A23 82� �'The District: �Health Deportmenf �:
ry CASWELL - CHATHAM - LEE - PERSON COUNTIES �
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-� s Water. Supply and Sewage Disposal
� Q IMPROVEMENTS PERMIT No.
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,� � Owner: ��j � R"'"�.-.i,e� ����-,r�_
� � � � Location:
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� E{/PS � _+(� y �`,a � -�-r
A ��•�'�-��1 � � �
. �% � Contractor:
� � Water Suppip: Private —� �blic
_ �.i7 _
�'o"vD]�l)'vei P1"v.
Size o1 tank:
---"----- _.
Other disposal facility: ' ,e
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Water supply and sewage dispo al facilities • location� install�tio��d
protection must meet state and local regulations. • `�
Sept1C tallk Should be pumped out every 3 to 5 years and shall be main-
talned by OWner in such a manner as not to create a public health hazard.
Septic tank and nitrification_ line MUST BE INSPECTED AND AP-
eme��+ nF.F RF A�EPOR770N OF THE IAI���'ALLATION i1s'MCF,QI�iYT
.
Date approved:
Well• -
Sewage Disposel : 5' �- �� ' •
Hy: �
C0!!i$C6t0 C� C0111DI0l�011
Date Approved: ��..(_
' �U �I L• A� '
Location. 01 well and sewage disposal facilitaes sketched on bac]c. . _
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. WELL PERMIT
Caswell-Chatham-Lee-Person Counties
1.DATE ISSUEDaI�/Z DATE DRILLED: COUNTY: L% �SD
; OWNER: � ' ROAD/STRE T:
:ADDRESS: � PERMIT.VOID AFTER ONE Y
DRILLING RAC O : �'��� •
" NAME ADDRESS _
- WELL CONSTRUCI'ION
�Distance from Nearest Property Line Distance from Source of
Pollution ^
,_Total Dept : Ft. Yield: GPM St tic Water evel:_�Ft.
Water Bearing 2ones: De th. t.�;_�gt, �� Ft. Ft.
�Casing: Depth: From�_to. Ft. Diame r, f
TYPE: Steel Galvanized steel �Inches
If Steel, does owner approve- Yes No
Weight: 1,� Thickness: (��Height Above Ground:��&nches
Drive Shoe: Yes= Na:
were Problems Encountered in Setting the Casing? Yes No_��
=f "yes� give�son: —
Grout: Typa: rreat sancl Cement: Concrete
! Annular Space Width �_Inches
� Water in Arinular Space: Yes No �/
� Method: Pllmped Pressure pourea r��
�.. Depth: From ' t0 � Ft.
Materials Used: No. Sags Port and Cement�Weight of
1 bag 9'L� lbs.
• If mixtur�(sand, gravel, cuttings) - Rafio:�to
ID Plates: Yes ✓ No ChlorindtioA: ygg (��•
4 x 4 slab Yes_��C . Na
I HEREBY CERTIFY THAT THE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED I CORDANCE WITH REGULATIONS SET•FORTH BY �
CASWELL-CHATHAM-LEE RSON DIST. HE TH DEPT.
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Signature of Con rac or � Date�' �
,� FOR HEALTH DEPART T E ONLY .
REASON FOR 'IVO. SPECTION: n _r��- �
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S arian's ' nat re Dat
Sketch•w._ 1 location on reverse s de. Use established reference
points �•
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