A36 4AThe District i-iealfh Departmenf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
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Dat �
Name of owner. ', t`_i 4�rt�. �"� C' :� l a� G� n�
Name of contractor:
Address and Directions
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Person or firm doing instaUation: sJ 1 m.�'�j"1 j�t— ��'� �-�
Address �� � 1 � C� � �%, �� i
No. of persons to be served Bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing_
machine
Re—com�mended: Septic ta aC'�
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus3 be inspecied and
approved by a member of ihe Disfrict Health Departmen� siaff 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)
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A�altration Dat�: a - 7-��
Amount ��ld: ___y7�
Re�i� #:
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7ax Ma� #: � 3 �
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APPl.ICA770M Ft3�SE3iVIC�B •
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•f� TW� INF�RNWTION IN TNE AQPl:ICATIOAI F�R AN Il1A�ROVE�UlENT P�iMrI' 18� INCORRE�'T FAL8�FiE� .
C!-IANGED C�R T�IE �ITE IS ALTFRED TWEA! THE IAAPRl�i�i{A�PT PERAAIT Ai�ID AUT'H�ORi�►►'i'tOP170 ..
GOi�iS UC'T SHALL BE�nYE IWVALID. � -.
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�a P�c ��a t�r: co,���rr��,�Q o� _J , s,u N�s ��
Ho�,a �: � � c� a �� adar�� �� ,i ^ � � ' r�
Busimess Phone: 2s�/ Z � �N °/' r s �t, l i � � Q
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�) �s a�ec! �dldlreas �`' c�nt av�ee; ,�� ����' r�C C e��u N S�u+ � �d e al
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3� Pe�per�I D�cri�orr: Lat size: �_ Tawrishlp:
D(r�tions io the prog�dj/ (lna�uding,ra,ad n�ames�and
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Lat #
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4) l�r��so�d U� ae�d Stnar.tur� D�ri�stion: answer eaci� af the tolinwing quest�s: �
� a) Proposeei . Existing ✓Typ� af Struc�ure: " Width: � Depth _____�^
b) Numher of 6edrooms- � Alumber of acaupar�ts or peo�te ta be� served: . •
c) 6asement Yss fNo Wi�l there be piumbing in•the•hasemanYt
d) 6aryage Dispasat: Yes� No _�
��� �PPj� T�IP� Prlvate _(newr _ ar existing_.). Pubitc,� Commw�ity�_._.� SP�9 �
Ara any welis an adjaintng properiy? Yes Ala _ lf yes, pl� ind�ate appraoclmata locattori on th�
.sibe pi�n. •
8� Do� your prope�{ contain�r�riou�ty ld�nt�ad Jwisdltctl�r►�1 w�tl�na�? Yes No
Pl.�4SE �OiE THE FOL1yOWlIdG:
➢ A Pl.AT OF TWE P940PE�PTY Oit Sf'CE PLi1�! H�U�T HE SU80�iCfE� U4P1"[t�i '�6�i1S �l.1C�T10N.
➢ PROPEitTY LlNES AND CORNER� fIA1JJ7 BE CLEl1RLY MAR�. •.,
9 THE PROPOSED LOC�4TIOM OF ALL 9TRUCTURES i1A�19T BIE STA� OR FiAGt��.
9 TNE �1TE MUST BE REA191LY ACCFSSI�L� F�12 tiN EV,ALUATtOA{ Blf THE HE�►L.TH D�ARTME�IT
STAFF. • • �
1 h�reby make applic�tion to the Person County Heaith Departrnent for a siie evaluati�n for the on-si�s s�rwaga disposal.
sy for the ab�ve-descrii�ed prop�ety. 1 agree that th� caritents of this appi'u�tion are trus and represent the maximu�.
f�ciii� ta he placad on the pr . I und�{st�nd ifi the � is ait�red ar the intend�d use changes, tY►e permit sha�
beca irniaitd. (
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Cwner
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Date
Pc•�a, ��. osr271aa
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Applicant:
Location: �
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T��x M�aE� P�rcel #
S�orb ciii v i•s�i o n
Fh���se Section Lot #
11.�-11 '�Lc> > 1�u•,.a� �,,. %—�i � 1
Improvement Permit `-�'�^�
Permit Valid for ✓�'ive Years No Ezpiration .
Type of Facility: �i;�r� �G••..1u �<k�.�. -(= x�� New'� Addition Water Supply U�
# of Occupants�p MC,,,� # o�f B�rooms 3 .rojected Daily Flow �to� g.p.d. �
Proposed Wastewater System: . Type:
Proposed Repair: CA„�wer-t-,�..5� - i2c.�a..,. Type: .
Permit Conditions: ( a�� rc�yxav- ln�;} c�.�a ���;�1�__ �` �« sc ���. �-� o.� �� .�-
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Owner or Legal Representative Signature: / l�-' �` /d—'' � Date:
Authorized Sta.te Agent: �,,.,,�,�� „ " Date: i�- y-��
The issuance of this permit by the Health Departmeiit in does not guarantee the issuance of other permits. It is the responsibility of the
a}�plicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement Permit is subject to revocation if the site plan, plat or the intended iise changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Autho.rization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: l��v�ti� Type � a- Wastewater Flow �g.p.d.
New ✓ R air Ex ansion Soil LTAR: • a�'s g.p.d./ ft 2
Type of Facility: r 't i,� Basement _ Yes ✓ No
Wastewater System Requirements '
Tank Size: Septic Tank: �r�'s�r,a gal Pnmp Tank: — gal Grease Trap: � gal
Drainfield: Tota1 Area: �2�o Q sq ft Total Length �/� ft Mazimum Trench Depth z y in
Trench Width � ft Minimum Soil Cover: Co in
Distribution: � Distribution Box 7� Serial Distribution
0
Minimum Trench Separation: �-t� ft
Pressure Manifold
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Authorized State Agent: � ��,,
Permit Expiration Date:
The type of system permitted is _
the permit.
Owner/Legal Representative:�
.�o
Date: /v� /- �S/
Alternative. I accept the specifications of
Date:
PCHD7/30/2002
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Name ��S Lu,g� Tax Ma� #� A3co Pascel #� A
Subdivision � ��� '� � Section/Lot#
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Autho ' ed te Agent . � r- Date .
'� System cnm�ionents rc�br�esent a�ipmximate�contours only. The contractnr musf, flag the system prior to
. beginning the instaAa�ion to irisurs tha�t propergmde is maintained
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pGi-�, rev. 09/12/01