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A26 124
Person County Health Department � Well Pe.rmit � Date:�)-�lo This Permit Void After 3 Years '� Owner: �a v►� i e S vd a b% � SR# -1�� I.ocadon/Directions: Subdivision Name: � � Drilling Contractor: k �MS� W�LL CONSTRUCi'ION � Distance from Nearest Property Line Distance from Source of Polludon ;r Tatal Depth: FG Yield: �GPM 3tatic Water i.evel FG � Water Bearing Zones: Dept� �FG Ft. Ft. Casing: Depch: From S� to �� Fc. Diameter: Inches TYPE: Steel ' Galvanized Steel� If Steel, does owner approve: � No Weight: Thiclrness: � Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No �If "yes" give reason: d Grout: Type: Neat Cement Concrete ;4 � Annular Space Width �_ Inches Water in Armular Space: Yes No Method: Pumped� Preesyr�_ Poured ✓ Depth: From to C..�:! Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, gravel,�uttings) - Ratio: to ID Plates: Yes � No ►� 4 x 4 slab Yes —T No � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCfED IN CCORDANCE WITH EGULATIONS SET FORTH BY THE PERSON COUNTY H P 5443 C�/�'A � Sign e Con ac Date ��{ �, � --�6-10 /�� ���1 r ! arutarian's Si a re Date Issued t` � �� � r V W Sanitarians Signature Date Complete3 Sketch well loc rion on reverse side. NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. (1) (2) � ApPlication Date: � I'°� 6' � � f� J10� ���� Tax Maq #: �� � a.� , � Amount;Paid: � C_. � ►� Parcef#: � � R�c2ipr�: ��2�7 �,�1q � � Ij `1-� 1 ���� ... � ���� �� ' ��� ��� : ��.�:a-��.�.,,.,. ��:��.n. �-���.n.��. � ���� �� �,�, ��-c7� APPLICATION FOR SERVICES l IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALSIFIED, CHANGED OR TitiE SI i E IS ALTERED THE IMPROVEii�iENT PERMiT AND �iUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Ownerlagentl rospective owner): /�ur'S �» alc��-� -� Home Phone: ,,� 3�^,3 (o�f£�`�� Address: �9s C. �. f�Na�Mc=�s %. Business Phone: �/ � - / k 5/ - � �z � T•'� ��� r.� ��r� �-�' S y 3 2) Name and address of current owner: ��-�rr G�5 ��v✓c 3) Property Description: Lot size: �. /� Township:Oli �.` !� Subdivision: �i�Y ��fcc= Lot #:�_ Directions to the property (including road names and numbers): - �� N T.�h-�- RT ��/ � 3� Z Tff �C,� �� X � 3'� -- 4) Proposed Use an Structure Description: answer each of the foilowing questions: � a) Proposed�Existing _, Type of Structure: �'� D�v/�-�2 Width: `f� Depth: �� b) Number of Bedrooms: � Number of occupants or people to be served: �_ c) Basement: Yes , No �I there be plumbing in the basement? d) Garbage Disposal: Yes o_ 5 Water Su I T e: Private new or existi , Public , Community _, Spring _ ) pp Y YP f/ t — .., Are any wells on adjoining property? Yes� _ If yes, please indicate approximate loca ' n on the site plan. � 