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A24 56« s Lot Size: Sewage Disposal Size of tank: PERSON COUNTY HEALTH DEPARTMENT SEWAGE DISPOSAL Other disposal facili IMPROVEMENTS PERMIT NO. Issue Date: � � � � � Ownez: C Loca ion: r 3�, o WP✓ 1 ` P<' , Septic k Contractor: • Building Contractor: Water Supply: Private Public All wells should be 100 ft. from sewer system. I�o. bedrooms Nitrification line: Water supply and sewage disposal facilities location, installation and protectiion must meet state aud 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 czeate a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND APPROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO US . THI PERMIT VOID AFTER 3 YEARS. Date Well Approved: Signe gp; — Sani� ian, Date Sewage Disposal Ap roved: / _ � Counter- y i_ /�' , gp= �' signed r ��� - : � , (Owner or hi representative) Certificate of Completion Date Approved: � /�j �� / B : � anitarian o � (Over) Location of well and sewage disposal facilities sketched on back. � \ Pr �o�r,� � v- ofF SQ�-/3l� 3') -� �1��11 Person County Health Department Well Permit DATE ISSUED:�J `r) l� E DRILLED� r� ��� C OWNER: ADDRESS: DRILLING CONTRACTOR: -P rse NAME ADDRESS , - WELL CONSTRUCTION Distance from Nearest Property Line Distance from Source of Pollution Total Depth: i_Ft. Yield:�� GPM Static Water Level Ft. Water Searing Zones: De h Ft. � Ft. �� Casing: Depth: From��to� Ft. Diame�,er�nches TYPE: Steel Galvanized Steel �� If Steel, does owner apg��: Yes No weight: Thickness:� Height Above Ground: Inches Drive Shoe: Yes No Were Problems EncOuntered in Setting the Casing? Yes_No_ If 'yes' give reason: � Grout: Type: Neat S /Cemen Concrete Annular Space Width Znches Water in Annular Space: Yes No " Hethod: Pumped P s re Poured�� Depth: From �to� Ft. llaterials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, g�r}vel, cuttings) - Ratio: to ID Plates: Yes V No 4 x 4 slab Yes� No DRILLING LOG De th From To Formation Desczi tion ��J� oe., � ��� � I HEREBY CERTIFY THAT THE ABOVE INFORMATION ZS CORRECT . WELL WAS CONSTRUCTED IN ACCORDANCE TH REGULATIONS SET PERSON. COUNTY BOARD UF HEALTH. PE�VOED_ AFTF�t/Q't1REE ian's THAT THIS TH BY THE Date Date issued Saaitarian's Signature Date Completed Sketch aell location on reversa side. —, _ . _.._.. `.__�..� �� __ u_,��. �. `"`� CJ�� �v ,.✓ � � ,. � �s, 15� - ,,. _ _. . �. !$ . f �: �j ��� I�r*c ���-� of� r, i :` �nnti+ GAilA11NA nPPA�iTMfNf Ot nn1�Mn�.r�rn�nn�..�-� �.•v..��•—�•�•• ��-•---.•.^ UIVItl1UN UF tNV111UNfAtN1AL h1ANAUtML-NI - U1IWNIJWAICJt bL-(iIIUN ' P.O. eOX 21881- RA�fitiH.�t•C. 2te f t, PHOAlE <81Q1 733-bQe3 WELL CONSTRU�TtON RECORD � Qusd. No. 8erlai No. Let. _ Lonp. Pc_ Minor Bestn Basfn Code Header Cnt. aW'� �^t•— RiLL1NG CON7RAGTOR RANKIN r�JILLIAMSON,INC. STATE WELL CONSTRUCTION RIL.LER REGIS7RATION NUMBER .