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��RSON COUNTY HEALTH DE�1�vRTMENT
WELL AND SEWAGE SITE, LOCATION Rv�ROVEMENT PERMIT
Map #� �0 Parcel # � y 3
lg Township �, ���.
° q 0053 .
Owner/Contractor /�c.���G i,rJ.�r�„�,,,�.. Date � -3 - ��
Location/Address �.,,q-,��..�vr� ��P, 1����: �, ! � y�� n _
N��
S.R.# // �1'l
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /a��c.LCty Size of Tank / 8-�
SFD �/ Mobile Home p,�:rJ. Size of Pump Tank �'/A
Business # of Bedrooms� Nitrification Line �Do `� 3'�
Max Depth Trenches �� d
Permit Void after 60 months. Permit Void if not in compliance with zoning regularions.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by j,tl.,��•� ;�D .u�t�w,
Comments:
Date3-3 6-�3" Installed by�dey�� l�,.?�-�,�ri Approved by�J-�-Q.11 .£� .c-�-�.�`
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WELL SY�TEM SPECIFICATIONS
Individual Semi-Public Required Slab I/ �}- -G -%S ��� `'���
Public Replacement Air Vent �
Site Approved ✓ Required Well Lo� 1/�
Well Head Approved We�l Tag V' __
Grouting Approved !� S�- 6->S C�� � o�
Comments:
Date 1�-/0-�'S Installed by Approved by� `� .�} ���-.
Tlus report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit The
environmenta! health specialist is not responsible for false or misleading infocmation cocrtained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the app(ication Neither Person County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:4vnipro�pennitsam O 1/95 rev.1.0
ORIGINAL
1�'� , , - , •-
: PI:RSON C�UNTY P:N�RONMF:NTAi. Hi"ALTI1
� -. WELL^ L�OG`\ /� r/�� ��/ ;7�u�
'� . 1�`� 1 1� �1� C3 �� � w"" � LJ 1.
��: 5_ �5 � o„
Own�r- �(1� I�RE.�V.�l .. � S�2# 1 1`�
Location%Directions:
Subdivision �Name: r � Lot #
Drilling Contractor: �
WELL CONSTRUCTION - .
Distance from Nearest Property Line Distance from�Source of
Pollution � � ,
Total.Dcp.th: . Fc. Yicld: �� GPM Static Water Level Ft.
Water Bearing Zones: D:epth . F��F� - FL �t.
Casing: Depth: � From � to t'1 Ft. Diameter:_�lp�_Inches
TYPE: Steel - Galvanized Steel �CS
7f 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 SandJ�ement �✓ Coricrete .
, Annular. Space Width � � Inches � �;
Water in Aruiular Space: Yes No ;� �
�Method: Puinped � Pressure Poured � ES
Depth: From to � F� �
Materials Used: No. Bags Portland Cement Weig}it of .l bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ✓� No � � '� .
� 4 x 4 slab Ycs � No
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I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT ,. ,.
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. � _. �
. -t� ��_c��c � ,-
Signature of Contr tor Date ��--