A23 149z
Person County Health Department �
. ��wage System Improvements Permit
Date:J��iThis Permit Void Af[er 5 Years Permit #
Owner: SR� ��
Location/Directions: _ / i
Subdivision Name: Lot # G
Lot Size: ype of elling:
Water Supply: Private: Public: Community:
Bedrooms: _�_ Garbage Disposal
Basement Basement Fixtures
INFORMA N D B�L
$��an' er tive
REPAIR: REEVALUATION:
--------�--�f—��----------- ---
Size of Septic Tank: –�.�%q,�— gallons Size of Pump Tank:
Nitritication Line: / / •
Depth of Swne: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: - /�
Date Well Approved:
BY
Date Sewage System Approved:
- �P� �.Ld Y�-:� s.e�`--
Well should be 100 ft from any sewer system
Sanitarian
BY Sanitarian �
CERTIHiCATE OF COMPLETTON ,�
Contractor. �
------------------------- �
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person Counry
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revceation.
(G.S.130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOT'E: Make sketch of installation showing lot size and shape, location oi house, septic tanks, privies, water
supp'lies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at l+�ter date. Note location of water supplies on adjacent lots.
(�i
(Z)
m nnn,.
■����������■��:�����������■
■�������o���■�,�■■��■������■
■�������������■■�������■■�■
■������������■■�����������■
■��������■�■■��■■��������■■
■��■���������■���������■�■
■�■■�■�o��������������■�����
■����������������������■��■
■�������������.��■■■■��■���■
■�����������■ ���������o��■
■■�����������■ ���������n�■
■■������������■�����■��■��■
■�������■ � �
..
� �
+ ��
Site,Evaluation Application
�Fee Collected YES !/
��1 , �2-1L-��
�
Date : /� ����
NO
APPLICATION FOR IMPROVEMENTS PERMIT
1. Permit requested by: owner/prospective�s��"
, agent:
Address:
Home Phone �� :
fvZ�o N
2. Name and address of current owner:
Business Phone'�:
3. Property Description: Lot size: �6 6,�
�
4. Tax map ��: Township:
Subdivision Name: C�� �� it, �t, ,v Lot ��:
5. Directions to property: State Road �� & Road Names, etc.
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width:
Depth:
C
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? � public?
Other source? (Specify):
Are there any wells on adjoining property?
11,
community? spring?
lt so, iaentity location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A- 5(F)
gned wner or Autho zec� Agent
z
H
�
H
w
x
�
w
�
�
r
0
r+
m
Iro
�
n
�
r•
rt
�
I'ermit Issued
Permit Denied
Plat Observed V �
�
, � - -- -__ _ _ .-
�
:
r
k
," �
FACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (X)
:�, SGIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTUEtE (12-36 in.)
(Clayey soil.$) �
�. SOIL DEPTH (in.)
�. RESTRICTNE HORIZONS (in.)
(Im�ervious Strata� rock)
o. SOIL DRAINAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMF.ABILITY
(Percolation Rate)
8. OTHER (specify)
S
�
S
�
U
� .
U
S
I��
S
�
U
S
PS
u
S
�
PS �
S
�
PS
U
U
S
�
PS
S
PS
u
S
S
r�
�
U
S
�
S
S
PS
U
S
PS
�T
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
u
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Prbvisionally Suitabl.e �.•U - Unsuitable
R�COt�4ENDATIONS / COt41ErITS :
�TTE CLASSIFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas, wells, water bodies, slope patterns, etc.) �
� Iica4ion Date• a�'� `D(
Amount Paid: �dc�
. �ecefot #: `��S—
�•
Person Countv Heaith Department
Environmentai Oiealth Section
APPLICATION FOR SERVICES
Tax flAa� #: !'� � 3
Parc�! #: � � 1
IF THE INFORMATION IN THE APPLICATION FOR AN I_iUIPROVEMENT PERMIT IS FALSIFIED. CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEiVIENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Permit requested by: (Owner/agent/prospective owner): .��i��9 �Gi.t�w> ��ycfc��C C/
Home Phone: Address: �� �w�G7-�J
Business Phone: _ �, ,6�d
2) Name and address of current owner: %� /�C_�
- /� ' , �c.
