A40 213�
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PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISPOSAL
IMPROVENENTS PERMIT NO.
Issue Date:������_
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Owner: r1
Location•
Septic Tank Contractor: �
Building Contractor: •
Water Supply: Private Public
All wells should be 100 ft. from sewer system.
Lot Size: � dI CY �
Sevage Disposal F cil/i�ties: o. bedrooms
Size of tank:___��V_U' Nitrification line:
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ETther disposal facility(f'
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Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to S years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line MUST BE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT US . T IS
PERMIT VOID AFTER 3 YEARS. � f
Date Well Approved: Signe
By: anitarian �
Date Sewa e Dis osa} A roved:
g Q p �� � Counter- ,,�
t
ey: �'�— signed ...�
(Owner or his represent ive)
Certificate of Completion
Date Approved: � �
Y�
Sanitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
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.. � . . , SO�o �na�. E-����xus�s
' Person County Health Department
Well Permit �
DATE ISSUED:7'i'' � DATE D ILLED: COUNTY: ��f�^
OWNER:' '� ROAD/ TREE • �„�-
ADDRESS: ° � V / b'n � � �[�'
DRILLING CO RACTOR: �� �� L. \� R
NAME — -ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Tota1 Depth: Ft. Yie1d:1�GPM Static Water Le 1 Ft.
Water Bearing ones: D th Ft. � Ft.
Casing: Depth: From�to Ft. Diame e.— Inches
TYPE: Steel Galvanized Steel
�- If Steel, does owner app� Yes No
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Weight: Thickness.�Zy�,eight Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If 'yes' give reason: /�
Grout: Type: Neat Sa ement Concrete
Annular Space Width �� Inches �
Water in Annular Space: Yes No
Method: Pumped Pres Poured
Depth: From to Ft.
Haterials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, gr�iel, cuttings) - Ratio: to
ID Plates: Yes � No
4 x 4 slab Yes� No �
DRILLING LOG
De th
From To F tion Descri ion
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCERW�i REGULATIONS SET/�ORTH BY THE
PERSON COUNTY HOARD OF HEALTH. PE T OI'D�AFTE�iRE� k�►a�.
Date
Date Issued
Sanitarian's Signature Date Completed
Sketch well location on raverse side.
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