A35 106No. of persons to be served Bedrooms 1, 2 3,�4.
Additional appliances to be used: Disposal, dishwasher, washing
machine �� �'•
Recommended• Septic tan � _
� ` _(_, ,;� t
Nitrification line: i �'���_ 3_�T �-r ;� ��
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus! be inspected and
approved by a member of the Disfrict Health Department staff before
any portion of the installation is covered.
Date Approved: �j—
By:
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
The Disfricf Health Department
Orange, Persoa, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date Q — / f`' ' ✓ ?
�— �
Name of owner �t• ��M�E '�el�[f�,A�
Address and Directions � � �11�� L � �% /
Person or firm doing installation: �% • C. C�L �� �'
Address �° X p e�• _
No. of persons to be served bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tankT 4�
Nitrification line: ��% ' '-� � Y�
Septic tank and nitrification line must be inspected and approved by
a member of the Health Department staif before any portion of the
instaliation is covered.
Date Approved:
By:
• � L � ✓, -
. �, /
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
. Cf�� � � zr,z�'
Application Date: %q ! '% ��� �� ������ Tax Map:���!��
Amount Paid: � /� __________ "' � Parcel#:
...,.�• �' � 4 .
Receipt #: � � � � � �
--^' -�" �cnwfln-��rn,�,�aaeaT.�.Il ]HIm�IL�.Ih�.
Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
.Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$Z00.00/$75.00
for Services
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Esisting Septic System
Applicarion: No Charge/ CA $150.00 or $300.00
iC 1) Applicant In� mation:
NaTne: 1► vr� .{- ��.../ N n� � i l 1 i Gt.►u S .
Address: �cti.1�, i ��s
!Zo 1Ll�ew ►.� � 02� s'Z
� 2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 3 3l�-�q�- S�r �3
(work/cell): 33ta- So�{- -3( l S
Phone:
3) Property Description: Lot Size: S.�}� Subdivision: — . Lot #: —
Address and/or directions to Property: I v �t o IJ.c Sti-cz s�'. t 1�CLZ Zcr�� crrA ,��- �s 7�-
❑ yes o Does the site contain any jurisdictional wetlands?
C�i'yes ❑ no Does the site contain any existing wastewater systems7
� yes C�'no Is any wastewater going to be generated on the site other than domestic sewage? -
❑ yes 0'ho Is the site subject to approval by any other public agency?
d yes Q'no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: .
❑Residential '
ew Single Family Residence Maximum number of bedrooms: �_/ Occu ants:
❑ Expansion of Existing System If expansion: Current number of bedrooms: �
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maxunum number of seats:
5) Water Supply: �ew well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring
. Are there any existing wells, springs, or existing waterlines on this property? es ❑ no
Please note any known ground water restrictions or sources of contamination;
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative 0 Alternative ❑ Other ❑ Any
1 cert� that the information provided above is complete and correct. I also understand that if the information provided is
inac urate, the s�ite i subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� � -/� �
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
e A �omple±ed `Lo! Prep�rata�n' form must accompany any apnlication requiring a site evalvati�n.
(10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Name: _.(,
Subdivison:
�it2 Plar�
iress: _�
Lot:
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,� '�eaPos�n
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C -t-.�\ �1'�'.�, ,
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$.
System Type: J��/
Septic Tank: OA�S gallons
Pump Tank: � gallons
Total Linear Feet: �Q
Max.Trench Depth: �"
,
EHS:
Date: ��
/
Tax Map: ��
Parcel: lDlo
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TA�N�G.
5�i �EM •�1�fiD
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Scale: � —�
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additicna! Comments: �i17.4/�2' /%i� � ��T' �/�+,D.� "� �D � t �/l1giG! /��
����,S.f ���.�0��
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Tax Map: ��Parcel: /D lo
Subdivision:
WELL PERMIT
(New�/ Repair_) ��c.a,G�,��S-1�
Lot:
Applicant's Name: 1S[���✓f�t'I'f!i
Mailing Address: D i
� '�� .
Phone Numbers: — �!�- . �//
Location of Properfy: /'f1 �d /t.�C��jt�/L� z,'�,.�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing consiruction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not arantee a potable water supply
Other Conditions/Comments: �,�'�il��j�j�, .P��'d...L1�y� �/h✓�iil
��f�jT/�✓T
Permit issued by: _���f���'�i Date: ������r"_'
QNew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
OLiner:
• EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597•7508
11/26/13