A40 240Q
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PERSON COUNTY HEALTH DEPARTMENT
� A 0443
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERNIIT
Tax Map # /� �F p Parcel # �. � �
Zoning Township F..�_.•-�'` �=4-�-
Owner/Contractor ` �P��+.�z. Date e�-2 8-9.s�
Location/Address ,� A�-�� � -�� �.� � � c�-. �ra �-��"�``
_ S.R.# ` , �
bdivision Name �Qf�" .�� J� '' ,�..ot# .2S =!�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area %� � v�¢ Size of Tank 1 B�-B'
SFD ✓ Mobile Home 1/� Size of Pump Tank I�i�
Business # of Bedrooms�_ Nitrification Line y-o a'X 3�
Max Depth Trenches
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is altered or intended use changed.
Well and Septic Layout by Gd.�%P� 8.�-�-�--
Comments:
Date Q- 3 9S Installed by�� /����r�, APProved by w..�� 19�-•-L•.-,.�
p�� WELL SYSTEM SPECIFICATIONS
Individual !�' Semi-Public_
Public Replacement.
Site Approved�
Well Head Approve
Grouting Approved.
Comments:
Date
Installed by.
Required Sl�
Air Vent _
Required W
Well Tag _
Approved by
`t6'
Tlus report is based in part on infortnation provided the homeowner or his/her representative in the application u�nitted for ihis pemut The
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 tkvs repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank systettlwill
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemutsam O1/95 rev 1.0
ORIGINAL
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I'I;IIt:uN �.��IIIJ'I'Y 1•:�J�)'1lUlJ1`11':IJ�fAI. III.A1.'lll
W�LL LOG
�i2i�: . � _ L ""'l�-.
(.��,�ne�: Tk�
I,ocation/Directions:
Subdivision �Name: .
�'ll' Contractor•
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Lot #
Dn ing . ' WEL�. CONSTRUC'I'�ON - .
�.- Distance from Nearest Properry Line Distance from�Source of
Pollution — � ��p GpM Scacic Waccr Lcvcl I't.
Total Dcp.th: Ft. Yicld: . .
Water Bearing Zones: D.epth _..,_� �.._---F�- F� ��
Casing; Depth: � From_ � to�_�t• Diameter: Ynches
TYPE: Steel � Galvanized Steel i�Ej
If Steel, does owner approve: Yes NO--- �ches
' Weight:_�'����5� �' Height;Above Ground:_____ 1 .
Drive Shoe: Yes______ No . !
. Were Problems Encountered in Setting the Casing? Yes__ No�
If "yes" give reason: Coricrcte
Grout: Type: Ncat _ Sand/�ement _ �
Annular: Space Width 1 �—_�ches � �=..
Water in Annular Space: Yes _ No�.
� Method: Pumped.:._._ Pressure__. Poured �_
Depth: From � d F�~ �
Materials Used: No. Bags Portland Cement_ Weight of 1�bag_____��bs.
Yf mixture (sand, gravel; cuttings) - Ratio: to .
I]J Plates: Yes � � No_„______ �
. a t a �t ab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE YNFORMATION TS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY•THE PERSON COUNTY HEALTH DEPARTME►�I"I'. �
. , �.-24-gs
Signature c�f C'c,���tr� �nr i'��'�'
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