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. ,S PERSON COUNTY HEAtTH DEPARTMENT
SEWAGE DISPUSAL
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IMPROVEMENTS PERMIT NO.
aQ Issue Dates 'X' - �(_) � '(..'
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,�'t �ii '" W Owner: ~ t v1 V .` J� C.. L �> !~t I �Y
`-�` ' '�iT{ Loc t'on
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Septic Tank Contractor:� ,�_c,,_. ��d •��
Building Contractor: �
� water Supply: Private�Public
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:All wells should be 100 ft. from sewer system.
Lot Siza: / C��� �� C 1� i
Sewage Disposal Facil t}es: 1o. bedrooms ,�_
Size of tank: � ��� f Nitrificat'an line:
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Other disposal facilit�� 1
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Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line MUST BE INSPECTED AND
APPROVED BY A MEMBER OF TNE PERSON�CO. HEALTN DEPARTMENT STAFF BEFORE
ANY PORTZON OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS. `'��
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Date Well•Approved: Signe
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gp� �Sanitarian •
Da Sewage Disposal' Ap ed:_ ,,,,� ,��
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By, ( '(�^ S,�j-� signe � � �..TrC•vrfs,
'. • (Owner r h' zepresentative)
Certificate of Completion
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Date Approved: ���'!! �V �+ BYj�/�li�/�-�'� ����
\ Sanitarian '
(Over)
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. Location of well and sewage disposal facilities sketched on back.
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DATE �SSI
OWNERs_
ADDRES3:
DRILLING
Peraon County Health Department
Well Yetmit i
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' DATE DRILLED: C�11NTY:
�M ROAD/STREET. e;� � i17.{� I "' ')
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WELL CONSTRUCTION
Distance from Nearest Property Line Distance.from Source of
Pollution_ 9
Total•Depth: � 5 Ft. Yie1d:�GPM Static Water Level �;�/� Ft.
Water Bearing 2ones: Depth Ft Ft. Ft. Ft.
Casing: Depth� From�_to Ft. Diamater: /;, Inches
TYPE: Steel Galva�iized Steel ✓
if Steel, does owner approv • Yes No
Weight:1 ? Thickness:�Height Above Ground: /�. Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes_No L�
� If 'yea" give reason:
Grout� Type: Neat Sand/Cement Concrete
Annular Space Width Inches
water in Annular Space: Yes No
Methodi Pumped Pressure Poured
Depthr From Fj to �� Ft.
Materials Used: No. Hags Portland Cement Weight of
1 bag lbs.
If mixture (sand, gravel, cuttinqs) - Ratio� :' to 1
ID Platess Yes ✓ No
4.x 4 alab Yes l� No •
DRILLING LOG '
De th
Froin To Formation Descziption
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE
PERSON COUNTY HOARD OF HEALTH. PERMI,T VOID AFTER THRE$ YEARS.
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, Sig u of C ntrac or r.Date
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anitarian's Signature Date Issued
Saaitarian's Sigaature Date Completed
Sketch well location on reverae aide.
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