in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, NCDENR. You may call or write the Person County Environmental Health Department if you need any additional information or assistance. Sincerely, ��Uti��`� ` Ginger H. Thompson Environmentat Health Specialist Environmental Health Division Person County Health Department Enclosures: 1. Copy of site evaluation 2. Copy of Rule .1948 A 1721 PERSON COUNTY HEAL'TH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT Owner/Contractor Subdivision Name Lot# Permit Void after 60 months. Permit Void if not in compliance with zoning Permits may be voided if site is altered or intended use changed. Well and Septic Layout by /) Comments: Date - Z ` Installed by�1�t��0 .VVY�Approved by, WELL SYSTEM SPECIFICATIONS ivi udTal — �emi-Public , __ equir�b � Site Head Well � Installed by Approved by �T 2-17a �y-1 no 0 �� —14 Z !� �� D �7s I�Q �T— �5 This report is based in part on information provided the homeowner or his/her representative in the application submitted for Uus pemut The environmental health specialist is not responsible for false or misleading infotmation contained in the application. The environmental heahh specialist is also not responsible for concealed conditions on the property or for statements in tlus report that may have resulted from false or misleading statemems provided to lum in the applicatioa Neither Person County nor the environmental health specialist wazrants that the septic tank systecn wil( continue to function satisfactorily in the fuhue or that the water supply will remain potable. c:lamipro�permit.sam O 1/95 rev.1.0 ORIGINAL c ��c - vt�• PERSON COUNTY HEALTH DEPARTMENT SUBSURFA�E WASTEWATER SYSTEM MO1vITORING REPORT _Zq_�� 7-z�-2oo0 �6 A-3� g Date of Inspection System Installation Date Type Tax Map Parcel # r�� oaK �� Properly Address Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? YES / NO ❑ � a ❑ � ❑ ❑ / ❑ ❑ / ❑ EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? �� Inches of solids(pump/dose tank):� Elapsed time readings ? Counter readings ? Drawdown rate: ^� DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? `� Diversions/swales properly maintained ? �] Vegetative cover maintained ? � Protected from traffic/unauthorized uses ? Distribution devices in good condition ? Field free of settled or low areas ? PRESSURE DISTRIBUTION SYSTEM: Turnups/cleanouts/valves/taps intact & � accessible ? Pressure head properly adjusted ? ❑ COMPLIANCE: Comp(iant Non-compliant Needs Maintenance / / / / / / / / REMARKS � SQp�'c ��-a�►K v��- o� ccP�s� � le � Y�_ Q�ae�� Q1a �� -i� n�- � -�lo q�-- ��e. � ;.,��- �'l�Y� a ��(; b � ,�d�wy � a k ; �, �nd�9 . p�- ��oii ��i el9X iv� 9 �� C4,�� 'f��"� � e i� � a u��seµ�- �"�e- Spp�t � �R'�t l� Qt� Ya�. ❑ N I fi ►�l O VZ° S �t v- e Q i ( �� ti��t� L✓°�S f�tc�'hA-� .�Q(r �i �Q►r -�t► s �C--�lr. +' , ' ��/l P�� j , _. ._-- PERSON COUNTY HEAL'TH DEPARTMENT WELL , LOCATION IMPROVEMENT PERMIT Ta�c Map # f% �y Parcel # � Zoning Township �� a �G 0 A 1505 Owner/Contractor � .- ��v c J Date � - �3 - � Location/Address��(� �e� �� , oN /e�� '�� F�w�� i.�'��d � s.R.# i33y Subdivision Name Lot# _ - ��.-- �:,� v..� „�, �x�s�,',� SEWAGE SYSTEM SPECIFICATIONS Rep ' ot Area ize of Tank SF obile H me 'ze of Pump ank B sines of Be oom __ N trification ine ell oid aft r 60 onths P nay be oide if sit is � Septi Layo t by ` '.e Approved ell Head Approved -outing Approved_ Comments: � Depth Void i not in complian e with i onn r�ded se chang d. by WELL SYSTEM SPECIFICATIONS Semi-Public Required Slab ti/ Replacement Air Vent Required Well Lo� Well Tag , n . .. �� Date Installed by Approved by This report is based in part on information provided the homeowner or hisMer representative in the application submitted for this permit The environmental health specialist is not responsible for false or misleading infocmation contained in the applicatioa The environntental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the applicatioa Neither Peison County nor the environmental health specialist wazrants that the septic tank system wi►1 continue to fundion satisfactorily in the future or that the water supply will remain potable. c�amipro�permit.sam O1/95 rev.1.0 ORIGINAL , � , . . . . • .. Date; �' � y Owner. Location/Di .. � .r_ _ ... .. =--- -.- .'.-'�._ . . , . PERSON COUNTY ENVIRONMENTAL HEALTH � WELL LOG ' �� ....� ,.. M C S'ubdivision Name: Drilling Contractor: � . �_ � ..._... . . -_ �tSw.� ' . r J * � 4'. . _�. , . � •. . SR# __- - - T .. llistance from Nearest Properry Line /a Distance from Source of Pollution lvp '' Total Dep.th: /�o _ Ft. Yield: �y GPM Static Water Level o'�� Ft. Water Bearing Zones: Depth 5cs Ft.�F�. �� FL �'�, Casing: Depth: From _ C� to�_Ft. Diameter: Inches TYPE: Steel - Galvanized Steel / If Steel, does owner approve: Y�s No � Weight�: � Thickness: /� HeighrAbove Ground: �� Inches Drive Shoe: Yes ✓ No - Were Problems Encountered in Setting the Casing? Yes No �' If "yes" give r�ason: Grout: Type: Neat Sand/Cement ,/ Coricrete Annular. Space Width Inches Water in Asulular Space; Yes No _ .. Method: Pumped . . . . �Pr:ssure - � Pourzd �/ �_ �. � � • •; - : . Depth: From O to �. � Ft. � � Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixtule (sand, gravel; cuttings) - Ratio: to �ID Plates: Yes ✓ No � � •- � . �� 4 x 4 slab Yes�—No � 0 r� I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT T�S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSO�i C�Ui�'I'y HEALTH DEPARTMENT. � ✓ -a --- �Signature of Contractor Date �.. � 0 � 0 R �