' oc c - / � ,�C 2'�'�3 Z�
3) Property Description: �ot size: � Township: vU'��t'%�� �� ..�
Directions to the property Inclu ing road names and numGers): ��c,o�S7 Ga �c�y�/�'
/t T — < <r .;c. t� v.L ,;� �fi�i�. . !r-�os-�
4)
5)
�iu � ! T2-' c</ / u. . 7�G2.�a�-� /9�� •L.�C�FT �c��
/4T �d.�i�LCC� �9sfici�+
Proposed Use� Structure Description: answer each of the following questions:
a) Proposedld; Ex�i ing ❑
b) Stick Built [�,.fOfOdular ❑ ingle Wide 0, Doubie Wide 0
c) Number of Bedrooms: d) Number of occupants or people to be served:
e) Basement: Yes 0, If yes, # �asement fixtures:
fl Garbage Disposal: Yes O,
g) Dimensions of Proposed Structure; Width: ,� Depth: �
Water Supply Type: Private ew ❑ orexisting ❑), Public �, Community �, Spring ❑
Are any welis on adjoining property? Yes ❑ No � If yes, location
6) Please Indlcate Desired System 7ype: (systems can be ranked in order of your preference)
_Conventional ,_Modified Conventional _ Alternative _Innovative
Other (specify):
CLE�4RLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAfV TO THIS APPLICATION
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposat system for
the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as applicant, I am responsi for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County alth Department to conduct their evaluations. I understand that I am responsibfe for notifying the
Health Departmen .if my op ontains any wetlands as designated by the Army Corps of Engineers.
. ��
wne or Lega epresentative Date
PCHD, rev. 10/12/99
, �
�
+' ..
���.
���..;�.;�.
�i �:;
- - • •
�� ���
PERSON COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH PROGRAM
� � 2Q-B Court Street �
Roxboro, North Cazolina 27573 :
Februazy 22, 2001 (336) 597-1790 -
Mr. Clyde Kelly
Oakland Ltd.
P. O. Box 1033
Roxboro, NC 27573
Re: Applicat4on for Improvement Permit for wastewater system at Kelly Ridge S/D
Lot 2 owned by Mr. Daniel Pegg ,
Dear Mr Kelly:
On February 15, 2001, the P.erson County Health Department, Environmental Health Division evaluated the above-
referenced property at the site designated on the plat/site plan that accompanied your improvement permit
application. According to your applic�tion the site is to serve a three bedroom residence with a design wastewater
flow of 360 gallons per day. The evaluation was done in accordance with the laws and rules governing wastewater
systems in North Carolina General Staturr_ 130A-333 and related statutes and Title 15A, Subchapter 18A, of North
Carolina Administrative Code, Rule .1900 and related rules. ,
Based on the criteria set out in Title ISA.. Subchapter 18A, of the North Carolina Administrative Code, Rules .1940
through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system.
Therefore, your request for an improvement permit is DENIED. The site is unsuitable based on the following:
1. Soil depths to saprolite unsuitable (Rule .1943).
2. Unsuitable Topography (complex�slope patterns) (Rule.1940)
3. Inadequate Available Space (Rule.1945) .
4. Soil Morphology (unsuitable soil structure and clay minerology) (Rule .1941)
These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated
sewage on the ground surface, in surface waters, directly into ground water or inside your structure.
. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative
- systems. However, the Health Department has determined that none of the above options will overcome lhe severe
conditions on this site. A possible option might be a system designed to dispose of sewage to another area of
suitable soil or off-site to additional property..
