A36 8The District Heaith Depc�rfinent
Orange, Person, Chatham, Lee Counties
SEPTIC T�►I�K PERMIT
Date _� � � � - ` � ��'-' -
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of owner ��� ��Td1's - � ` :3 �; r ��:'t �
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Address and Directions ,. � � ;'' � f _ r - �
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Person or firm+,doing installation: �� , � '` ""
�
Address
No. of persons to be served bedrooms 1, 2, 3, 4.
Additional appliances to � be used: Disposal, dishwasher, washing
machine
Minimum ftequirements: Septic tank �
,`l.,lt�. 1.� i,� ., ir .._ . r #,� y�,�'..<
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Nitrification line: � t-;..��' -e
t
Septic tank and nitrification line mus! be inspecied and approved by
a member of the Health Departmeni staff before any portion of the
installation is covered.
Date Approved: �
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4: _ �
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By: - y ,r� r' ` `�,1. tx ,
.: S9nitar',ra�}i' VJ�
t t/ �
O. David Garvin, M.D., M.P.Fi.
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.
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i
The Districf Health Deparfinent
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date �- -1 � - 1��4-,
Name of owner: ��� d�/'t Gf l�l �� %� �"j �=�� � 1'�
Name of contractor: � � i �
Address and D'uections ��` � � �'� `' ��! A' �%� � �-' r
,
n') !'i � � �� � � F n,� '� '' i'1 L� � ,
Person or fum doing installation: '' f�L1S"�
Address ��cW„��---�� �.
No. of persons to be.served Bedrooms 1,Q 3, 4.
Additional appliances to be used: _ Disposal, dishwasher, washing
machine 11�21 �'
Recommended: Septic ta �
Nitrification line: 8 ( � / � IQr
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the District Health Department staff before
any portion of the installation is covered.
Date Approved: L�-- f �"'
gy �
� Countersigned
Signed -
Sanitarian
O. David Garvin, M.D., M.P.H.
District Iiealth Officer
(Over)
NOTE:
�ti.�
� �� �
�
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.
Applicatton Date: � ���� � � Tax Maa #: �.3 �
Amount Paid: i 2. .00 �
Recei t : ParcEl #:
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APPLlCATIOM FOR SERVIC�S �
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IF THE INFORMATtON IN THE APPLlCAT10N FOR AN -IMPROVEMENT PERIIflIT 1S INCORRECT. FALSIFlED,
CHAfVGED OR THE SITE IS ALTERED THEN! THE INiPROVEMENT PERMIT AiVD AUTHORIZA110N TO
CONSTRUCT SHALL BECOME INVALID. • �
�1) Permit requested by: (Owner/agentlprospective owner): � � �����
Home Phone: �.S'�/9- 3 3S7i Address: , S ��
Business Phone: 1� }�i �c�0., � � � � � ��,�>y� "
_:4.�.,..2) Name and address of curre�t owne�:
. `�Y' �
3j Property Description: Lot size:3, l Township:
Directions to the pro
Subdivision: Lot #
4) proposed Use and Structure Description: answer each of the following questions:
a) Proposed , Existing � Type of Structure: Width: � Depth:
b) Number of Bedrooms: v Number of occupants or people to be served: �
c) Basement: Yes , No � Wiil there be plumbing in the basement?
d) 6arbage Disposal: Yes , No�
, , -
5) Water Suppiy Type: Private _(new _ or existing � Fublic_, Community_, Spring _
Are any wells on adjoining property? YesyNo _ If yes, please indicate approximate location on the
�siie plan.
�'6) Does your property contain previously identified jurisdictionai wetlands? Yes_, Ido_
�
PLEASE NOTE THE FaLLOWING: _
➢ A PLd1T OF THE PROPERTY QR SiT� PLAN MUST BE SUBMITTED WRH THIS APPUCATION.
➢ PROPERTY L1NES AND CORNERS iIAUST BE CLEa1RLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAafED OR FLAGGED.
9 THE SITE iNUST BE READILY ACCESSIBL� FOR AN EVALUATION BY THE�HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a siie evaluation for the on-siie sewage disposaf
system for the above-described p�operty. I agree that the contents of this application are frue and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the' permit shall
become� invalid.
Owner or Legal
�S
Date
PCi-ID, rev. 06127/02
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l�aaoiro� �+-�-++ m��m.71 ' IE�om]L�]!a
,SITE PLAN
Nam Cl 8'X1�t'�'�`^� Taa Nfap # ��D Parcel #.�
Sub ' ' " Sectioa/Lot#
l� - —0 �
Authorized State Agent Date �
Sysrem cvmpnaeats reprrsear sppmximsre conmurs anly. 73e c,anuacmrmust9ag t6e syaum prior m begiaamg t6e mst�ll�don tn
:n�,•,*. �atpmpagnde is msinraiaed
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SI'I'E LAYOUT
Tax Map #: /r/ � � Parcel # �,_ Township
Applicant: y��ia��"
Subdivision• Secdon• Lot•
Location:
1�c(����5 � l�i,� � r �� —�' (� �f- a�- -� �� ��, s � ��
Ty,�e of Water Suvulv: � IndiPidual Communitp Public
Rec�uuements:
Site Approved by
Grouting Approved by
Well Log
Well Ta� .
Air Vent
Hose Bib
Concrete Slab
Well Driller.
Well Approved By: Date:
'�°5ee Attached Site Sketch'�*
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Od�er conditions:
PC�ID, rev. 09/07/01