A26 138�
,���.�erson
County Health Department
Well Permit
Subdivision Name: Lot #
Drilling Conuactor: I7 t� E�us L� � f=L r O,
WELL CONSTRUCTION
Distance from Nearest Property Line / S F t— Distance from Source of
Pollution o'��
Total Depth: '� �S FG Yield: '`/_ S GPM Static Water Level ,� oa F�
Water Bearing Zones; Depth Ft. Ft Ft FG
Casing: Depth: From 0 to � 8 Ft. Diameter.�Inches
TYPE: Steel C�ks��7 GalvanizedSteel ✓
If Steel, does owner approve: Yes�No
Weight: Thi ess: /� S' Height Above Ground:� Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No t/
If "yes" give reason:
Grout Type: Neat � Sand/Cement ✓ Concrete
Annnlar Space Width 4 �. Inches
Water in Annular Space: Yes ✓ No
Method: Pumped Pressure Poured��
Depth: From n to a0 Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag '�� lbs.
If mixture (sand, gravel, cuttings) - Ratio: 3 to I
ID Plates: Yes '✓ No
4 x 4 slab Yes�No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALT DEPARTMENT.
r 3- -
ture of Contractor Date
�I�3
anitarian's ignature Date Issued
SanitariansSignature DateCompleted
Sketch well location on reverse side.
'd
�
cu
�.
'd
�
z
�
' f��TE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
���' �plie�,"etc. Note special problems existing on lot. Write in measurements in order that installations may be
�_`*:;ated at later date. Note location of water supplies on adjacent lots.
k
�
�
� Person Count
�- Se�nrage System
Dat�: is Permit Void,
Owner'
z
y Health Department �
Improvements Permit '
After 5 Years Permit # ����?�
.. ,�� �. r� � SR# � —
Subdivision Name: `' Lot #
Lot Size: �� C V'�P_ S Type of Dwelling: �-. U�
Water Supply: rvate: � Public: Community:
Bedrooms: � Garbage Dispo al �
Basement Basement F' es '
INFORMATION CERTTFIED BY
Environmental Health Specialist: ' o�er representative
REPAIR: REEV UATION:
-------------------------
Size of Septic Tank: �� � gallon � Size of Pump Tank: �
Nitrification Line: � f� � � -
Depth of Stone: 12 inches
� Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved: Well should be 100 fG from any sewer system
BY Environmental Health Specialist
Da w e ys m Appm ed: �' �=°i-�
B Environmental Health Specialist
' CER CATE OF COMPLETION ,�
Contrac.tor. ' �
-------------------------- �
�
�
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and N
nitrification line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If �
the site plans or intended use change this pemiit is subject to revocadon.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)