A39 45. , Ap�itcation Date• 3 "°�'°�'00
Amount Paid: �
ecei t #�
�r
n ��V
C.� �
Person Countv Health Department
Environmental Healtfi Section
Tax Map #•
�arcel #•
. APPUCATION FOR SERVICES .
!F THE INFORMATION IN THE APPLICATION FOR �AN IMPROVEMENT PERMIT IS FALSiFIED. CHANGED. OR THE SITE IS
ALTERED. THENTHE IMPROVEMENT PERMIT ANO AUTHORIZATION TO CONSTRUCT SNALL BECOME INVALID.
1) Permit requestad by: (Ownedagentlprospective owne�: 4i �'tr� K. � a r• d
Home Phone: � Address:
8usiness Phone: �ifl�5��
2) Name and address of current owner. ��� � W adc .��}O� -e_.
3) Property Desc�iptton:
Diractions to the property
4)
���� � ��
�a�vrt��
_ . 5��
�t�:1� T� � � dq �J�tS
H��I..Jl�� ���!
Pcoposed Use and S
a) Proposed 0, Exis�n9 �
b) Stick 8uilt I� Modular �, Single Wide Q, Double Wide �
c) Number of Bedrooms: � � Number of occupants or people to be served:
e) Basemen� Yes�, No � If yes, # of basemeM fixtures:��n I�
fl Garbage Disposal: Yes 0� No 0?
� Oimensions of Proposed 5trtu�ure: Width: Depth:
�I�•.I l'!,1!• i-i [`7!1
� Watsr Suppiy Type: Private$�(new � o� existing �), Public Q Communiiy �. Spring 0
Are arry weUs on adjoining property? Yes �CNo � lf yes, loca�oa
6) Pleaae Indicate Deaired Syatem Type: (systems can be ranked In orde� of your preference)
Conventional Modifled Ccmrentlonal _ Altsmative lnnovative
Other (specify):
' �OG� 1/lOG�5�5
�/
CLEARLY STAKE ALL CORNERS AND LlNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PL.EASE ATTACH SURVEY PWT OR SffE PIAN TO'iHIS APPUCATION
I hereby make appUca�on to the Perao� Caunty Health Department for a site evaluaUon for the on-site sewage dtsposal sYstem fc�
the above-described property. 1 agree that the contencs of lhis appUcatlon are trua and rep�esent the ma�mum faaUNes to ba
placed on the propeciy. I understand if tha site fs altered ar the intended use changea, the permit shall become irnalid. I understand
that as appticant, i am responslbte foc idenWying and marlcin9 ProP�Y lines, comers and making the site aaessi'ble for the
personnei of the Person CcuMy Heaith Depa�tme� to condud their evaluatlons. l understand that 1 am responsible tor notifying the
Heaith Departrnant if my property contains any wetlands as designated by tha Army Corps of Engineers.
`}C.►�, • `1-4. . C���.
Owner or Legal Representative .
3— �.z.-Oo
Date
;. •
�� A 1683
���
PERSON COUNTY HEAL'TH D�PARTMENT
WELL A�TD SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # f� .� � Parcel # �-} JN
Zoning Tp nshi c �• s a"�
Owner/Contractor M��`a��0.�n'e''"' Date� 27�
Location/Address G�G � ��
G,��i� ��n � Il►« S.R.#
Sutidivision N�cne
t.�y�ut
\
�
�
,
� �
�
�
�
a
�� �Yi
, A �'li fl �
C�
►
��
Lot#
Installed
o�,�.p � i ta�� wli,00a ��
I VlSi�,G� S�I O n CU �) iDG�,f' G� �V l l��
0,(,t�- f� �ti�
Sy5-feV� CeX(5 ) �� ���'�'
- wl� �- � � �;�'W' w/
�5�1c� f
- r �i�V�i�WI (�l?' �V�D1M
�r� � �Y�vf" lD' Dl'YI � �Ord�
`5fo�oG�%eQUel����� ow� ���st�
� re►rn . v� ��. - -� � � --..�„�. � .., ��_� �
AGE SYST�M SPECIFICATIONS
Repair Lot Area ) ClCYe Size of Tank���f'/Cr�•
SFD �� Mobile Home Size of Pump Tank ��
Business # of Bedrooms_,� Nitrification Line �h � X��
Max Depth Trenches 1� ��
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is a tered or intended use changed.
Well and Septic Layout by
Comments: /�G�L( `{'D , � cSl l � P
Site
Well
Comments:
Date
Installed by
by.
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Zeplace nt Air Vent
Rq d �
e T
Installed by
Approved by
This report is based in part on infortnation provided the homeowner or hisJher representative in the application submitted for this petmit The
environmental health specialist is not responsible for false or misleading infotmation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Peison 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.
ORIGINAL
c:�amipro�permitsam Ol/95 rev.1.0
Gl,���s(
� f��
rv1�
The Di�trict f-lealfh Department ;
Orange, Person, Caswell, Chatham, Lee Counties
�SEPTIC TANK PERMIT
Dat � � �
Name of owner ��'����� �%/T' �
�–. ., � w -
Address and Directions �
�
Person or firm�lejng inst ation: �
.. �l/ -
Address —' .�a� �J
No. of persons to be served bedrooms 1; 2, �4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank "
Nitrification line: �d �����
Septic tank and nitrification line musf be inspec3ed and approved by
a member of !he Healfh Department siaff before any portion of the
installation is covered.
Countersigned
P :
Sanitarian �
O. David Garvin, M,D., M.P.H.
District Health Officer �
• .
i
.i . . ' . � . . .
<Over) ' .
. � ;. :, . .
,
;
. : . . , . . . _ . .. . ..._ , , -- - . . .. . _ _ .. . _ . .__ __._ __ _..._ .. _ _. .__� _. __........ _._.� . ...... ... .. .. _ .. _... . .. _... . . . _ _._ ._.... .
�.
ike sketch of installation showing location of house, septic tanks, privies, water supplies on
jacent property, etc. Write in measurements in order that installations may be located at later
:e.. � ; .
;
i .
1