For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall
not be issued for this site in accordance with Rule .1948(c).
However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABLE if written
documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. Yo� may
hire a consultant to assisst you if you �vish to try to develop a plan under which your site could be reclassi�ed as
PROVISIONALLY SUITABLE.
. ' You have a right to an informal revie�v of this decision. You may request an informal review by the soil scientist or
environmental health supervisor at the local health department. You may also request an informal review by the
N.C. Department of Environment and N�tural Resources regional soil specialist. A request for an informal review
must be made in writing to the local health department.
• You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition from a
contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. �
To get a copy of a petition form, you m�y write the Office of Administrative Hearings or call the office at (919) 733-
0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23. and all other applicable provisions of Chapter 150B. N.C, General Statue
130A-335 (g) provides that your hearing would be held in the county where your property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form witty the Office of Administrative
Hearings WITHIN 30 DAYS OF THE.DATE OF THIS LETTER. Meeting the 30 day deadline is critical to
your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review
that you might request. Do not wait for tlae outcome of any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you aze required by
law (N.C. General Statute 150B-23) to send a copy of your petition to the Narth Carolina Department of
Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Depaztment of
Environment and Natural Resources, 1(O1 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health department. Sending a copy of your petition to the local health department will
NOT satisfy the legal requirement in N.C. General Statute 150B-23 that you send a copy to the Office of General
Counsel, NCDENR.
You may call or write the Person County Environmental Health Department if you need any additional information
or assistance. '
Sincerely,
��'
L � �
Michael E. Cash, R.S.
Environmental Health Program Specialist
Environmental Health Division
Person County Health Department
Cc: 7anet Clayton, Environmental Health Supervisor
Marc Kohlman, Health Director
Daniel Pegg, owner
�
A�
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG550000
���
'�1�3�fo�
�
TO DISCHARGE DOMESTIC WASTEWATERS FROM SINGLE FAMII,Y RESIDENCE AND OTHER
DISCHARGES WTfH SIMILAR CHARACTERISTICS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
DA1vIEL R. PEGG
is hereby authorized to discharge wastewater from a facility located at
Lot #2, Kelly Ridge Subdivision
Semora, North Carolina
Person County
to receiving waters designated as Hyco Lake, stream class WS-V & B, in the Roanoke,River Basin in accordance
with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I, II, III and IV hereof.
This certificate of coverage shall become effective August 3, 2001.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day August 3, 2001.
� ��� ��!�' "i i ��
Q������ _,. ., �
1h��1C�;:� ��, � � '�►`„"S
Greg Thorpe, Acting Duector
Division of Water Quality
By Authority of the Environmental Management Commission
Latitude:
Longitude:
USGS Quad #:
River Basin #:
Receiving Stream:
sue� ci�s:
36° 31' 18"
79° 03' S5"
A22SE (Alton, VA)
03-02-OS (Roanoke)
Hyco Lake
ws-v � s
t
N
•
Pegg Residence
Lot 2, Kelly Ridge Subdivision
Semora (Person County)
NCG551141
04/12/2667 11:48 3365991806 JIMMY LEWIS
�Apr 1V, 2�D1 11;42AM �uar�e �(. ;t�r3�t 8� �1s:oc, ,'
�
,�
�� ne K. Stewari
; , SaGwifS, INC.
>NiYLl1NG
�QINEIR!
Clvil . $qnCC.'i
�rn'v�n�sYtltp�
1onn,rc� � Cr��q�
�ixnli �vo: 1� C� �'! 1�}�
Permit Name: Vfnc�nt VWYTS
ENC3IIVEER'S ��R77FrGRTJQ
I1�Ih�.I��
ti: �c�9 F. ?
i�� ���y ����
!, �ry�n F. Staley, as a duly regisf�r�d Proksslan�! Engineer in the Stafa
of North Camlln�, havfnp bean author�zed tn observ�:
� pertndlc�qy ❑weekly �]iutl timQ
fhe conStruCtio» of fh� pro]ect, Vincerrt WWTS� for ihe Permlttee, hersby
state th�i to the besf of my abilities, due r,�re and dilipence w�s used !n
the observ�tlon of fhe constru�flpn such lhaf fhe consfruction.was
obsenred fa b� bul/t withln substanfia! compll�nce and irrterrt orthe
�pproved plans and specf�catlans.
