A40 263� r B 1020
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n� :�vid �t�ITNTY �iEALTH DEPARTMENT
WELL AND SEWAG� SIii:, i.^vi t1TIQN IN�ROVEMENT PERMIT
Not for waste water systen: construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �b Parcel #_
Zoning Township
Owner/Contractor � � ,44� UFr� 5
Location/Address (' � r
Subdivision Name
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F ��`cJ�'�
Date r
Lot#
SEWAGE SYSTEM SPECIFICATIONS
S.R.#
Repair Lot Area S.7 � Size of Tank /�
SFD Mobile Home Size of Pump Tank /J �
Business # of �s s Nitrification Line �(qD � X 3�
f'nn-l-rhr��rs �s-4 {-;r�pY Max Depth Trenches o2(�, — d2$
Permits may be voided if site is
Well and Septic Layout by
Comments: �
ianged.
Date Installed by� ,�,� ����,,�s Approved by �
., pO 3-4 -9 i 3 2
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual � Semi-Public Required Slab C�
Public Replacement Air Vent �
Site Approved Required Wel( Log
Well Head Approved Well Tag
Grouting Approved %
Comments:
Date
Installed by
Approved by
This report is based in part on information provided the homeowner or his/.�`
representative in the application submitted fi�r this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on thE property or for statements in this
report that may have resulted frorr� false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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w �..,� �' . 6 AC . EXCLU D ING C ENT EL R/W � N • O S A .
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2 IF � CENTRAL TELEPHONE C0. ��'� 3 MP �4�'63,�W Mp NF
I�P ' UBSTATION RIGHT-OF-WAY 3g.0� � gp•06 �2 �� � - —
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" EOP IF 5��. �g� 44��W IF � � ' . �o�+D � -' �� MP � _ � -
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Date:3-/3�-� 7 '
Owner: � . � 5�
Location/Directions:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
. . .
SR#
Subdivision Name: __ Lot #
Drilling Contractor: P�. c��.�/,I Il��a
. WELL CONSTRUC`I'ION —
Distance from Nearest Properry Line /O Distance from Source of
Pollution /.Uo f
Tota1.D_ep.th:� /Yv Ft. Yield: ��5� GPM Static Water Level .s/ Ft.
Water Bearing Zones: Depth �_Ft. /o?v F� � Ft� �t.
Casing: Depth: From�to�Ft. Diameter: � Inches
TYPE: S teel - G alv anized S teel �–
If Steel, does owner approve: Yes No
� Weight: � Thickness: /�S� Height� Above Ground: l y Inches
Drive Shoe: Yes �-- No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement ,i Coricrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Me.thod: Pu.mped - Pressure � Poured .� - � -
Depih: Fr�m O to ozv Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes � No � � �
� �i ;c 4 slab i'es_� I�Ta
I HEREBY CERTIFY THAT THE ABOVE II�TFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON Cvui�T�' HEALTH DEPA. TMENT.
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; ,____ �. .____..._.
�. , i , _._ --_---
Signature of Contractor Da�c
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