A36 19� � , e .�
` �" The District Heolth Department
• CASWELL - CHATHAM - LEE - PERSON COUNTIES
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s Water Supply and Sewage Disposal
IMPROVEMENTS��ERM�IT' Na �
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p � Owner: �� � P � � �� 1� tZC' �
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Location:
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� Water Supplys Private _�.� Public
Sewaqe Dispoual Facililies: No. bedrooms Dishwasher, Disposal,
washing machin t r auto�tic appliances
Size of tank: NitriRcation line:
�'1 C"iti l v� I'
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-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IN L TION IS COV-
ERED AND PUT INTO USE.
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Date approved: Sign
Sani i
Well:
Sewage Disposal: Counte -
signed
BY� (O ner or his representative)
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CertiScate of Completion t f ; �
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Date Approved: � ' By: � � '�
S itarian
(OVEB)
Location of well and sewage disposal facilities sketched on bacic.
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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.
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APPLICATION FOR SERVICES
Improvements Permit. (Established/Recorded Lot)
ments Permit (Unrecorded Lot)
ments Permit (Mobile Home Replace)
of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
I_ Improvements Permit (Addition) I Replace Existing Well �
1. Permit requested by: . - 7. Dimensions or Proposed Structure:
owner/prospective owner/agent:�l /��'%��� .� ` Width: � r�
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W_ � d�rw.v
� Home Phone #:
a
usiness Phone #:
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Name,and address
�S�l� 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
�`��� that this sewage disposal system is intended to serve?
ent wner: 9. Water supply t5•pe:
:J��l�c�:�� private �. public ❑ community ❑ spring ❑
�� � �, Are any wells on adjoining property?Yes ❑ No [�.
�� � 2 S`� '3 If so, identify location:
Description: Lot size: I Gi, c.rP
Tax Map#: �- 3 (
Parcel#: � / 9'
Townshin: � °Di� 5�� �-
Directions to property: State Road #& Road
ames,�tc.
Number of occupants or people to be served: 3
10. Type of structure/facility: Proposed: DExisting: Q
Type of dwelling: ��
House: l� Mobile Home: L�]'Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No (�"
Basement? Yes ❑ No�If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COunty Heal�h Depai'tment 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 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after [he date of the evaluation of
the site by the Health Dept., this application sh�become void s pa' �eiLed �l�
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Permit.,Issued ❑ Signature
Permit Denie� ❑
Plat Observed ❑
Date
..:;`.. ': • FACI'ORS-SITEEVAI.UR770PF `: r 1��.1 . . :i AREC12. . ::: ;< AREX3> ARFAd
1. SLOPE (%) 5 S S S
PS PS PS PS
U U U U
2. SOIL7FJC7iTREp236IN.) S S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:I CLAn PS PS PS PS
U U U U
3. SOIL S7RUCT[JRE (I2•361N.) S S S S
(CL.AYEY SOII.S) PS PS PS PS
U U U U
3. SOILDEP7H(IN.) S S S S
PS PS PS PS
U U U U
S. RES7RIC71VEHOR(ZONS(IN.) S S S S
(IINPERVIOUS STRATA. ROCK) PS PS PS PS
U U U U
6. SOILDRAINAGF/GROUNDWATER S S S S
(F�CI'ERNALR WI'ERNAL) PS PS PS � PS
U U U U
1. SOIL PERMEABiLTi'Y S S S S
(PERCOLOA770N RA'I� PS PS PS PS
u u u u
8. AVAI(.ABLE SPACE S • S S S
PS PS PS PS
U U U U
9. SR'ECLASSIFICATION(SEEBELOW)
SOIL SER1E$
S-SUITADLE PSPROVISIONALLYSUI7'ABLE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope patterns, etC.� C:Wh1iPR01DOCSWPPSEC.SM }�IpNCE.PC
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PERSON COUNTY HEALTH DEPARTMENT 1'' - r%�
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # /g- �j Cp Parcel # % g
Zoning Township �� a Sc-� �
Owner/Contractor ��►'Jr� G e Date — D—
Location/Address Src � Q dH �� �
.R.#
Subdivision Name
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P
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area Size of Tank / S �
Mobile Home Size of Pump Tank
# of Bedrooms�_ Nitrification Line �X � S� i%� a __
� ,• _ � �'„ .0 , , ;,,lo wr/�, �, ,�1,-� Max Depth Trenches
w� �LP �uH
Permits may be voided if site is altered or '
Well and Septic Layout by
Comments:
ed use changed.
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Comments:
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. 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.
c:\amipro\permit.sam O1/95 rev.l.l
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