6) Dbes the properly contain previously identified jurisdictional wetlands? Yes _ No _ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LtNES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be pla d on the property. I understand if the site is altered or the intended use changes, the peRnit shall become invalid. � j fl D Owner or Legal Re entative Date • PCHD, rev.10/17/01 r� �,Q�� I:�CiC _ � Y � New �Addition # of Occ�tPan��!�� Projected Daily Flow: _ Proposed W er Proposed Rep�� r��v�� ����� ����F���i�Es��'�.. ����� � -r��C � �s�. � � � ,��Cf.'C ,?� �r,'cCc F�lfit�P�'���[i��'1'3� ��'�'�6'i1�.: , .- . TiraeufStruc�ure �J �FII A;'P�. WaierSupply. �� T�1 q � Pertnit Conditions: �� Ci'1`�- ���e�, �--�-' �s-�-o� Ov+mer or Legal Autharized State Agent Dafe: . o�: �2`�3�c�C The issuancs of this permii by the Heaith Departmetrt in no way guarantees #he issua�ca af other permits. The pem�it holder is responsible for checking w�h appropriate goveming bodies in meeting their requirerr�ents. This s�e is sub�t to r+evocation ii �he site p1an, piat, orthe arrtereded use �twnges. Tl�.lmptnveinerrt Permit shail not be �d #�y a ci�nqe in cwnership of the si6e. This perrroii is subject #o campliancm with the provisi�ns of #he Laws and Rules ior Sewage 'ireatme�rt and Dis�osal Sysi�ams of �e North CareW�a Administrative Code. Wastewater System cription: Wastewater Flaw: Y p.d. Typ�� � FacxTiiy " New i� Repair Ca Expansion ❑ Baseme �Y' � o Basemerrt F�tures? Wastewater Svsfiem Reauiremerits � Tanicage: Septic Tanic size C� �� _ Pump Tanic sizs � gal. Grease Trap s¢s ��� � gai. Trenches: Total tength ''�i� �dtts � ti. Totai Area � � sc1. fiL Max. Trench Depth:r�� in. ABgr+egate Depth:� � in. Soil Cover. � in. Trenc� Separatlort �ft. on cerrter Permit Expiration Date• �-�. ` 1 1� �`F� . Authorized State Agent � �— Date: �� ` � 3 G� l �'See attacl�ed site pian and addendum pages for add"�tionai permit canditions. The #ype cf system p3ermi#bed C� does � rlaes not ��r irom �tee type � on fihe appiication. 4 acce�rE the spec'�f'ications at this � Perntit . OwnerlLegal' �epneser�tive. Sigrtature• Date' �taerativn �ermit System Type (in acxardance vvith Table Va) This system t�as 6een ir�sfaited in compliartca vv�h applbcabte 11odfi Cat+nQma Ge�ral S�futes; Laws and RWes for Sewage Treabme� and Disposal, aRd alt canditions of fhe Impr�rt Pe�mit �d Cassshuciion Au�on issuanca af iltis permii itnpli� tto guara�t62e that �tte syst�eem i�d wia fi�tion �oi�e�f ��Y 9� ���- Authorized State Ag,ertt. . � . - PCHQ, rev. 03/Q7101 ►!I r `/ � � \ � 2 . � a Noe��� -.�a,� � . � � � i o. oo .�`.-_ � ' - �, ] �/ �' � . , . ' � 2�q, �g, • � �, Q�I � �, � � . , N � ' ..