A26 1371
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The Districf Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposai
IMPROVEMENTS PERMIT No.
Date Z— �'� ' � 7
Owner: � Gt. t� j ta 1'� � C�--�'� —
Location:
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Contractor: �
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� Water 3upplp: Private Public
Sewage Disposal Facililies: No. bedrooms Dishwasher, Disposal,
washing machine, other automatic appliances �
Size oi tank: �-� Nitriftcation line: ��
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet 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 nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATIOId IS COV-
ERED AND PUT INTO USE.
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Date approved: Signe i /Q• ���/�aJ. ,/'���,
Well: Sa�3itari
Sewage Disposal•
By:.
Counter � �
aigned -�%'f"�
( wner or his representative)
emU� YQ1D after 3 Year
CeriiSeate ad Completioa
Date Approved: � '�� � 7By:
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
1 ' supplies, etc. Note special problems existing on lot. Wrfte in measurements in order that installations may be located
�, at later date. Note location of water supplies on adjacent lot$' "'
" (11 , (21 I � n
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSU DATE DRILLED: � COUNTY: \ C�
OWNER: • ROAD/ST�tEE : "
ADDRESS: T Vj�Ip� R ONE Y �
DRZLLING CONTRACTO : �V W�1
NAME ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollutiop� �
Total De th• Ft. Yield: GPM Static water Lev Ft.
Water Bearing Zones: th• Ft Ft.
.Casing: Depth: From�,to �.Ft. D�ters Inches
TYPE: Steel Galvanized Steel
If Steel, does owner appr�qYes No
weights Thickness: 1 Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting t�e Casing? Yes_ No_
If 'yes' give reasons /
Groutz Type: Neat San / ment: � Concrete
Annular Space Width Inches
Water in Annular Space: Yes No ./
Method: Pumped � Br��ure ,Poured
Depth: From to L�_ Ft.
� llaterials Used: o. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, g�el, cuttings) - Ratio: to
ID Platesz Yes o Chlorinationz Yes No
4 x 4 slab Yes� No
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I HEREBY CERTIFY THAT THE ABOVE INFORHATION �S CORRECT D SHAT THZS
WELL WAS CONSTRUCTED IN ACCORDANCE TH GULAT O SET RTH 8Y
CASWELL-CHATFIAH-LEE-PERSON DIST.
Signature of Contract Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOE !q INSPECTZON:
• Sanitariaa's Signatuze Date
Sketch well location on reverse side. Use established reference
points.