Sigrretur�e: � Regigfr�iion No. 25449
ry�n F. St�ley, E
Dete: 4J7�l02
cc:
is �����t��y ��:,�
irham, NC 27707
;919� a90.299�
X �si�� a90-61c5
Iil: '��O�aSS4isi.cJm
IWW. � IG5Af5'. �DIi�
_ ~ SE.AL � :
_ -
= a:a•�9
:
�,�„ *�,�,��
�'� "'�� F � .•�
�►•,,,,�n�•,�r•
���/�
Aoalication Date: %�� C�.� �
Amount Pa1d' � v
ecei
� � �� ���_ � ���.� ��
. . �C � �TZ�''� �'
��.�.a-.m---,--�-� ����. �.Q�.�.
rax Mao #: �� 3 .
��i �. 1 � `�
APPL1CA710N FOR SERVICES
�
1) Permlt requ ed b:(Ownerl�ent/pr+cspective owner): ��� � I S S
Home Phone: 2 -o �� l � Addt�ess;/ � 2��f 5.�
8usiness Phon 6 0-� o Z. S..�
2) Name and address of ct�ment Owner: �h n! ' � 1. S�3
� 2 �� �.L�.� r �}— ,-
. �s � 2'?�ts� .
3) -Property Description: Lnt size: Townshlp: Subdivision: ���.1 � i��� Lot# �
Directtons to the property (Induding road names and numbers): •
4) Proposed Use a,r� d Structure Description: answer each of the foilowin qu�i ons:
_. 'a}� Proposed ✓ Ex�sHng , Type of�Struc�ure: �� .� �c r Width: Depth:
•-' b) Number df Bedrooms:' �_ Number af oc�upan or people to d se�ved: -
• • �) �Basemeri� Yes .�No �WUI the� be piumbing in #he basement? :
' • . d) 6a�bage Oi�posai: lfes , Nu � . � .
5) Water Supply 7'�►pe: Private _(new • or existin , Public . Communityy_,, Spring
� � Are any welis on adjoining property't Yes�No _ tf yes, please indicate approximate loc�tiori on the
'site plan. � .
6� Does ycur property cant�aln pr+eviously identifled jwisdlctional wetiands? Yes_ No ✓,
PLEASE NO'TE THE FOLLOWING: ' '
➢ A PLAT OF THE PROPEiiTY OR SRE PLAN MUST BE SUBMtT�ED WITH THIS APPLICATION.
➢ PROPERTY UNES AND CORNERS MUST BE CLFARLY MARl�D. •,
➢ THE.PROPOSED LOCATI�N OF ALL. STRUCTURES MUST BE ST/4�D OR FlAGGED. �
➢ THE SITE MUS'� �E REp►DILY ACCESSIBLE FOR AN EVALUATiON BY THE HEALTH DEPARTMENT
STAF�. ' , '
I hereby make appilcatlon,to #he Persan County Health Lepartment ior a site evaluation for the an-siie sewage disposat
system for the above-desctibed proQerty. 1 agree that the canterits of this application are true and represerit the maximum
facii'�i�as#p be piaced on the property_. I understand ifi the site is aitered or the intsnded use changes, the permii shaU
�
or Legal Represerrtative
1 f� � �
Date
��.... ._.. nelMff��1
_��� �� ���� ��
�,� ������
IIEm�.a-�� � ���.]t IHL�.�.Il�.
