A34 95~_"``� �
�The District Health Department �
CASWELL - CHATHAM - LEE - PERSON COUNTIES
�
Water Supply and Sewage Disposal
IMPROVEMENTS PERD�T �T �
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Owner:
Location: �
� Contractor. � � - h -
� Water Supplp: P�i�ivate �� Public
Sewaqe Disposal Facilitiea: No.
washing machin other sut atic appliances —
Size of tank: _.��� Nitriflcation line:
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Other disposal facility:
, Disposal�
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Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. - -
�`
Date approved: �� '�� Signe - '� �
�-I Sani ian
Well: '
Sewa e Dis osal: � �
g P ' Counter- ,__!
aigned
By� (Owner or his representative)
Ceriificaie of Com lion
Date Approved: � � By:
. an► arian
(OVER)
Location of well and sewage disposal facilities sketthed on back.
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WELL PERMIT
Caswe 1-Chatham-Lee-Person Counties
DATE ZSSU � AT DR D COU�IT1�.j
OWNER: ROAD/STREET: D/C[
ADDRESS: PERMIT VOID AFTER ONE YEAR
DRILLING CONTRACTOR: ,�,,,a ��
N�iM ADDRESS
, WELL CONSTRUCTION '
Distance from Nearest Property Line ;$ ,� Distance from Source of
Pollution
Total Depth: �� O Ft. Yie1d:��GPM Static Water Leve1:��Ft.
Water Bearing Zones: Depth: 3�9 Ft. Ft. Ft. Ft.
Casing: Depth: From_�to�Ft. Diameter: Inches
TYPE: Steel �/ Galvanize Steel
, If Steel, does owner approve: Yes No
Weight: Thickness: JS/� Height Above Ground:�Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat San¢/Cement: Concrete ,�
Annular Space Width � Inches
Water in Annular Space: Yes v No �'
Method: Pumped Pressure Poured �/
Depth: From p to
Materials Used: No. Bags Por landFCement�_�Weight of
- 1 bag �lbs. '
If mixture (sand, ravel, cuttings) - Ratio: .3 to
ID Plates: Yes � No Chlorination: •Yes No ✓
4 x 4 slab Yes �G No
De th
From to Formation Descri tion
a0
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY '
CASWELL-CHATHAM-LEE-PERSON DIST. TH DEPT.
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i ture Contrac o� D�
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FOR HEALTH DEPARTMENT U5' ONLY
REASON FOR NO ZNSPECTION:
' �� J�4�t.� Q.s- ?
�� 9�"/ Sanitarian's Signht e Date
Sketch well lo atian on revers side. \Use es reference
points . v, rJ �__ -C '�r ` j� _ �q� �
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