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The District Health Departmenf
CASWELL - CHATHAM - LEE - PERSON COUNTiES
Water Supply and Sewoge Disposctl
IMPAOVEMENTS PER IT
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Owner. d �- -
Location: G'
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Contractor:
Water Supplp: Private L- Pubiic
Sewage Disposai Facilities: No. bedrooms Dishwasher, Disposel�
washing machin o er sut atic appliances �
Size of tank: � Nitriflcation line: ��Q'�E
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must mee4 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 nitriflcation line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS GOV-
ERED AND PUT INTO USE.
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Date ap roved: Signe
tarian
Well:
Sewage Dispos : Counter-
aigne�
BY� (Owner or his representative)
Certiiicale oi Coaiplefioa
Date Apprqved: 5 "�� By�_.L� —�
- . Sanitarian
(OVER)
Location oi well and sewage disposal facilities sketched on Dack.
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� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
1 s�upplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSUED: �-' ' DATE DRILLED: COUNTY: Q YS n'1
OWNER: �1 . ROAD/STREET:
ADDRESS: � f ��,'{��D� � PERMI"T� V ID AFT R ONE YEAR 5�����
DRILLING CONTRACTOR: . _ ,Q�/(,L//y� �Ti I �X_�%
ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft. Yield: f�GPM Static Water Level:�_Ft.
Water Bearing Zones: Depth: Ft. Ft. Ft. Ft.
Casing: Depth: From � to�_Ft. Diameter: (,o Inches
TYPE: 5tee1 Galvanized Steel �
If Steel, does owner approv Yes No
Weight: �_ Thickn'e/ss�: � Height Above Ground:�a Inches
Drive Shoe: Yes: V No:
Were Problems Encountered in Setting the Casing? Yes_ No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement: ✓ Concrete
Annular Space Width j3 Inches
Water in Annular Space: Yes No
Method: Pumped Pressure Poured �
Depth: From Q to d�_ Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, gravel, cuttings) - Ratio: 3 to �
ID Plates: Yes l� No Chlorination: Yes No
4 x 4 slab Yes—� No
De th
From to Formation Descri tion
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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
CASWELL-CHATHAM-LEE-PERSON DIST. HE LTH DEPT. �
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S nature of Contractor Da e
��� Sanitarian's Signature Date
on reverse side. Use established reference
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