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The Distri¢f Healfh Deparfinenf
Or�nge, Person. Cesgvell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date � i��'� ' J �i� "' V7�
�11 II�II r+L..._.. L
Name of owner:.
Name of contractor:
Address and Directions ��,. �' � "� ►
u.�1� ./` ;�1 _L � ��,,r,�E�.
. - . - - - � - � . . :
Person or firm doing installation: '
Address
i �;1 U 1� C�
No. of persons to be served .;,,.
Additional ,appliances to be used: Disposal, dishwasher, washing
machine ; � � CI �', .
Recommended� . . ..,. � _ Septic tan ' �� 1
Nitrification line: L�—Tx � ^++ +. ,i , i
�� .
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mu�s� be inspected aad
approved by a meiiiber�of tiie Districi�Heal2h Depa*tment staff before
any portion oi the installation is covered.
'' t .t:.
Signe� � '� � 1'
Sanita�ian �
O. David Garv�n, M.D., M.P.H.
District Health Officer
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COuntersigned . .
(Over) ,
...-._.. CY.�,F .. ' . � y' . . `� .
Date Approved:. �0:"'�6''��
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Application Date: � �� ��—Q � Tax Mao #: ���
Amount Paid: 1 �� /
Rec�iQt #: �'7 1 �i � Parrx! #: fO
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APPLlCATION FOR SERVIC�S �
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMEiVT PERMIT IS IPICORRECT. Fl4LSIFiEfl,
CHANGE� OR THE SITE IS ALTERED THE1N THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
COIVSTRUCT SHALL BECOMEINVALID. -
1) Permit requested by: (Owne age prospective owne�: ��.5 -�-�C'
G�-u--�t°irte-P�oRe: 33 �.'3 Address: �� i�-i�'(Z�l 5 n t�V � gl a IS
Business Phone: ��_�,,�q - 5a�s Tiu..� Lt �l CsT o�J . tv -� 7
2) Mame and address of cumerrt owne� C. i ��-� �1 S 1 C��-��
� L.L. G t�LGk� �� '
� " U
3) Property Description: Lot size: ��� Township:
Directions to the property (Including road names and numbers):
Lot #�
4) proposed Use apd Struciure Description: answer each of the foilowing questions: [t � i �j
a) Proposed v. Existing �' , Type of Struciure: � G� � ��11i idth: � I Depth:�
b) Number of Bedrooms: "�-� Number of occupants or peopie to be served: �,��'S' �� 4C6� 5(J�N �
c) Basement Yes , No �= tNill there be plumbing in the basement? - � C-3 S�,�, N�� FJl�- M�
d) 6arbage Disposal: Yes , No _-
5) Water Supply Type: Private�/ (new _ or existing�, Pubiic� Community� , Spring _
Are any welis on adjoining properiy? Yes_ No _ If yes, piease indicate approximate locatiori o� the
'site plan.
6) Does ycur property carrtain previously identified jurisdictionai wetlands? Yes_ No��
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN' MUST BE SUBMITTED WITH THIS APPLICATiON.
➢ PROPERTY LlNES AND CORNEI2S MUST BE CtEARLY MARKED. �,
➢ THE PROPOSED LOCATION aF ALL STRUCTURES M1JST SE STAI�D OR FLAGGED.
➢ THE S1TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. �
I hereby make appiication to the Person Caunty Health Department for a siie evaluation for the on-siie sewage disposa!
system for the above-described property. I agree that the contents of this apQlication are true and represent the maximum
facilities to be placed on the property. I understand if the siie is aitered or the intended use cf�anges, the permii st�all
became invalid. . -
or Legal Representative
/D -1 1-n �
Date
PCND, rev. 06127/02
Application Date: � —�3� �
Amount Paid: l��
RECEl�#: I �J L� R�
Tax Maa #: �`' ��
ParcE! �t• �
� q 37 �-.-�`-��_.�� I�I�I�.� ��T
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���� APPLlCATION FOR SERVICES
..:.. .. ..: .... .. . ..
