A35 34A,4pQiicatian Date: �0�-� `�� i ax iU1ap �: 1'� 3�
�mount Paid• .0 d
Rec�iPt #' P3PC2� ,'�• 3 � /�
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APPLICATION FOR SERVIC�S
COP�ISTRUCT SHALL �E�OnflE IIVV�`+LID.
1) Perrtnit recguest by• (Ovvner/agent/prospeciive
Home Phone: � �� �� Addr
Business Phone: / _
2) i�aene and acldress of currerot odvo
3) E'roperty Descripicon: Lot size: + � � � a+vr��.��uN.
Directions to the property (Inciuding road names and numbers�:
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5)
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�,,,,,,... Lot #
�ropos€d lDse �nd Sfi¢�cture �esc�ipiion: answer each of the following questions:
a) Proposed / Exisfing , Type of Structure: Width: Depth:
b) Number of Bedrooms: Number of occupants or peopie to be served:
c) Basement Yes , No Will there be piumbing in the basement7
d) 6arbage Disposal: Yes No
Wat�r Suppiy Type: Private (new �or existing�, Public� Community=, Spring _
Are any wells on adjoining proper#y? Yes_ No�lf yes, please indicate approximate location on the
'site pian.
6) Does your propeety c�ntain previously ac�entifled ju�isdic#ional we$Bands? Yes_ No_
PL�►SE NOTE THE FOLL.OIAl1IdG:
9�► 4�LAT OF T�-9E �'ROPE�3'TY OR S1TE I'LAN NIUST BE SUBf�II'�TE� 1All�i '�99-!IS AP9�L9CA�ION.
9 PFtOP�F2TY L1NES AiVD COR�IEi�S �AUST BE CL�ARL�l IVIARKED. -,
9 T9-!E PROPOSED LOC.�'T1ON OF �►L4. STRUC�fIlI�ES flflUST �E STAKIE� OI� FLAGGED.
� T�iE SITE AflUST �E REe�DIL�! AC�C�SSIBL� F'�R AiV EVALUATIOi�I B'l TL-IE l-11E�►LTH �E��RTME�lT
STAFF.
I hereby make appiication to the Person County Health Department for a siie evaluation for the on-site sewage disposal
system for the above-described property. 1 agres that the contents of this application are true and represent the ma;cimum
facilities to be placeri on the properry. I understand ifi the site is altered or the intended use changes, the permii shafl
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Dat
PCND, rev. 06/27102
andon Duncan
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Keith A. Wdtts
D.B. 202-893
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Physical Sur
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2i' 2�,2 CaG
W�odsdale Twp., PE
Nov., 1998 Sc�
30 15 0 30
SCALE ' IN F
Ernest B. Wood:, �
252 N. Lamar St., Ro�
James Alien Watts
D.B. 173-516
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References
�� D.B. 147-1'59
D.B. 219=113
P.C. 7, H. 35-
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �� Parcel # ��� Township:
Applicant: �1'�1 vu Q
Subdivision: Lot #
Location:
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Type of Water Supply: � Individual _ Community
Requirements:
Site Approved By: �CF I�l l��v�
Grouting Approved By:"a� IA( tg�fl�
Well Log:�� �ol►S�InS�
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Public
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Driller: �rn�e -
Well Approved by:
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:
PCHD rev Ol/27/04
� �;� � ` ���.:� �� °�o°c� ao � 3.� � �
�.� - - � a o �p � G�nP� �Ve� � Dr�l�� �`.�
- __ (� � �T�T��
�sa�-na-�ua,.� .��n.4.ffi:ll � ZE���.Il�l�n. �`s'� � '° 1 O- � 7' ��
Owner: �i i
Location-�L1 � G V
Subdivision:
G�
Grout Log
Tax Map�}3 f Parcel # 3��A
Lot #
- Well Constrnction
Distance From nearest Property Line (Minimum 10 feet) � p
Distance from Septic System (Minimum 60 feet) (�
Total Depth: ��/ � ft Yield: � GPM Static Water Level: ZS ft
Water Bearing Zones: Depth'�p o ft ft ft ft
Igut
Casing:
Depth: From �_ to �� ft. Diameter: 6%H in
Type: Galvanized Steel �/
Weight: Thiclrness: � � �. Height above Ground: 1 Z in
Drive Shoe: '� Yes No Any problems encountered while setting casing3 _Yes �No
If "yes" give reason:
Grout: "
Neat: Sand/Cement Concrete GraveUCement
�. Annulaz Space Width � inches Wa,ter in Annul Space Yes �No
Method of GrouY: Pumped Pressure Poured � Depth to F�
Materials Used:
No. Bags Portland cement � Weight of 1 Bag �� Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: ✓ Yes _ No 4 x 4 slab Yes _ No
Liner: -- ,�
Depth: Date Installed: Grout:
Drilling Log
Installed by:
Location Drawing
F om To Formation �
y e Cef l'n ` �
— 5 {,G � �'
!L� S�on t �
S 3N� c Roc � � k
, ��
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth
by the Person County Health Department. '
Signature of Contractor� %��''`�
ID # 326� Date ��0-17-D �
Pump Installment
Pump Installation Contractor. �a�''ns}�� %/ ef1 (�t�II iny State Registration Number: '3 Z6 7
Pump Depth: Z y� ft Static Water Level: Z,� ft
Pump Make & Model: e �uckr� Pump Size and Rating: �_hp � gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to the well owner.
Pump Installer Signature � rj"'�"' Date: � p" �%- OS PCHD rev 01I27/04