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PERSON COUNTY HEALTH DEPARTMENT � '
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # L Parcel # � [)
Zoning Township ��- �-i JE?('
Owner/Contractor � F��d Crc�,A�nl Date 2 ot �s
Lacation/Address %. g.�, ��� 3 ,�1�r� r., x_ f��a � t�P o n. �-•
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ision Name
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TIONS
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Repair Lot .Area �, "� � Size cf Tank /�?a0
SFD � Mobile Horr�� Size �� I'ump Tank �
��usiness # of BedrQatn� Nitrification Line "5 00' x' 3`
_v� _____: Max Depth Trenches ?�f
Permit Void after 50 mc�nths. P�?•mir �I�i�i if not in compli�nce with zoning regulations.
Permits may ye void�d i.f site is aitered or tend�ed u�js ch��n �.
{�lell and S��7ti.� Lay��a� b;� �,�_� G-
[:omments: Con`�C� �i _.�?�,,� ��� _:�SZ�tisl ��`-�
o . _ i i - i�� ��� . - ^ �`y`i� - � - - � ., I ., _ ,. , 1 �—
, Date '7� /� -- 9S Installed by_ �-.-�� � �App�oved by t.v��2�2 .� .�c�y,��
' WELL S'YSTE.�!� q��,C�'ICA1'.ONS
� Individual_� Semi-Public _ _ i �e�uired Slab � __ ___
Public __ Replacement __ � � ;r Vent �' _ __
Site Apprc��zd_ V__ __ ,�.F�uired Well �.,;�� v
Well Head ��ppr. ov�d _., f'��� �1� Tag _� ____
Grouting .Apprc���ed v� E w. n. !
Commer:ts-
Date �-S - 9 S Installed by ti �vu�c�o_Approved by w.�2 ,�:,���
Tlvs reporc is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this pemut 'Ihe
environmental heaith specialist is not responsible for false or misleading info�nation conTained in the applicatioa The environrrtental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist watranfs that the septic tank system will
continue to function satisfactorily in th� futLrP or that the water supply will remain potable. c:�amipro�pernrit.sam O1/95 rev.1.0
ORIGINAL
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Date: �r�� �
Owner: �l�i, �tj�F �
Location/Directions:
Subdivision Name:
Drilling Contra
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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Lc�t # ��
Distance from Nearest Property LinetiM�✓i tC1 � Distance from Source.of
Pollution .IOFJ �
Total Dep.tli:�$S' Ft. Yield: -� GPM - Static WaterLevel �� Ft. _
Water Bearing Zones: Depth �' '. il Fr. j�",1Ft�l�Ft� �� �t.
Casing: Depth: From�_to�Ft. Diameter: �..;. as Inches
TYPE: Steel - Galvanized Steel 1--� �
If Steel, does owner approve: Yes �----�10 G
� Weight:_�� Thickness: .Height�Above Ground:� Inches
Drive Shoe: Yes c_---- No � � -
Were Problems Encountered in Setting the Casing? Yes No `_..
ii "yes" give reason:
Grout: Type: Neat ` Sand/Cement '-- Coricrete
Annular. Space Widch � Inches
Water in Armular Space: Yes No �---
Method: Pumped Pressure Pouied ----- �
De� �: From - � to �yt`Q-} Fc. �
Materials Used: No. Bags Portland Cement�� Weigtit of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes '� No � �
� 4 x 4 slab Yes �� No . -
. � � DRILLING L(�G
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
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