` � ,v � o� � , 2 � � ,,, � ; �� � � �'� N�s•,��. � �. ; � � � e r� � ' (!1 • . ��� rUr � At � ��� � � '� )'`'4'�'`� �� � . �� �� 7 • . ���^! �OL�I�. � � ' � � � '� � rn J� ,�� � l:�?�,t �-' J ��,�;�,� ''� � • � ) ` '-� :.. ���'"'r,� ����� ,°G ^' ' 2 r �, � � -- -- ... . . . � �. . � ; 1 / 0,�, . � e��, 1 , �v, « � � a c . `� � ,t%���� `�� .-r�. � � I �, r � � ; oi . _. ' ,sL�� ,�i ��-�.. b-�+� 51;aS � '9'C' �` ') � , S(IN �f��'"►J � ( , > 1 •�.. • � � � 3 t1� �s � � 2a�,.� �'1'-.. .' n 1 ,�p-tiy's ,f►j/1 �1 �/" ' �� `'' ''°.,,u.�, •°L s �' �-�' ,�'��� � . � ,,�1iL��"'r � """�" � w w Q 1 l'� �-; t�-G �. yl'l�t.w �� �J� � - � ,,.,,,,�,,, �'�� V� �, � ��b °� ZS � y �a� $p �o..� , w `" �' �Q �``.` �� ��'S �.a 1` � � aqp c,� ���, � 1��� a,,��.��b� � � . qi�,. � � � `�. ��t�5 � � -, � � -�� ` ���b�l��s� ., �� �'�'� b�� /�I O�c �, \ kp ►�tJ , N �� , � • •� � w ` � ,� �o.�����J . � �, � � • � � '� '� :� �' � . . � � . < � , : (.1� � • ` � � J ' /� � � � •,.� �� �ro ,� � �ti�i q� ��'� �' � � � �� °� s�`. � �"�� � .�' 'd���� � •'�r �f� �0�. �y f� � �a �� � e � � /�� • . � :: �:; • � . . . .. . � � , . . . � . ;;. ' ',::,, '.'',.. . . .. . . �,.� .::.:.. . :::::.:'.�;:,`�:,..:�:t,i;a':>��•;,•:'.,::; ' . .. ,.,:' . . ;=.•.'1+,.:.,.,. .. .... . . , . .. . � . : j', , . . � . ' . . . � � 4,. . . 1 . . ' ' . ` .' Y.,'.. . . • . 3 9 Application Date: �'a �-�� ��� � � ��`��� Tax Map: �� G AmountPaid: ��� �Ja'`��c� �� Parcel#: IZ� � ��",� . � Receipt#: i0 3q.s`� - � O � �� �} � 'C��c� . f � ll ���� �� .� 6 q � 3 .___�� S _ �- � =�-� ������- �,o � a �.�.:cawn�r-ucan-n_zraT..�c3a�n.�tn.�I. IE`�C�c^s.cn.Il.tb_`iT n Application for Services T� 0 (Sentic Svstems and Wells) 3"3 r� � Services �mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit reyuired) ❑ Well Permit (New/Replacement) $225.00/$125.00 ❑ Construction Authorizatiou (Fee is dependent on the type of sy: ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Char�e Important: If t1:e information in t/:e application for an Improvement Permit is incorrect, falsified, or the site is altered, tfien tl:e Improvement Pertnit and t/:e Autltorization to Cot:struct shall becorne invalid 1) Services Requested 6y: Name: MoNr�� U J'1�rluwz ��n Phone#(home): SS4- SS3u Address: 3lo So 5�.�,� ,,•-A '►2oa (work/cell): �t -� t�i - a57 - 73y 1 2a��,w�c a�s7y �,,,b RK— 5S'1— �130 2) Name and address of current owner (if different than applicant): Name: �i r��i�� .L G�A�I•a �c;�pr�1 Address: � g f �'-3k s�•� F� r �C �� N,,,rc� IP M: ►Is .