A23 109Person County Health Department
, well Permit
DATE ISSUED: � �DATE DRILLED: COUNTY:
OWNER: ROAD/STREET:
ADDRESS: � f'�
DRILLING CONTRAC R:
NAHE ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line .;%J ! Distance from Source of
Pollution •
Total Depth:���Ft. Yield: � � GPM Static Water Level {�� Ft.
Water Bearing Zones: Depth c�S Ft Ft. Ft. Ft.
Casing: Depth: From lj to��Ft. Diame'te/r: -� Inches
TYPE: Steel Galvanized Steel y
If Steel, doe owner approve. Yes ai No
Weight:��hickness: ,%��Height Above Ground: %8 Inches
Drive Shoe: Yes � No -/
Were Problems Encountered in Setting the Casing? Yes_No y
If 'yes' give reason:
Grout: Type: Neat f/ Sand/Cem� Conczete
Annular Space Width �� Znche�
Water in Annular Space: Yes No
Method: Pumped Pressure Poured_�
Depth: From d to 2 T
Materials Used: No. Bags Portland Cement�Weight of
1 bag�lbs.
If mixture (sand, gravel uttings) - Ratio: � to �
ID Plates: Yes��l��'
4 x 4 slab Yes No
DRILLING LOG
De th
From To Formation Desc i tion
1'2_ L -s'o �' e
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, �
I HEREBY CERTIFY THAT THE ABOVE IN£ORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATZONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PERMIT A• ER TH E YEARS.
r � �`�
i o Co ractor Dat
�-I 7-�7
i rian's S nature Date Zssued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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Per.son � County Heaith Deparr.iment .
Sewaqe System Improvemen#s. Permif-
Dats: ,� �rh'h��peaciiit Void Aftez3 Years: ..� - �,
Ovvner:_ � T�i°�� j��.��- �:
Locatio�ur;ectio�:��r� �
Subdivision�Namc• � � �/ e 5 _ L.ot#
Lot Size: _ .���� Type of Dwelling:.
Water Snpply: �Private: .—f�_ Publi� �� �
Semi Private• If not Private Tax Map# '
Parcel # oF Water Supply or Name of
Supplier# ,
Bedrooms: G�� ���
B2S8iI18I1C•. B�II1CAt F1XEI1Ye,S
INFORMA��N C�RT�7�D BY . •' }E/ /Y,r �L �i
va�uua►aa�4v'TD����4rA� / il�J(..-L,E/� owl1C! or TCPiP,3Cn18tIVe j
x�Pa�: R�EVAi..uATTON: _ _ _ _-- _ �
.._. _. `—;,.._ — — -- �-.... �. _........ `. _ , _.
Si�e of Septic Tank: gall ns �°
Nitrificadan �L;,�• � r �
Depth� of Stone: !2 inches
Max Depth of Trenchrs;�� ��j �
OPER.ATIONAL PERNIIT: yes no '—'
Remarks: � --:.;�..,:.,, .
..� ^���.�.������
Date Weil Approv ��Wel! should be i00,h. from any sewer system
BY Sanitarian
Date Se e s' A ved: �� •`
$Y � • Sanitari . .. �
�ATE OF COMRLEITON �
ContracWr.
--__--_ ___.:____...__________.--_ � '
Sewage System location, �nstal]ation. az�i prp�aon mtut meet state and Iocal �
regnlations. Septic tasilc s�n1d be pnmped out every 3 to 5 years and shall be
maintained by owner in such mazmer aa not W c�ate a public heaIth hazard. �
Sepiic tanlc and nitrificatian line must be inspecced' and approved by a member of �
the Person Covnty Health Department before arry portion of the insWlation �is
wvered aad put intu use. • fi�l
Locstion of sewage disposa! sewage system sketched on back, •. �. :.�
(OVER) . '� � •
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