A35 37The Disfrict Health Departmenf
Orange, Person Chatham, Lee Counties
SEPTIC TANK PERMIT
Date .§;,•` � Y,
, �.
Name of owner
�� . �:
Address and Directions '� `
i:
Person or firm doing installation:
Address
No. of persons to be served bedrooms 1, 2, 3, -4.
Additionai appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank j �
s� � ' t
Nitrification line:
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Septic tank and nitrification line must be inspecied and approved by
a member of !he Health Department siaff before any portion of the
installation is covered.
Date Approved:
P "
Sanitarian
By: �'�' � - �-
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanl�s, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date. ' .
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Autho�ized State Agent
SiT�. S�S�TCH
Taa lY1ap # 3S Parcel # 31
� Section/Lot#�
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� Date �
sy� ��o� ��� �pro�� ��u� �y. The contructor »utst, flag the syste»s prior to
beginning the installation to irtsrsr� thatpropergrade is maintained
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Scale: � � `-�p•
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PCHD, rev. 09/12/01
}���2SON CZ3U�IT`l E�1V�R�NMEidSAL !-lEALTi;
Pl.F�SE S�� A��Ct�E� PLd�►N F�OR WE�.L SrTE LAYUl9�
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Tax MaP #: .
TownshiP W""`'"cS��1.1 �-
ZoNng .
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s�an�won:
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Tvpe of Water Suppiv:
Reauirements•
Well Permit
� Individual = ommunity Public
Site Approved by � � �Z
Grouting App v bY '
Well Log �
Well Tag
Air Vent
Hose Bib
Concrete Siab
Well Drilier: 'flC�l 1��1 '
Well Approved By:
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Date•
**See Attached Site Sketch'"""`
Welis must be 10 feet from property lines.
V.yelis must be 100 fee# from septic systems.
Weiis must be �at least 25 feet from any building foundation.
Other conditions:
�mr�c.n,d (n,Sf�( ( r� ��� �� e`�s �n�'
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bor�d ��-�t .
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PCHD, rev. 11/29/99 -
-�f�c. Foot Va( c1 �( 5 S c� �-� �� J4'S'
0 r� Ioorc.d_ W c.( (.
���. S� ���.� �� �o� oo � 2309
� '� �`�— � � �LT I�'I� i� C'`�°�p�'I a�o �ntK-� N U� I LU �ms�.s � �
��-�3sm������.� ���.��� D�o Dr��(lloo�l
Well Log
Owner: ��� �� � Tax Map � 3 r'.�' Parcel #�
Locarion: jVl -`- -S IYY� I,�,
Subdivision:
Lot #
Well Construction
Distance From nearest Property Line (Mini.mum 10 feet)
Distance from Se tic System (Minimum 60 feet)
Total Depth: Z�d ft Yield: � � GPM Static Water Level: ft
Water Beari.ng Zones: Depth � ft � ft ( Q 5 ft ft
Casing:
Depth: From �
Type: Galvanized Steel
Weight:
Drive Shoe: Yes
If "yes" give reason: _
to i0% ft. Diameter: b�,Y in
Thickness: . � Q8 Height above Ground: in
No Any problems encountered while setting casing? _Yes No
Grout:
Neat: Sand/Cement %� Concrete GraveUCement
Annular Space Width _� inches Water in A.nnular Space Yes No
Method of Grout: Pumped Pressure Poured � Depth O to ZO Ft.
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
Drilling Log
I.ocation Drawing
From To Formation
i
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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 �,�U � ID #� 3 � O Date �J '( S�(�2.
PCi-ID rev O1/16/02