�c ��sY � 3) Property Description: Lot Size: u� Subdivision: � f��r ��- Lot #: AZIo -1 �`-i Address and/or directions to Property: (�i��-ree Ko,cbcu i`-r�� ��5��/ 4) Proposed Use and Type of Structure: Residential ✓ B mess/Type: Other Number of bedrooms (n �'J / Number of people served (seats/employees): Basement: Yes � No _(with plumbing: Yes � No � Garbage disposal: Yes _ No � Approximate size of building foundation: Length Width 5) Water Supply: Private Well � (Proposed Existing _) Community Well: Public Water System: Are there wel(s on the adjoining properties? No � Yes (please show location on site plan) Note: A comnleted annlication must also include: ➢ A ptat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated I am submitting this application to request services fram the Person County Aealth Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): h ���/'�' Date: � ?`Z �0� 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-�97-1790) � � K �1 �.. � � � �, � '''� � ��� .�: -'� � �a ,,�- � � ,� -� ..4' � «, :'� �� -�� .. . . � �. ��`�� � . ��': �r . �` .�'�. �` x� { _ � � *r'�r .. � r � � � � �...- ' � . - . . - � ��� � � � ��� . - n �' `� �✓' �, �." � . � � �� .f _ � . - ��� . . - .. . ... . � . ' ' . s '.�. M . �,.r': . - �' � � � ��� � / � , � x' � � .. � y � i2� J �-�u.�. -A g: // �^ � :y:. � yy� . � � . � / $ ,..� . �g�z�.� y� � n c ��� � ��L � �3 � E � �� i �`' +. S' .� Y �Y i^'�L'v� �- � � . . _ �' � > � G �. � � i S b^J`" _ . -tc F f t � .�:`� ? � a � �.�� �„ v ,:�a � �'",� .�,�,� '�i` a � -. . � / � '�.�, � � b < s ' � �`'4 �{` � ���' .. f ,� ,.. I � �._ � , .. . v / '� i � t{ � t 4 I � � � f � 3 j tf� ��� b�"c 2: a. r � ( .:�. $ �� ' � �` ! _ .i,f.. L � �b ti � ' � � �= �,�� - - - � a � 4 , >> ���� � � � - , �� �� � F� ,�' - � �}��` I F i � � � � � , _ " ' � M 9 � � � a f �� : �aF �i � }� ��` � - �< :� :'� Y Y - � #�- �:h+b�,a.�' 1 =. t - i . .. 4 ' ,F:'. 1 � - ' � � . . � . f - ��_����7f�, i�; .�- ) .t.- . � x 4, t sx- „ (t �^z: ,. a� x �� r . , f I ' k .. 1 } ' y t b'E.✓�- �.5+:� F.y � � .� r' . ,.: @ '"�.� . ` S � � Jl J � � ' . � � � � �Y i. ; � � �� - 3 t � h' _ - t 'H-'�' �3 Y�., 1 �� 3 � F-� �: i I� . }i :f AF - �' Zh �. � iY � � I . � > � � � � . � _ ', F ' t. ? . , ,� ' �� "�T� � , �� w � _ .. � �� � �^ � . , . .' � F , � � �a� x� � '� � , . _ , ,. . s ,: ,v'•. p, � ^ d _ 1tl:.: t .. .: � . � �_�� . _ ` ?�. ... � 1 ��:. F.�'" Y .': ,t `�ti . ... �� ^� . i� �:. ' � - '. w � �+c� �' � � . �: .�.�r . �..£ , �., ,��''s : ; �ti,- �� a: � : ? �� r'K - � . ,. -- � i � , A � ; � e k' '� } e:- �� � �� : � . �; `^ . ' � � F � . � :� .�4.. � .. . ,_. �u^ � . � f ... � .. .. .. �.. r �. _ .. � . i-s - . 50 Foot Lines � � \ �F � i00 �oot Lines I� � `�_�`�� ��� �����.b� � ,� � � �. a �� .� �L.J �J ��� � ���-�.��m� � ���:�� 1�—���:Ii�I1� Ta�x Evi ;p � rc�i � Sui� dii�:�i�s�ian ' . ► . , Fh.�.S•e;�S�cct�iaio:'L��t � �'�rmat'Yal'ad fo� �/ �ve �F Type of Fac�ity: �'�a� # of Oc�ants /�g,�( ,_ # oi Propose3 Wastewater System: Proposed Re�air: --/�� Y�a�rose�ent ��rs�i# l�To� �iitation � / � Vew �✓A�dditi�n �s 3 _ Proj e�e3 Daily Flow 3 �u D • w... . . .