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-:::::::�::::,.::,:::,.;;.,-,:�.:,.>;:.;:.;:.;>�;.::;:.:;:.;::::� .:.:::::::::::::.::::.:::� ' cariee�: � d�';>::>:>::>�-::T><::<:`::
``�, /� ;;>:.;:r;:: <..: _ ::<:.::..;;�.;�..::;.;::;:.;::,_.,:... �:Se .:..... ... �q: ..� :.,:..:::. ;..
� Ju ❑ improvements Permit (Recorded lot) -$2D0 00 Well Permit (Nern
�� ��1 ❑ ImpravementsPermit-$150.OU ❑ nstrtkttonAuU
o-...� ,��, / (Mobile Home Replacement/Addttion) $150.001$200.00
�� �� ❑ RepaidReptace Existing System Permit ' ❑ Permit Revision f
CO(�ISTRUCT SHALL BECOAflE INVALID.
❑�
� 1) Permii reques4ed by: (Owned�c ent/prospective owner): � � �� � �-���� �� �j —�-J`' � '
- e: �3 � �'�S 5�O 7-�3 Address: �t f z 2 �-� A�� t 5 n(�,��
• � Business Phorie: 3 3 G, '1 � q-$�'3S "i� l�y� j r�� r r � ni r l. �, a 7�,<S �
�ax .�:;6-3.�9-q4 l �-- � -
2) Wame and address of currertt own�r. LL. �� ��� �-t- � E{ c�z�..�- _
� � �= ��-c�
3j Prape Description: Lot s�ze: Township: Subdivision: Lot #
Directions to the property (Including road names and numbers): �
4) P'roposed Use and $tructure Description: answer eact� of the following questions: ,
a) Proposed . Existing , Type of Structure: Width: � Depth: �,
b) Number of BedFooms: � �. Number of occupants or people to be served: _
c) Basement Ye� , No _ Wiil there be plumbing in the basement? �
d) 6arbage Disposal: Yes _; No _ �
5) Water Supply� Type: Private +�ew _ or existing L", �ubl'�c� Community , Spring _
� are any wetis on adjoining propetty? Yes��Pdo _ If yes, please indicate approximate location o� the
'site plan. � � - ',�
6) Does your property cantain �ireviausfy identified jurisdiciional wetlands? Yes_ No L---
,
PLEASE NOTE THE fOLLOWING:
➢ A PLAT OF THE PROPE3ZT1( OR SITE PLAid MUST BE SUBMITTED WITH THIS APPLHCATION.
9 PROPE� LINES AIdD CORNERS MUST BE CLEARLY MARKED. -,
➢ THE PROPOSED LOCAT10T1 OF ALL STRUCTURES MUST BE STA6�D OR FLAGGED.
��IiE S1TE NiUST BE READILY ACCESSiBLE FOR AN EVALUATIOPI BY THE HEALTH DE�ARTMENT
STAF�: �
I hereby make application to the Perso� County Health Department 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 piaced on the property. I understand if the site is altered or #he intended use ct�anges, the permit sf�all
become invalid.
�= � z-���� G- � ��� - 0 7
or Legai Representative � Date
PCND, rev. 06127/02
S1TE�
� !09 _
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VICINITY �AAP
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E.Y. IIIlKfR50N PROPERTY
PLAT CAB _ , HANGER _�
FIIED IN PERSON [d.NlY REOISTER OF DEEDS ON TNE
_��_ DAY OF �__W_. t0___ 0___� 0'CIOCK __Y.
""'�'_�_"""""""""'�'�""-'
flE6ISTER OF OEEDS � .
LEGENO
� • NA1L FOUND .
NS o NAiI SET
IF • lRON FOUNO �
IS o IRON SEi
11P O LATHENA7ICAL
POINT
C41 ■ CONCRETE MONUMENT
FOUNO
ura[ss stw+Eo. seN.eo uro o�Teo, n��s �s �
PRELIY(NAR7 PIAT, NOT FOR FECORDATlp1, SALES
on ca�veru�ces.