�� 48 PERMIT NUMBER: WELL I.00ATION: (Show sketch of the location below) Nearest Town: Cou�ty: 1�,�5� Depth DR1tl.IAlG tOG (Road, C mmu ity, oc Subdiv ' and Lot No.) From To Formation OescripUon UWNER ��-� �� � �� M J� C C K � AODRESS Strest Or Routa No. - — Stale Zip COde r � �� DATE DRILLED y�Tf� USE OF WEIL�� � TOTAL DEPTH GUTTiNGS COttECZED Q Yes � No - DOES WELL REPLACE EXISTING WELL7 ❑ Yes ❑ No S7ATIC WATER LEVEL: FT. Q above 70P OF CASIN(3, p below _ TOP OF CASIN IS�.J FT. ABOVE LAND S,URFACE. YIELD (gpm): � � METHOD OF TEST � � � WATER ZONES (deplh); CHLORiNATION: Type �._. Amaunt . CAStNG: Wall 7hickness . ft addsti�na4 space is needed usa back of form. Deplh Dla tter or Wei ht/Fl. at�rial I.00ATION SKETCH_ From _.��1____ To �� F�•='— _'�"`-- ��� (Show direction and distance from at Ieast two 5tate Roe or olher map retetence poinls? From ________ To Ft.— From To Ft• - GROUT: Material Method Depih From � To�Ft• �M� From 7a Ft. _ - ?. SCREEN: Oepth Diarneter Siot Size Material From To Ft. in. in. f•r�m To Ft. in, in. From - To FL _ in. in. 3. GRAVEL PACK: Deplh Size Malerial From �To Ft. . - From To Ft.,� s. t� � �� 4. REMARKS: 1 DO HEREBY CERTIFY THAT TNIS WELL WAS C CT OIV'Q� OROHE WElL10WNEA CAC 2C, WELL CONSTRUCTIC STANDARDS, ANO THAT A COPY OF THIS RECOR !'eraru�c <:uunty ttoattt� t�eNrctmaiit , J'�II�� !�_,l��oll Permii �{� � N�v DATE ISSUEGs v� S� + W►TE ORILLED! _� � CWNTY � 1'p rS� OiM6R: ,^ J� � �OAD/ TREETi ' r �Y'�' { '�(�,� ,J DRILLING CONTIiJ1C?ORs � �� � l��.Sw1 �WQ.J �`v�✓G IiAME ADDRESS MELL CONSTRUCTIOH Di�tanes fzoa► Nesrast Propasty Line Diatanen LrOm Source of Pollutlort Total Depth: Ft. Yields GPM Static water Level Ft. Nater Baaring Zones: De h Ft. tf/ Ft. � Casingc De�th: Yran�_to Ft. DiameLnr� 1 Inchea TYPE: St3e1 Galvaoi:ed Steel �� If Steel, doas ownar a Q : Yes No weiqAt: Thicknesap� Y Haight Abova Ground, Inches Drive Shoe: Yes No Were Problema Encountered in Seiting tha Caaiag? Yaa No� If 'yes' give renson, � ___— Groute Typa� «ent 34ad/Canen Conc=eto Annular Spnce Midth _���.. Inches Water ia A[u►ular Space: Yea No !letDod� Pumped F s e Poured'� Depths FYosn —�to� Pt. Matorisls Ossd. No. Baqa portlnad Cement iieight of 1 ba9 ]bs. ' if mixture (sand, r vel, cuttings) - Ratio: to ID Plataas Yea� No 4 x 4 alab Yna No • DRILL2NG IAG De th From To Fortnation Deaeri tion �� �A. r' I1�� '� �� �� �. I HEREBY CCRTIFY THAT THE A80VE ZNF+ORM1►TION IS CORRECT 11tiD ?HAT THIS WELL utAS COHSTBUCTED IN J�CCOSDANCE�j T�Fi REGUIJ�TIOl15 5ET F�T�N BY THE PERSON. COUNTY BOARD UF HEALTH. 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S'_ z:il !'�,G: : r f •; f � . . f� . . � . - . . . . . . . . � ' � , . ,'.. I• , . � � zF.s� ..so �` _�=..' ','� COh1F�ETED--- -.:. ��-- — `S .�St %� . ` \. �`� • �' } � . .� � . . } ii 'r� �Jr ' ��X _ � � � .. � , �- y �, ..Y ::_y -- — — �" - ,"'; L f��. REGISTRAT'O�i N�. .C. S6b � ,, , . `� h <.. y � �' - �,.;�', ... � . - � � ,.s �� `-. � � � " , � . , � A � � � ,�.; .. ` r 1 � -. �M � � �� � - - . . ' . .. � . �ta.f.