� . . � u�r,;!�. � :, � ?so�� � �� � Authorize�. sfate ' �X� i�.J �v� ����;��.�.I gP•d Type: Type: ' The issuanc� Qf this perm�it by tbe Health Departmeat � does not guarantee the �s �s�ss of other permifs. It is the responv.b�7ity of the aPP��aP�Y owner to in sure tha# all Person Couaty Planning and Zomng aad Bu�ding Inspestions reqirirements. are met. �is Imgaroe�nent �srmit �s subject to rev�ca#ion i# the sife. plan, plat or t�e inteaded use ci�anges. 'I'he �ng�ovemeat Permit is.�not _�,-.:-.� affectesl ii� a c��ngs in o�v�ter.shig�ui�th��soperty. �his��es�mit�vas�:�sued in:eo�lianc� witti the pi'a.�►isiopss ot#he.N�o��ar.alina. . �::�: �Z�rs�=�d .Rul�s fa�' Sesu�`;Treu�i,�azt:-�nd':�isnosal Svstersis' �3.5�'s ;N���::':3�8�,::1900). 1Veither Person,��n����u,e��..#h�:�:� ���n�evtal �ealt�ts�� - , �he. se�tic ta�k.sy�#�m. � . . �c#ieni safisfac���; . . . � . �#h�#es:snpply �viil3ema�n.patai�Ie���° ����_ . � _ =- - - -- �y:w.._ _ . _. ��;�;.�.->�,�.r-,�,,.� ,�..a, - �::. �.:,� .�:::��-:r�i»�;�::s:,�:� i':�. � �A�aitlio�szation �Q ��Bs�cct�a�tes�+ate� Sysie� (18e���fu��g �ernait)�� . �'.- ;1 �7-`�':,' � . � Ses szte plan and additional attachments (_). _ • - . � .._ . � Proposed tewater System: � ec�l�e� 1 EZ ��oc.t or �J�tawh-L✓� Type��_4 wastewa,ter Flow ,3 Ga ,g.p.d. ,�. New �Repair= ExQ 'on � Soil I�iA1Y: • 3 Z g.p.dJ ft Z �. Type of Faci7iiy: . Va , S�`� Pn,� . Ba"sement es _ No . '��s��a��- S�st��a ���a�e�� � �an.l� Siae: Se�ac .'�a�:� / Daa g� �P Tamk: �—gafi G�se T�p: —g�i I)r�fi�d: Tat�l �eea: �,:.� sq � 'Total Le�tia �.Sb it ' 1�I�� '�reaich �a�la ,_ j 8_ am �renc3a �Vic� 3 ft Soii Cmoer. �_ �m lYi�im�'I`Tesacli Sep�raiaoia: �� ft . �is�+ibn4son: ✓�is�abmtion �oa �erial �istn'b�tion �r�sare 11�na�old . / �:..K ':� .M2 1' �1� �1 . ���1/1�I��� /I / I / � � � � _�17�i�I� i � - �n�Snorize� S�ate � Pe�it Date: �/— /- The type of system permitte3 is Conveational ✓ Ac��ten �lt.�rnative. I acc�t the specifications of the P� � ��e�f�� ��r�sE�t�ti�va: %�!� l�ir�.,r^c_ Daie: �( � O I — 'Lov S ' pG� rev. 11/10/05 � f •������� ����J �� � � �` `�/ '�l' `V l �7 �� �un�vn�c-.mm� �aa�«m.� g'��a��a Natne o � Sub ' ion ` � � . Autho�ized State Agent SITE SI�TCH Ta.g Map #��.Par.cel �,�� Seckion/Lot# _ � 'L-.�-Df� Date . System cvmiio�ents rie�i�esent a�ips�oxi��rte �contours only. The cont'ractor must flag the system�rior io ; begin�ing the inrtalla�,ion to i�sure that prolberg�wrde rs mair�tained / , �- T J � .�, � �;a � S �k►� �; . — / , 3teo f . , � o� �b�ed l'oom °�i , .� o��P' � =-'-i' / _ a�� ��� , , 6 or 2riQ� (sl� .°`'� ' �-b x .� ,/ _,�, -- $" nc{► b�ms �e �- ` r �(•.f I fYB .� �'� ,� 7 I � 4 � <o r�, a ��' � •� c� .., / • � � y "" ___- ; r r°Ta< F '��� . a��ry' 1..