WEI� PE�'T' .
i'I.E�E S�E A'1'I'A�D P� ��I� �PE� sY'� �'i�Ot7'�C
'�ax l�ap #: � Z3 Parce3 # �_ To�vnship
�Plican��f nl ►J i S �� � t� s s .
Saabdivision: t� L�/ � nc S 5ection: Lo� Z
�
. I.mca�ion: � �
�
� . . � �. �i�► . ,� � � i.. _ i /`
G°� /s ��� �'i✓a y �Qo� .
�'�e �f Water Su�e�ie: ✓ Indiv�.dual Community Public
�8e�u�aneasffi• '
Site Approved bp �J�S ' � 2� 6 �
Grouting Approved bp
Well� Log .5S 2 -I 3—�
Vi1ell T ' � � �
Air Vent
Hose B�
C�nc=ete
�►wp I
Welll I9ri
��� - I , :. • • - .; ':' ,���. .is. �./ i. _ !: ,
�
'�See Attac�aesi Sit�e Sketch�
Wells must be 10 f�et from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from aup builditig foundation.
Other conditions- -
PC.��, rev. 09/07/Ol
,: � � . �V f-�- �£,en^, ��--
.L���� �� ���� ��
�. 'ti"a
� ^ � `�.S � �i.J .d. V` 1L �l.
7E����� � ���.�.Il IE-Z�.�.Il�
' Si'�'�. s��.'g'E�.
Name ��'r.l �[ ► S � u I i s s 'Taa lYla� #� Z�� Parcel # 1�-9
Subdivisio - � Section/Lot# z- _
_Z /9 D �
Autho ed te Agent � Date .
�� Systerr: componen�r rgpresent approximate�cantours onl,y. The contractor must, j`lag t�ie syst�n prior to
. beginning idse instaAation to insure thut pro�iergr�ide i.s maintasned :
r._... _ ._ __. _____._. ..___ _ -__ __--- -- -.. _._._ --------_..,_- -___ , __ _
r" G'HLURiNA7(3F2-i------ �
/ CONTACT CHAM�R �
i � -� --- -- - -�'��3,3 ` � �
/� �
i �
. HYCO IJ1KE � VEKi - � `- � ���
� NORMAt. ELEV. = 410 � i '! $,8'�e�,2%!, - � ,�,' 5.24'' 22� � � , . 27 s�, ►7; � \
i�� "t.�i ��o(a� cP�i o 1� ' � 25.00' 95. o � --- � �. �
� LAKE HYCO, Mr GREG OHMDTEQE / . \ \�
� PH 1-910-599-1174) ,' � '` I _ '
� � � ) �6 x � \
. �' i � CON� DISTRIBUTI01 BOX ' '
`�� �, i / D/ LTER SEPTIC i4Nl(
�-- � � (� 8 28 (1�250 GALGON) .
/ ` / PRI � SAND FlL RS • � ' •
/ / yENTS � .- - _ �
. % • __ - .�-- l
� '� '' � ^%` �� M� r� q\ �
� . r I �� �
�oo' M� 'Zo P� W�u'. / � � I , ^ -----c�� out �,
I , �s ' �
�
. . � � � f o,��A ��o ��E � o \\
•� • � � � i ' ,# gEp N ?ROP, � °� �
/ `'� / H��S 00 � M �
� ` �� � 4p��E' I z 4�� �
� i' .' �
�' � I ' � �/
, � ,
/ I ' ._- -'--'``., I ��j' / �
!80 ` �� I // � - \�� ' � / �
r
/ / ��.o",..�'`'�'F� / �
� � ( •`I ��.1�. �g,`� �� ..' 1
; ;\ � �-� i `� .� /
1
// � � � M _ � , ,
/ � I
� � , \ �
, ��'!1� �(I��?O/YS� // ;n / ' � ��_ � �
�t / 1 / - �a ,
Go�✓,�;� �" � I %"
��� , Z _ _ �d. � : ��
r. �s�i�-i ��o �� ` , � �
�!° � i - ,,! z° � .
