A40 220PERSON COUNTY ENVIfiONMENTAL HEALTH
WELL LOG
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Date: � 2 � �� '
Owner:.�•�ts �o�� ' � SR# � � �
Location/Directions: �`�'QT R;v�� 0>4„7���ah ��`t" c . -
Subdivision N1rne: __ Lot # �
Drilling Conbractor: �'L�7�►- ���,� e� ie.
� WELI, CONSTRUC'I'ION
� Distance from Nearest Property Line Distance from Source of
Pollution j�/. v
Total.Dep.th: /(�� Ft. Yield: !o GPM . Static Water Level 2S Ft.
Water Bearing Zones: Depth �d Ft. F� F�_��t.
Casing: Depth: From I� to S3 Ft. Diameter: (/� Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Y�s No �
� Weight: Thickness:� /�� Height�Above Ground: /�� �� Inches
Drive Shoe: Yes � No . �
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sand/Cement Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
._ Method: Pumped . .-- - Pr�ssure . . Poured � � - - - .
Depth: From U to 2 v Ft. �
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes�_ No �
4 x 4 slab Yes x No
� DRILLING LOG �
De th �
From To Formation Descri tion
D �^I � !7v e✓�J' es�l
Wv � � o �r tir �4•
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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 PERS0�1 C�Ui�1TY HEALTH DEPARTMENT.
�% ` _
ignature ' on r tor �Dat�
Jurr-�^�95 02:16P PER50N COUNTY HEALTH
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��rv.lces
_ Imprc�vements Permit (Establishcd/Recnrded Lot)
_ Improvements permit (Unrecarded Lot)
.._ Irtiprovements Pec•tt�it (Mobile Home Replace)
Improvemcnts Permit (Addition)
O � N , -, P.OZ
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;equesc�,q: . , _ :;, .
_ Reinspcction of �xisting Sys�em (Lo�n Clc�sii
� RepairlRe�lace e.xisting SePtic System
_ Perrnit for New �Vell
_ Replace Existin� Wel)
Water Sainple to be C
� Bactcria _ Chctnical _ Petroleum
` Pesticide
_ Leaci
l. F'ermit requested by: 7. Dimentiions or Froposeci Structure:
wnertpraspective ownerlagctit: Width:
Add�ess: Depth:
8. What type (if any, additions, expansions, or
�� replacement is anticipated tc� the stiucwr� vr facility
that this sewa c dis �Sal s Stem is intended to serve'?
a ome Phone #; �� y` T—
�C usiness i'honc �i:
�
z
Name and add�ess of currcnt owner.
��
�. Property Uescription: Lot size: S� v'a �i-�-
. Tax Map#: - �b
Parcel#: _�20
Township: �!-�{-T t1� l V�j2
. Directions to prc�Perty: State Road # c4z �toad
lames, etc.
l—i � -� 1�1 � d��D �F ��—�
12l V�'� Le -t—n ni st? -�'�-ri�rL> �
�9. Water supply t}•pc:
private �' p�.�blic (� conimunity ❑ sPring C1
Are atty wells on adjoining pruperty'?Yes ❑ N� [�
If so, identify Ic�cation: _ _
1Q. Type of stntcwre/Facility: Propcysed: ClExisting: ❑
Type af dwelling:
House: C7�1VIobile Home: ❑ Buciness: ❑
Type of business: N��
Nutnber af Employees: ���
Ntunber c�f bedrootns: �_,
Garhage Disposal? Yes ❑ Na [�
Base�nct�t? �'es ❑ No [1�It so, # of liasement fixture.s:
�. Number of occ��p�n�s vr peoplc to be served: y'
.,�.� , ..r_.�_. .�._..�.
CLEA1tLY S'�'AKE ALL GORN�RS UF THE P�tt)PF,RTY AND TH� COkNFRS OH ALL
PRQPOSEll STRUC7.'URES.
i hereby rt�ake applieation tc� the �'erson Coutity Health Depalrtment for a site evalc►atiim for tl�e �n-sitc
sewa�e di�posal sy�tem for the above described praPerty. I agree that tt�e cc�ntents of thi� aPPlicatic>n are true
and repre5ent the liiaximum facilitics tc� he placed on the praperty, I undcrstand if the site is altercd c�r the �
intended use changcs, the pemiit shall become invalid. a andcrstand that Ucfore an Lnprc�vements Permit can he
issued, I must present a survey plat of the pmperty to the Health Ue�t. I understanci that in the event 1 havc nat
deliverect u survey plat of the prop�rty to the He�lth llePt. within 6(1 X)AYS after thc d�tte �f thc e�•�luat'ton of
the site by the Health Dept., this np�.�licatian shall bccome void and �I1 fees p�icl fc�rfeitcd.
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�wner or Autt�oi�ized Agent
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A0��44
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map #`%� �� Parcel #� Z a
Zoning To ship F�i'`,(�=c�-e�-
Owner/Contractor ,g� h{u-�-� TR��s .`8�4re/�'c�.�Date --79-y.S�
Location/Address �-,-, .�'� �-c�.../� � 3�`�;-
�
gubdivision Name f.�-�.p` �-r%u-�. � ' 1,ot# C_
S.R.# /57.��t�.°-r
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � o0a�y Size of Tank JB-�-
SFD ►/ Mobile Home Y Size of Pump Tank �'/�
Business # of Bedrooms�_ Nitrification Line lf-DD'x �3�
Max Depth Trenches , .
Permit Void after 60 months. Pernut Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by til,�� i�
Comments:
Date
Installed by Gc//�
Approved by.
Comments:
y
i
�
r
Date
environmental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repo�t that may have resulted from false ot misleading
statements provided to him in the application. Neither Petson County nor the environtnental health specialist wazrants that the septic tank system will
continue to function satisfadorily"in the future or that the water supply will remain potable. c:�amipro�petnutsam O1/95 rev.1.0
ORIGINAL
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