---, �r � . _.. _., :a� 1 Sc�4c� � �'= /00' �o�� .-•-""._' _ `y -.. _-'��- ; �.��� �� .� f - � ��J ^. �_ � ' i � � � --�'�`�-�� � � ���� �s T �3Q.-sr � -x^� -r--� ��3 �1.� �11L � �.IL� �,pplicani: e, �ocaiion: � � �'� �;,.-keP ��'L7 a� r K-S-i l� le+ cti. (� — ltz� �l� a � (a P" �ic�� i� � /�' � � � �H a ,u %�t r►-Eree � ^ ��flo�L��� N L� ��� ao 3 . . . .��' �� � �� � . Syst�m Type (in Accordanc� Wizh Ta.ble Va): TH6S SYSi'�� ��A� �E.;.� i1�1�T.�l..LE�J tf� CDf�It�Ll�4A�C� I�VtTH �PP�ICABL� .�4QRTH C'Ai�QL1NA G����aL Si}�Ti1T��, �3U��� ��R Sc��iI.AC� TR�AT11�Ei�T ,�1VD DtSF�OSAL, �.l�D •�+LL CONI3lT'iO�lS �� � THE DI4�FR01��:�1��T P��II i.�ND GOk�STRUCTION �tlT�-lO�f�TI� . . .,�,�_ � . Z—Z —a� - . ' P,utho State Agerrt Daie . Installed. B . � � ��. Date: � 2-' 2'OR ' � . � . � �' . _ /1�p `� � � u 7 1o,y ��� � � ,� � . o �, ti'1 �� . � q �y.n . � a`1�I,� , q����t � o I� 0 a ���� 3� g��� ��-9Se������� ��E��..�5 a � ���� �8 a ��� Ta: IViap ���_ Parcz! � Sys�e� Type (►abie Va) �[� Z�_ O�rve�e�;'ApQiic2nt � � � S�b�iivision �;r�-�r�e J AddresslLa�cfion Se��Pha�� Ls�t Y ,�_ Stat��ID/da�e S "�� Capaci - oo uai. Tes and Fiiie� � " • � Baffle Sealant � Riser ifi apAlicable � �'an�C Outiet S�d Pe�nan�rrt IVla�ces- . Pum� T�n� Watefproof /Seal�n# Rise�- Water Ti�ht � . � � ��ana� C�ecic VaIvelGaie V«�ve �lfarm (visai�le and aurlii�fe) �3ecirical Cam onents � � Rate m , . A praved Pum i4�ode� 8loc� Und�e� Pum � Pum Remova! �Ropel�l�ain . = D"as�aba�aoaa.: S�t�m � Serial Distn%ution �ressure iv�annod Low Press�re Pi e � A t. Pip� ilrlaie�iaf a�td G�ad� �, Vadv�s � �d#h 3 f;. ✓�S . z-z- I in: ?�0 �. - �fi8l�C�] Cd'�t�� � �✓ r Trenc� Sp�c�ng� �oc:'� De�fih and Quali c Darns/St��dovvr�� �tc. Press�re Laie�a�s � Hale Spacin� � �qui�d' ���ba�9i� From� Wei1s � ' From Properiv lines � Surfa� Waiers Public Water ��applies Verrticai Cuis (>2 i�.) 1l�ater L�nes \ 1 _ /- � _ 1 _ .T _ rT� . ' . . ��asesnenfslRight of O�a�P �as�s�ents R�a-d� e � e �erator C��s�e�� �� i:ai�.� �� �� �O i�■� �c7d r�r. 31� 3/G1 PE42SOId COUPITY ENVIRONMENTAU- HEALTH � , PLEASE SEE ATTACHED PLAN FOR 1NEEfl.!L StTE LAYOUT . �� � �� �� � . . Tax Nap ih ZoNng 7owcmhtp ..�- pppUcuit ' �n0� �U�C�t �•T , �7�/'� --� ��c6' i� �' �u�� � �1n�ct'� �.,_ � . �-i�l/L�f� Saetlon: t�� suhdWwon. Tvae of Water Suap_IS�'. Reauir_eme�ts: Wel! Permit �/ Individuat = ommuni�tyy Pubiic Site Approved by _ . Grouting Approved by � Well Log Well Tag � Air Vent Hose Bib - ' Concrete Slab Weil Driller: Wetl Approved By: . Date: **See Attached Sit�e SketcM'""' 1Neils must be 10 feet from property lines. . Ij,y,yells must be 'I 00 fee �from�� from ny bu iding foundatuan. Weils must be at lea . Other condiiions . 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