A40 141The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ond Sewage Disposol
IMPROVEMENTS PERMIT No.
._,� Date : _ � r! ,4-1.'
�._ S Cc, i,� .
Owner: ' � �'�
Location: �—� 'VOIa
J:l�f.� f�`��7 � ' r /% }� e.e
�
a Contractor: �1'��
�
� Wa3er Supplp: Private � Public
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal,
washing machine, other sutomatic appliances
Size of tank: �!��''<<���'�!� f Nitrification >inP� f' "���) �?
Y �%.,�/I' _
�T.i�7 � -�=�-
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 an3 shall be main-
tained by owrier 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 11IEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. ,%.'
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Date approved: Signed_�_ �ff� � � � � `' ' ����'` �
Sanitarian
Well:
Sewage Disposal:
By:
�
Counter- �
signe �
(Owner or his representative)
Certif'icate of Completion
Date A iz- � y-�y
pproved: By:
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on bac;�.
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.
Application Date: 02 -CJ `'( - � Tax l�Iap: ���
A�nount Paid: rarce? #: � 4 I
Receipt�#: �
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1�.: �x�� �-:L r�c> i��z ra <cr r-� �i::...»z 71 I[�� .�.-.�-�.1 v� ��.
I�.���g����on �o�' �e�-vie�s (5eptic Systems and Wells�
Sea-vic�s �e uested
� 3mprovesnent Permit (Site �vatuationj ❑ �onstraction Authorization
�200.00/$300.00 (if > 600 � d) (Fee is dependent on the tyoe of system permitted)
l�Iooile �iome.Repiacement or �uilding �ddition �J Permit Aevision I
$1�0.00(ifsitevisitre uired) �75.00 �
C�'Qil �ermit (idew/Ileplacement/�2epair) 0 Repair of ��isiing Septic System �
$300.00/$200.00/$75.00 No Char�e
�) �ervic�s Requeste y:
Name: c (� Phone # (home): � ��,�
Address: S d � (worlcicell): _ Z
_,'7 �i., � _ ir /i /�-, ���
�
i)Pt�nn� a�d ad rass o�f ��rr��t aw�nea- (9� (�li���9'�31� �han applica��):
Name:
� Address:
�) �ro��r-d� i3eser�gt�o�: Lot Size: ' Subdivision:
Address and/or directions to Property:
�ot #:
4) ��-oQosed Use and 'T3�pe of Struct�are: ,�
Residential Business/Type: Other ��> �
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _) � g X��
Garbage disposal: Yes No
5) �Vater Supply:
Private Well (Proposed Existing �
Community WeII: Public `Vater System: . .
Are there wells on the adjoining properties? No Yes (please show location on site plan)
1'�l;ote: ,� eornplete� n��lication niusE �dso ir�clude:
���lat/site plun of tdcQ �r�per�y t,�iat s,{aotiv.s pr e�er�y dia:�en$ao�s c�nc� t,�ae �ize �c�acl �ocr�tion of r�ll
p�•oposed structures. � .
� A sagned capy af idze `�a� �'r��aration'�'r�r;za veri�yan; that i6ae �ropeYry i� rear�y �o be. ev�aluale�l.
� atra submitting th6s ��pDl�catioi� to �e�uest 3ervic�s #�rosaa t�e �Qr�on �ouniy ?�e:�lth i�epattQr►2�nt. � unc�rsta�d tha�
i$ th�e in#'or�aiion �ravider� 3s i�eaa�rp�t oc i� #:�e ��#e :s sa�s��ue�nt3y al�e�e�, �r i#' i;�Q ;aatended u�e charg�s, a��
per�aa�ts aud app�-avals shafll becarne ia�tialic3. n ,� , /% -
;�ab���u�-� (Cwner!T egal Re�resentative):
�/�,
c./� �3��� :
10i08 Person County inviro�l�nenta! �?ea�th; �"'S S. �iior?an St., Sui�e C; R�Yboro, NG �757: (336-�Q'7-l�'90)
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�7Y1l.�'717L°�bI111.71�71.+�7m..��A..11 ��£:.�A..�1�JCil
Building Additions/ Mobile Home Replacements
T� Map #: .�"j} �t o
Approval Requested for:
Parcel#: /
Mobile Home Replacement
_ /� Building Addition
Applicant Name: �--� ►J�.a �: � C e
Address: �3 0� u,v���e Al�� 1\ S
X b0 �-0 1�1 C� 7�' 7�/- .
Phone #'s: 3 � 4 - 83�3
Pernut Located: ✓ Yes No
Installation Date: rz
Design flow: ,3(,0 (gpd)
Current Contract with Certified Operator on file (if required): �_ �
Water Supply: � ✓ Well � Public or Community •
Wastewater-system shows no visual evidence of failure on: ` o' (d
(Applicant's signature if site visit is not required) x
' � Addition/Replacement Approved
Enviromm �tai ea Specialist
11/15/OS
�rz�� �
Date
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M/�el,09 -,�
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Tax Map #� Parcel #
Existing Sewage System Report For: Mobile Home Repl cement
� Addition Type:
i
Requester: C� Home Phone#
,���'�?� i I'�! �P_ �,�l ��l �,� l�i�� Business #
J
O'' al Pernzit Located: ✓ Water Su 1: �`���
n� pP Y
Septic System Designed For: Residential Business Other
# Bedrooms J # Employees Other
System Type: Tank Size: / Nitrification Line: �%
I�ate Installed: � �- � Certified Operator Required:
/v �
On-site wastewater disposal system shows no visual signs of malfunction on ���Z .
Permission is granted
Comments•
Environmental Health Specialist Date: / �