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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Owner: _
Location:
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Contractor:
Water Supply: Private Public
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Sewage Disposai Facilities: No. bedrooms Dishwasher, D�isposal�,
washing machine, other �aut matic appliances �`����o�v' �[��,
Size of tank: 1 <<�' Nitriflcation line:
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Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state an� 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 HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE I� LLA ION IS COV-
ERED AND PUT INTO USE.
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�Date atrroved: � � 5igne
�]/J Sanitarian
Well: �ll1�
Sewage Disposal: 7� � r
By:
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� �Certificate of Completio
Date Approved: � �
Counter �' ' � �
�,yj signed—�t��� �_ ? r --
-f}-ti— (Owner or his representative)
anitarian
Location of well and sewage �al facilities sketched on back.
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WELL PERMZT
Caswell-Chatham-Lee-
DATE IS ED: . TE RILLED: 1
OWNER: R
ADDRESS: '� ��
DRILLING CONTRACTOR:
Counties
F COUNTY:
WELL CONSTRUCTZON
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft. Yield: GPM Static Water Level: Ft.
Water Beariag Zones: �ip th: Ft. Ft. Ft.
Casing: Depth: From V to .Ft. D' er: Inches
TYPE: Steel Galvanized Steel
If 9tee1, does ovner app��4� Yesg No
wei ht: Thickness•` � Hei ht Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting the Casing? Yes_ No_
If 'yes• give reason:
Grout: Type: Neat Sand1 nt: Concrete
Anr.ular Space Width � Inches
Water in Annular Space: Yes No "/
Flethod: Pumped� sure _Poured ✓
Depth: From V to � Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag � lbs.
If mixture (san� vel, cuttings) - Ratio: to
ID Plates: Yes o Chlorination: Yes No
,4 x 4 slab Yes No
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I HEREBY CERTIFY TfiAT THE ABOVE INFORlSATION IS CORRE D rHAT THZS
WELL WAS CONSTRUCTED IN ACCORDANC GULA ZONS FO BY
CASWELL-CHATHAli-LEE-PERSON DIST. PT.
Signature of Contrac o Date
FOR HEALTH DEPARTMENT USE ONLY
�REASON FOR NO INSPECTION:
Sanitarian's Signature Date
Sketch well locatioa on reverse side. Use established reference
points.