A23 80The District Health Deportment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewoge Disposal
. IMPROVEMENTS PERMIT No.
.Permit VOtD after 3 Years� Date�_� -�'�_.
�_._
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Owner: , S2 Y �� , �. � � ✓� ^ _
Location:
a ' c.�
Contractor: " ' �-'�
Water Supplp: Private Public
�s�r' :�� i'�F��rilY {S 1r'0!D �;F?"C� ONE YEf�R.
Sewage Disposal Facilities: No. bedrooms -� Dishwasher, D3sposel�
washing ma � other suto atic appliances
Size of tan : f _, , NitriBcation line: � "� '� � �
Other disposal facility'."' - I L
' � `: j� (Vj4?tti- i�t �%fiF!)1/:t�(
Water supply and sewage disposal facilities �location,�installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEf� b H DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INS7`A ON IS COV-
ERED AND PUT INTO USE. ! �
j �_� _.
Date approved: Signe
itarian
Well:
Sewage Disposal: Counter �� ���
aigned
B3'� (Owner or his representative)
Certircale of Completion
Date Approved: ,
anitarian
(OVER) `
Location of well and sewage disposal facilities sketched oa back.
NOTE:' Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
, supplies, etc. Note special problems existing on lot. Wrste i easurements in order that installations may be located
+� at .later date. Note location of water supplies on adjacent s.F�,
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� , y WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSUED: D E DRILLED:' ''���� { CO T
OWNER: � ROAD/STREET:�
ADDRESS: y G PERMI�' VOID A�TER
DRILLING CONTRAC OR: s. (tOA� '�r.l�l �nrJ� r�.i
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution y�
Total Depth: Ft. Yield: GPM Static Water Level: SV Ft.
Water Bearing Zones: De th• Ft.� �'%�Ft. Ft. Ft.
Casing: Depth: From��to Ft. Diame er: Znches
TYPE: Steel Galvanized Steel
If Steel, does owner approx Yes No
Weight: Thicknes/� :�1iS� Height Above Ground: ),�-3nches /
Drive Shoe: Yes: ✓ No: � �
Were Problems Encountered in Setting the Casing? Yes_ Noti�
If "yes" give reason:
Grout: Type: Neat Sand/Cement: Concrete
Annular Space Width �_Inches
Water in Annular Space: Yes No %
Method: Pumped Pressure Poured �/
Depth: From �_ to �_ Ft.
Materials Used: No. Bags Portland Cement'�Weight of
1 bag �lbs.
If mixtu e(sand, avel, cuttings) - Ratio: to
ID Plates: Yes�No Chlorination: Yes_tGNo
4 x 4 slab Yes Nos�
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I HEREBY CERTZFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGDLATIONS SET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. HEALTH T. �
Sig t o�r3Y ctor Dat
REASON FOR NO INSPECTION: �/!�! Y! !� V
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an�a�'i�Signatuie Date
Sketch well location on reverse side. Use established reference
points.
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