[ '`M• � � " � . Apalication Oate• q-S D3 Amount Pald• � •� �2e�ipt #- �..1��_.s��- I�I�II�.� �� - — � � �-�-°��- �s�-�aa-oaa�-�--- .o��:�.1L �C���.I1.�IIl.a APPl.1CAT10Id ��R SERVICES Improvements Permit Improvemet�tr Permit - $150.00 (Mnbite Home Replac:ementlP�ddEtlan) Exist�g System Permit Constructlan Authocfration for $150.U0!$2DO.OU Permit Revisian Fea - $75.�0 Tax 1Bap �• �� �� Farcai �: • � �o . ��� �`r`� , �x � � � ` j,f ��T /� � --_�,�.::: .,.; ::. �. - ' ..,.,� ,,,, . ,. O iF THE INFORMATION lI� TNE APPLICATION FOR AiV IMPROVEAAENT PERMIT IS INCORRECT FA►LSIEiED CN�INGED OR THE SITE IS ALTERE� THEIV TIiE IMPfZOVEMEAIT PE3ZMIT AND AUTHORIZATION TO CONSTittlCT SHALL BECOME INVALID. . • . ' ' /1; -.w`�"y"`. �Permit requested b�: t�wnerlagerttlprospective owner): �! �l t �4m, �. �oHG �'I'� � �,( Hame Phone: C9c9� ��6 �3953 � Address: 5�}O�SPRIN6�IELD �� • I.,�,,,, ../ �� . Business Phone: — � . _ �fZA��t�t�. ►�c ��7��9 �U(�-� ����� W'I(�/ 2) �lam� and address of.cttrrent awner. —Sf�M� R-5 ��pV E✓ . I�!� •�IiVI(X�t� l�,-,,,,p _ (%�t V .. C�a�t ow,v£R �ro� �!�/�'Z: 1NW"" • �� � �� , �Lc�z� GR � � R�.E� ( �.�u� � � � �--- C�x�„�� �E� -Cv�Ns ' �� 3) Property Descriptioe�: Lot size: Tawnship: Subdivision: A Lot #� S �, „ n-j�- Directlans to the property (Including road names and numbers): �v �. � Ry oFF Yi2�Gu�-s rrlrcL . �l/oRru oF Cp� n�arni� 4) Propose�! Use and Structure Description: answer each of the foilowing questions: a) Proposed . Existing . Type of Struciure: b) Number of Bedrooms: . Number of occupants or people�to be served: _ c) Basemen� Yes , No Will there be plumbing in the basement? d) Garbage Disposai: Yes No _ - .�,,-• - tc�� �tTN oF C��� , . ��� . C Width: Depth: 5) VUat�r Suppiy 'i'ype: Private �(new _ or existing_� Public , Community . Spring _ - , � Are any weils on adjoining property? Yes �/ No _ If yes, please indicate a�proximate location on the • site plan. � _ .. fi) �oes your property coniain previ�usly identified jurisdictional wetlands? Ves,_ Alo � . � PLEa4SE PIOTE THE F�Lt�WIiVG: � _ � lJ ➢� A PLAT OF THE PR�PERTY OR SiTE PLl�1A( fldUST BE SUBM1TfED NUITH TH1S &PPLICATION. �� � ➢� PROPERTY L1N�S AAlD CORNERS MUST BE CL�ARLY MARKED. � � 9 ➢'CHE PROPOSED LOCATlON OF ALL STRUCTURES MUST 6E STd10�D OR FLAGGEi3. ➢'i'i-lE S� MUST BE i2EADILY ACCESSIBLE E�f� AiV El/ALUATION BY THE HEALTH DEP.4RTWlENT STAFF. � � ` I hereby make appiication to the Person County Heaith Department for a site evalua�on for the on-site sewage disposal system for.the above-described property. ( agree that the cantents'of this application are true and rspresent the rnaximum faciiiiies to be placeci on the proper#y. I understand ifi the site is altered or the iniended use ct�anges, �is permit s�all became invalid. � ��/�� �� �:�'�- 9-s- �00�3 or Legal Repres�ntative Date PC;iD, rev. 06127/02 ' .. J���� �� ��/��/��\ ����Q� ' • � V •�i✓ J� V .iV �T �������}ITTT��� ���WJL ;►� ?