A35 135The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PER IT No.
f ,
Date � �� � �-
Owner:
�,ocation: �+ . S 3 3 S"' � �z'`�`�
3
.
Con ractor: ��'
Water Supplp: Private �� Public
Sewage Disposal Facilitiea: No. bedrooms � Dishwasher, Disposal,
washing machine, other automatic appliances
Size of tank: �O �� Nitriflcation line: �0 �%� 3�
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 INSTALLATION IS COV-
ERED AND PUT INTO USE.
C��� �`
Date approved: Signeci L��%"� �=� �����-
Sanitarian
Well:
Sewage Disposal: I Counter-
BY: i signed
� (Owner or his representative)
Certificata o� Completion
Date Approved: "'� � By:��'"'�' �
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
Petmit VOtD after 3 Years
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.
WELL PERlfIT
Lee-p�zson Counties .
Ceswell-Chathan+- ��_` �
v COUtiTY s
. DATE PRILLE`D� n..sniSTREE�1= _....n
DATE I
pWNER:
WELL CONSTRUCT2oN Distanee from Souree of I
���st ��==Y 3 �-- �.
Distanee ir°°� vels
Pollution _�pH Static Water I.e �.
� Yield: � in��es
Total �Pth= 2oneas• M�th:�Ft. D�°tuj
Water Bearin=h: �O1Q �J LO steel
Casiag= �eel Ga]vanized yes ��p
o.mez aPP � Grouad:��„Inclies
TYPEs If Ste� z Heiqht Abo�
TLickness: �_
Meight: —Yesz �ingy Yes,� No�
Drive Shoe � Settis+9 t�e
Were Psoblems En�°�tued �
Zf yeE� 91`� reasons ��nt: Concrete
Grout: 1YPe� Heat �� Inc.t�as �
�nular Space Width No��
iiatez in l�nulas SPau= Yes� � poured�-
d
DePth: Fro■ to Ft" pt y,leight of
Used: No. Ba9s Portla�d Ce�e �_
. Materials lbs. to
1 baq — a�l. euttis+9s) -�tioz Mo _
If snixtuze lsand� �osisiation: Y��—
ID Ylatesb Yes�o —
4 = 4 sla
� � - - �3AT ?HZS
�0� IHgpgMA2ION ZS C0� 5 �� 87
I �EgEgY GERSIF7 T�TI�CCORDANCE REGSJ
�yl, wA5 CONSTRUCfED D
C��_��H_yEE-YERSON DIST-
51gnature of Con�a
Date
gEASON F08 1b
Sketch �u 1o�tioa on reven�
P���' . �
Saaitarian's Sicaatnze
Date
side. Use establi��d r�f�ence
,�p4lication flate: �'-�� r
Amount Paid: � �
Rec�iat #: �
Tax Map #: � ��
Parcal #: � 3 J
P�rson Cauntv Heaith Department
Environmental Health 5�ct�an � : , ., -� _,
APPLICATION FOR SERVEC�S " "� . :
IF THE 1NFORMATION IN THE APPLlCATION FOR Ald IMPROVEMENT PERMIT IS FALSIFIED, C�iANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOl1AE INVALID.
1) Permlt requested by: (Owner/agenUprospective owner):,��l��.e/ ,� �,'clrm,�Q �; ,L.�f,;�,,cJ
Home Phone: _�,i_ �-�¢�i Address: �9 .D�-,� L,��-
Business Phone: a�i_. _ 9aa� �� :��,.� ;t.�N. z��73
,
2) Name and address of current owner. �a�.,r� �.s a6ov�
3) Property Description: �ot slze: /, ��OG Township: ��Q/�
Directions to the property (Including road names and numbers):
� .U, o,� C/�cd La�f ���S�t3SS�
T'��.,, P�qh 7�c1 Da� C�c -
L-7_'— P.ojearr� ew /�'�-.
4) Propnsed Use and Structure Description: answer each of the following questions:
a) Proposed� Existing ❑
b) Sdcic Built �, Modular� Single Wide �, Double Wde ❑ �
c) Number of Bedrooms: _� d) Number of occupants or people to be served: 3
e) Basement: Yes �, No � lf yes, # of basement fixtures: '- ' '�� "
a� : . .�^w�h��c. �:d�.���l. Y�s 0, ��3� . •- - --_ . _ _ ,._ .. _�. _ . . _ . _ ,
. .. ,,
~ g) Dimensions of Proposed SWcture: Width: � Depth: �f3 `�
5) Water Suppiy Type: Private 0(new 0 or existing�, Public �, Community 0, Spring ❑
. Are any weils on adjoining property? Yes� No ❑ If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
Conventional _Modified Conventional Alternative. _Innovative
� Other (specify): ,�x�sr.�J �'�uv�.�. �c�e%
CLF.�4RLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACIi SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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 ma�dmum facilities to be
placed on the property. I understand if the site is altered or the irrtended use changes, the permit shail become invalid. t understand
that as applicarrt. ! am responsible for identifying and marking property lines, comers and making the siie accassible for the
personnei of the Person Courrtyr Heaith Department to condud their evaluations. I understand that I am responsible for notifying the
Heaith Department ifi my property contains any wetlands as designated by the Army Corps af Engineers.
�- 8-�/
Owner or a epresentative Date
PCHD, rev. 10/12l99
�
. y'
;,�
l�
Pe.rson CounLy Heaith Oepartment
�xistiaq Sewage System Report For: Hobile Home Replace�enz
� Addition
Requestee: �U�I%'�� � �����
lq �rn�e �-�,. -
�b �(�� � -27 �� 3
--r--� . �
Home Phone�J��-(1���/
Business� ��� Q���
�
� Tax Hap� l ��7
i . -- -
Location/Directionsa ►" ICV�`�7 j"G��1 `` ,• (�, t'Jw� lJt�1V_�Ci—'
✓�� ;,,�, - Rd� . �/ � p�� � . �
,
Original� Permit Located � . .
8eptic System D igned Ear:. . _.
Kesidenzial Business Other (specify)
� E3edrooms � � Employees Other
� /� Q� C/
llate Install.ed ��"l �� v Water supply _� 1
T yg e o t 5 y s t e tn l�i�il/1Pf'�✓1�� ��
Nitrification Line. �l�v ( ��(
Tank Size ��� gC���
Certified Operatcr Required
ma
Yermission
On site c�aste�tater disposal system slicwes no visually apparent
].function on ������ �
.�.
According to the attached
Environme.ntal Kealth g'�G.
��
� � ���
DATE
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