� . w I `1`:. ' .
� O - ��'':,� �, `
�- � `� i
• ��
.�
,� � N I �-------.�, - �,
_ .-,.- ..�:-,:.. __ �� � � � p��� �3 ��� `�
�-�� � �.� ���� .����.� � ��/!p����,�,�9,�{� � , s �v ��t r�(�^y��/')
�v.-V'�"4 � ' _ � r�^a�""""' �• �J'
:..,��_:.�., � - � j2 ,�
. : :. _ -;���:����-���=�:� � � �. _�.
..:� . �_ :_ �::=��.+.:::: . y�� �C.�T7� o
�"[.�''rxn.-'���r�]r3C�8�{?-'�'Y.:" .iL7t��;x+,�' .. .
. � I� ,�,,�
Grout Log . � J�/""" �
Jwner: ^ � �% � r`S . . '��� ` . ' T� M�p�� Paz+cel # � � .
.ocation: Loi # _�- � �!�
�ub�division:
WeIl Conslracbo�
)istance From neazest Ptoperty Line (Iv�imoum LU feet) /5' � -
3i.stance fiorn SePtic SYStem {bi''a"m'�m b4 feet) _ r� �- �_ -
Cotal Dept� �p_ ft Yeld: ��_ GPM - Static GVat�er I.eveL• _ 2�� R
Water Bearing Z�= �P� � 5 ii 2 Ga ft ft ft
i
pcp� rom_.Q_.,._.�� 2 �. Diam+el�r:��-m '
(',-dtv�ani�d S�eel �
r�. Wei� /•� Thic�ness: !g- Height above Ground: �� � �
Yes Na Any problerns eacountered wiu'le settimg casing? Xes �/No
Drive Shoe: �L -
If "yes" give t�eason: , .
Groat: Concrete G�a.veUCemen.t � _
• Nea� Sand/Cement y�, ✓No � �
�•. Aimular Spaoe Width • ?� _ inches w � �- �� . � F�
1Vlethod of Gro� Pu�d � . .
Materisls IIsed: ' Pottland ccmen.t �� w��t o� 1 Bag �'� Pounds . -
No. Bags � �
If �(sand, gravel, cut#mgs) - Ratio 1p • • .
ID p�� ���No 4 a4 slab t/'SCes �No
Liner: � �� Date �nstalled: ��. Grou� �_^., �nstalled bY•.
�P
Dr�iag Log
yocation Drawing
n To �ormation
� -
lO � �
'L � ' �'
a s� • �- �
� � � a
. � �a�n�;i'!i4' �
� �
I ce�tifY t�at the above� iuforsnaiioa is con�ect and ti�at ti�is �well was � m�Oe ��ations s�t fa�rth.
�Y .
by the Pr,rson County Heatth Depar�emt-
�� _ ,3 ?� - Date . Z �� _ O
S�gnatnre of Conbracbur _� � g" L.�� •.� ID# 3 �
. � p�P �s�Ilment
Ins�aliation Contractor: iU/�_F� n� e� [.� e ��� � Lr�-� S� R��an Number. 3 3 7
Pu� � , $
pu�p De�t�L _. /'� o ft Sfiatic Water Levei• 2 5 O
�'tnnp Makre & MvdeL• lJI.SP b! S t�.. � _ P� Size and Rating:_�_hP � �`
ed and S�e wel��d camPIe3ed �casc� �Y'�eTf Rules m eff�
I hereiiy certifY t� � P� was insbll
on this date and that a cagy af t�is recozd bas beeu grovided to-the well owner_ -
�. � � , ga�; - -~ � -`D `7 PCHD rev 01/271Q4
pmu� instalter S�gnat'°�e - - = _- -- - - - - .- - - -- -
6'd 9LZ6-865-9�€ auauae9 '� Uifa�i �O1:80 LO �l 4a