A40 41. ----__ _
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.. �.. _ a . __ _ . __ . ..
� Peraon County Health Department
. Well Parmit .
P. �..... ' 1
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DATE ISSUED p� �D TE DRILLED� COUNj�(: � ' q ;-.
OitNERa AD/STREET. • ' .� ' �
11DDRESSx • � • .
DRILLING CONTRACTOR: �,.�.' ,
� NAME ADDRESS i
f ��
WELL CONSTRUCTION . " �
Distance from Nearest Proparty Line Distanca from Sourca.of ,
Pollutioa � , • `
Total�Depth: t. Yield• GPM Static Water L� al Ft.
Water Hearing Zonas: Dep �Ft. ' Ft.
Casing: Deptho From to t. Di e r: Iaches �
TYPE: Steel • Galvanized Steel \\
=f.steel, does owner•app Yes No � �
Waighti Thickness:�eight Above Ground: inches
Drive Shoes Yes No '
Were Problems Encountered in Setting he Casing? Yes_No �
If •yes• giva reasonx � �
Grout: Type: Neat S c�Cement Concrete '
Annular Space Width ���� inches ;
Water in Anaular Space: Yes No 1� ...
Method: Pumped Pr Poured• � �
Depth: From to�_Ft. _�. • `
Materials Useds No. Bags.Portland Cement Weight of _ • �C� �- �
1 bag lbs. � '
If mixture (sand, grav6l, cuttings).,- Rat3o: to __. "
ID Plates: Yes � No ' I. �
4 x 4 alab Yes� No • i �
DRILLING LOG - , . . �. __ � ;
. De th �
' Prom To Fo 'on D cri tio i �/1 � �
: � � at � � . v J �
� . .
' . �
I HER88Y.CSft�'IFY THAT TtiS ABOVE ItlFORMATIO IS CORRECT AN THAT THIS ' a� ,
WELL 91AS CONSTRt1CTED IN ACCORDANCB I SET RTH HY THE � '�
PERSON COUNTY BO]►RD OF I�LTy. PE � tjR�i�i � . . . . . , � � �
� ' � _ , . . .. ,s�.,..
• . . . . ' r4..
Si u o Co tractor Date .
. � �
itaria 's qnature Date Ias d � , " ( �'� r,` • � .
� �i • ; ..
;j .. _
�
Sanitariaa�s Sigaature Date Completed i •
Sketch vell location oa reverse side. �
I
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_ ~ The .Disfric� Health ' Department
, .
�'i.' Oraa , �Persoa Cha3ham, Lee Counties
I;SS�'�:; . : . � .
iS,;��,- •. ' ' � .
'��� � SEPT'IC tANK PERMIT
�: �
. . � Date �.•�. ��'` .�` ..�
�
. _ Nazne of owner ��`"'aw .+' � . ,..�� ��' ,�. .y�.
— . • �, € 3 o F � �?x,r` � "' r`�,,, 1� „ f
m�..r ,
Address. and Directions •° �"' '„. �' �'' ., ; � ':.
�Person o� 'fu�m;doing installation: ` ; '° �-. � ; f': �'.` � �'" "_ ��:
1�ddTPS$ � �" - 9 ai 7xF v.�+ii'.a.4'.x:' �,
p J. �
No, of persons to �be serve� -�---�� bedrooms 1, 2,�'yy4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Aequirements: Septic . tank _ �fJ
Nitrification line: _�,:- ,.> '� �;'� s� Y,i �.�.�".
Septic tank and nitrification line mus2 be inspected aad appsoved by !
a member oi the iiealth Departmeni slaff beiore any portioa 'of the' "': .
installation is covered. _
Date Approved: ,, �
• i l • � V' f � ,,,,,, ��• ; ,
p. ,� ,`�.j¢ +�� '='s' :�»
„-- ll. � �ii , % �i,/ Sanitarisn �
Countersigned
O. David Garvin, M.D., 1VI.P.H.
District Health Officer
(Over)
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