A27 214� � F�erson County Health Department �
Well Permit �
�a This Permit Void After 3 Years
Owner:��C
Location/Directions:
�
SR# ��� I
Subdivision Name: ���s Lot #
Drilling Contractor:
WELL CONSTRUCi'ION ►t7
Distance fro J�learest Property Line�� Distance from Source of
Pollution 0 o u- �
Total Depth: Ft Yield: �_GPM Static Water Level ��F4 ~
Water ge �g Zones: Dep�t�h ?5� FG � FG FG F�
Casin : th: From .�__ to Ft Diameter: 6% Inches
TYPE: Sceel � Galvanized Steel ✓ �—
If Steel, does owner approve: No
Weigh� _,L� Thiclmess: Height Above Ground: �y Inches
Drive Shce: Yes �_ No
Were Problems Encountered in Seuing the Casing? Yes No��
If "yes" give reason: �
Grout Type: Neat Sand/Cement Concrete
Annular Space Width � Inches ��
Water in Armular Space: Yes No
Method: Pumped� Pres� Poured L�
Depth From
Mat Used: No. Bags Pordand Ceanent t Weight of 1 bag
_ ���, lbs.
If mixture (sand, �1, cuttings) - Ratio: _� to �_
ID Plates: Yes No ►d
4 x 4 slab Yes �— No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SEI'
FORTH BY THE PERSON COUNTY HEALTI�- ,DEPARTMENT.
! W- �
Date
� �–Z7
Date issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
0
�! NO�� Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
• sup���Iies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
' at Ydte date. Nq,�lo.'�''�' of wg� yap{�ies on adjacent lo s.
{ ��� -�.M��:�.�L / �.� tP
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Person County Health Department �
Sewage System improvements Permit
►ate•�'7 Z?/-�'►�isPermit Void After SYears i� _�_
Owner: -- �
I.oCalion/Directions:
SR#
Subdivision Name: �/� f t�r',� �-y�� r�'�-�'�Lot #
Lot Size: a� �2 � ��-� 1 Type of Dwelling:
Water Supply: Privatc: —�� Public: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement Fixtures /
INFORMA�C�T�EI�BY F p /"/d�
A iAr �r i. _ - owmer o ieoresentative
REPAIR: `� ` f2EEVALUATION:
------- -----------------
Size of Septic Tank: gallons�, Size jf Pump Tank:
Nitrification Line:
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP P�mp
Remarks:
-------------------------
Date Well Appmved: �� Well should be 100 f� from any sewer system
BY Sani '
Date w ge ys pproved: - � U
BY Sanitarian
CERTIFiCATE OF COMPLETION
Contractor. ��, ��.v� r
------------------------- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Seplic tank should be pumped out every 3 to 5 years and shali be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrification line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this peimit is subject to revocadon
(G.S.130 A-335F) ,
L.ocation of sewage disposal sewage system sketched on back.
(OVER)