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Owner: r�
Location/Directions
�ub�':vision N�unc:
� Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL H�ALTH
WELL LOG
SR# / � � � -
Distance from Nearest Property L'uic ''' c�,..s Distance from Source of �
Pollution o d ,,�s
Total.Dep.th: =�.3 � Ft. Yield:_ �-o GPM Static Water Level Ft,
Water Bearing Zones: Depth �Ft, F� Ft. �t.
Casing: Depth: From D, to Lf-3 Ft. Diameter. G� Inches
TYP�: Steel � Galvanized Steel .�
If Steel, does owner approve: Yes No
Dri eht•�� �cJ"S�—���eight Above Ground: /� Inches
Shoe. Yes No
Were Problems Encountercd in Setting the Casing? Yes No
Ii "yes" give reason:
Grout: Type: Neat Sand/Cement � � Concrete �
Annular. Space Width 3 Inches
Water in Annular Space: Yes No ��-
Method: Pwnped � Pressure po�� ,J—
Depth: From �—to �r t.
Materials Used: No. Bags Portland Cement�_ Weight of .1 ba�_lbs.
If mixture (sand, gravel, cuttings) - Ratio: �— to 1
�ID Plates: Yes c� No � � � � �� � �
� 4 x 4 slab Yes �� No
I HEREBY CERT'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS �SET
FORTH BY•THE PERSON COUNTX HEALTH DEPARTMENT:
:
i
c-c/� � , % 3 -��
Signature of (�'ontractor --' Date
�
0
Person County Health Department
Existing Sewaqe System Report For: Hobile Home Replacement
��Addition
Requestee:
�r
f C _-UW .�0� L�%
�vYtD/�l /1/ C' .
Location/Uirections: � ��t
-r)� ,On►� �� nlvr-� �� ii �-, r�
0 riginal Permit Located �
Septic System Uesigne For:
Etesidential I3usiness
# Bedrooms `� # Employees
0
Home Phone# `��7 ��3y�
L
Business# ��
Q7/� ��'1 ��/l/j-Co
�
Other (specify)
llate lnstalled ��31--�i.� Water supply
Type oi System
Nitrification Line
Tank size ��
Other _,
_ �
Certified Operator Required �
On site wasL-ewater disposal system showes no visually apparent
malfunction on v! �/ -I ( _ r, ,
Yermission is granted to:
(� � G� ��
According to the attached site plan.
Comments:
0
l
A0��7
PEtZSON COUNTY HEALTH DEPARTMENT --- r
��TELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT .,.r ,1
T:tx Map # - 1-�L Parcel # � r]
�dr�ing Township ' �
Owner/Contracto �,�Gl Y •/ — , �, , r, / P Da � _ j� - �_�_��
Location/Address � �„ r,l �?.�-/�„� _.� . /��,�;� ev�t ro�,.� /.1� �'
sion Name�n���, �� �ri ✓;�r Lot#
rcT �oy, � �
rn��ri-,�,r,y„-�
S.R.# /�f�_/�c�r,�„�
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere . i tended se changed.
Well and Septic Layout by '�� ���,/Z--
Comments: �, ,.
Date / v -
te Approved_�
ell Head Approved
-outing Approved_
Comments:
Date
by j; r�,�„� Le,�„S Approved by.
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab L/
Replacement Air Vent
� Required Well Lo� _1
R Well Tag �
��
Installed by ,�l/ �1 �t s Approved by,
� �,, - 4 - .
This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this permi� The
env'uonmental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for slatements in this repoR that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the endvonmental health specialist warrants that the septic tanlc system w��l
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam Ol/95 rev.1.0
ORIGINAL