� .... - ii . ...�,. � . �i. �. _ �� u � • :.a ; [' ,. • :.a 1 Ta� I�liap # �?�.Pa�cP1 # �_ � s��nlLat# �s � 4-9-0� . ' �� . ' F•I. . :�. � i,:I'�' : J, ::f 'w /�l- i. : :�: T' � ,.�%. ,� A.�: y.,..� ; �I:' rl-:rrt -.R �M:�: �;� J. ,::1.: :.�. y:,- : -1. . :h : : •i� - ♦ � :�. �. ; n,I'.' "�I.��../r I..�.: _::/.- ...- m�t,i ni� [.� f Ct7` 5 L`�%ac.K -f.� Otd c,�t� ( , -- �.�G�mmc�d 10�` O�CaS �n� , — (Y)u.ndG,-Eo�y 0.�u�d�nrntnt �f �Id� wL�, C�o i(�cPa,`r-ab I�� � P� m P c� w-� c� ��-�" O� � � r ( /1 G.'�i . �3 �n5 �� t R-c movabl� 7r%^^ � �o rc.�•a,rc, a�y �[fccsS p � � t � w�� aF� �u�P��^� � F�It W/cc.nc�'�� � .��C���s,� � �Ylurlcc,� �I , � Z Pi��� � Ic��S � S�: NO �� � ,. �t ��, ��. fl9/�l��. ��� S ���.� �� � oD � 3 0.�-�/ . f � ��.�// .. ��/ _ _ �' �--�' � � � � � � �" " � c-.��'► -c _ G L • ��rn-vn�r-�rnn�nxn�c��rn.t�<az,� ���.en.�tC-�n L�KsJl9l'� UUUU�W %'��'1�3 Grout Log Owner: LV%ll��,.r tBa-rc�c�C Tax Map %� Parcel # 5lP Location: � �'/ «( Subdivision: C� ,,,r .- -� �a -�.� Lot # �_5" Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: .�Dc� ft Yield: /� GPM Static Water Level: �� ft Water Bearing Zones: Depth 11Os _/ ft i�S Ift ft ft Casing: Depth: From O to l�� ft. Diameter: ��N in Type: Galvanized Steel `'� Weight: Thickness: ' ��`b Height above Ground: � in Drive Shoe: � Yes No Any problems encountered w�iile setting casing? _Yes _�I<10 If "yes" give reason: Grout: Neat: 5andlCement ✓ Concrete Gravel/Cement � Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped. Pressure Poured ✓ Depth D to �� Ft. Materials Used: No. Bags Portland cement y.����t, Weight of 1 Bag � Pounds If mixture (sand, gravel, cuttings) — Ratio to ID plates: ✓Yes _ No 4 x 4 slab _�Yes _ No Drilling Log Location Drawing From To Formation : � «-�► . 7 � cC, � l � � c./ ?�'jv r- o � 'G � f�`�cy S�n�c Dr � � ,L GS �M; � � �� I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person Cotmty Health Departme . . Signature of Contractor ID #�D1� Date �-1? �� PCHD rev 09/30/02 �1�' 7��� ���� �� �, � ����JL� �aa-�a-�-,�„-*.�„-„ �sa-��.I� IF-���.71-�Iia �i�. ����r I'b.F.�ASE S�E A'�'I'A�H� PLAN F�R WELI. SITE ?.AYOUT Tax Map #: A a� 1'azcel #�J �4 Township �P�� �i � � iam �ncc K Subdivision: �rUcr �Va.�'�S Section: Lo� �s T.nr�tinn� S 7 N(2� Cc�ncord ' C.'C FFO � L/�%' %�rs /r1 ��� ��• L�'d r� I JL � �%�orc, A��rc,s Ori�c. � Ory F�Y /�d �2 � �x � C� T�e of Wat�r Suv�lv: � Individual CommumtY Pubh�. �tec�uireffients• Site. Approved bp ✓�' �� �"a 3� 0 3 Gmuting �A�P=oved by J�t �1 a3-� We]1 Log V � k� `i �a-3 "�3 Well Ta.g Air Vent Hose Bib Concrete Slab Well Driller. - Well Approved By: I�ate• '�See Attached Site Sketch'� Wells must be 10 feet from propezty liaes. Wells must be 100 feet from sepric systems. � Wells must be ax least 25 feet from anp bwlding foundation. Other conditions:_� )W C�d�'-�'on5 prov �'d� d 0� PC�ID, rev. 09/07/Ol f �' 1 � V V � M�� � �`