HAMLEfT-JENNINGS
& ASSOCIATES, P.A. •�•
PRDFESSIONAI tANO SURVEYORS �
212 S LANAR STREEi - PO BOX I266
rmxeoao rroRrN ccnnnouru vs»
(338) 598-9742 '
N/F
[.Y. 11ILItER50N PROPERTY
�.-7— a - :�_.,�. � "'
PLAT OF SURVEY
MILL HILL ��
BAPTIST CHUIRCH
OLIVE HILL TWP., PERSON COUNTY, N.C.
OCTOBER 2006, HAMLETT-JENNINGS 8 ASSOCIATES
212 S. LAMAR STREET, ROXBORO, N.C.
- N� JOHN J. JENNINGS� L-3052
,_. .. . . _ .. _ J06 tAttA1.PROPERTY ,... _._ . � i -_. _. .�. . i I . f ' �I
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/� /' � NEAI C. M�MLCTT^ CERTIFY 1MAT TNIS
SURVEY IS OF hM Ex(STINO OutCEI IOR PARCELS)
� ' � tITHIN .P�� _ COUt/TY AS RECORDED IN OEED BOOK
♦� / /' ' ALL PROYIS10N5 OFANORTH GMOLPNA 6ENENALPSTATIITEL•
� 1� . q-]O �$ A1EA�ED RfQARDiNO TNIS SURYEY HAV! BCCN
• Ow j /' IET. IIITNESS W NAND AND SEAI TNIS �11_ OAY OF
OS�LQREQ_. 20_Q6_.
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/ � PLAi pA5 ORAIM UOER YY SUPERVISfOX fRON
/ AN ACNAL SUtYE) �AOE UNOER MY SLPERV(SION
/ � fDEED OESCRIP710N HECOROED IN BOON r�.
r / pAGE ___, fiCJf0i1fR): THAT iN! BNNUARIfS
� / NOi SIINYETED FRE ttEAFLT INDILATEO AS ORArN
/ � , FNOY IIFOWWiION FOUO IN e00K ..L. PAGE
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% IXX.ATEO IS t:_J9.1iA4t�: THA7 TH�S PLAT 11A!
� % '�OQ:'�� SS/ �' 'Y '. PN[PAREO IN ACCOqDNK£ �ITN 6.5. 17-30 AS
� �=..046 o,y.'� :: u+er+oeo. i�rr+css w antouu� staunne.
� / � 4 7� � REQISTR�TIpI NU4BEl1 ANO SCAL TXIS �1_ CA1' '
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� � ' �.. � • • RECISTRATION MA�BER "'�'S'I�83.��"
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�uiiding Addfltions/ l�o�ile �oane Re�iac��ae�ats
Tax Map #:�
Approval Requested for:
Applican
Address:
Phone #'
Parcel#:
Mobile Home Replacement
� Buildin� Addition
Permit Located: � Yes No
' Installation Date: — ' i0 Design flow: (gpd)
Current Contract with Certified Operator on file (if required): �
Water Supply: _� Well Public or Community
Wastewater system shows no visual evidence of fa.ilure on: �l% '� 3l'� �P -(date)
� (Applicant's signature if site visit is not required)
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Comments:
,
� � r�r�di�aon/I�.eplac��nent App�aved
l..0 vl/��
Env' ental Health Specialist
11/1�/OS
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0 31-��
Date
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`YY L' LY.r ��g`iTal A �
Pg,�SE SEE .A3�A�ID P�r�1V �'OR WELL S� �A.�I'O�
A . .. .
Tax Map /}L ( Parcel #
Applicanf: � �. ,�
Subdivision:
Location: � A �---
.. ;
'T e of'PVater �Su I : ✓ Individual
S'P PP Y_ ._ Community Pubhc
Itequirements:
Sita Approved By: �
Grouting Approved By: r,�o Z�
Well Log• � w.r(( � � . '
Pump Tag: � .
Well Tag: '
Air Vent: ' .
Hose Bib: �
Casing Height: '
Concrete S1ab: � � � ' �
Well Driller• �v �.n I�r S'
Well Approved by:
*�**�ee.tlttached Site Sketch****
Liner:
'Installed by: _
Depth set: _
Grouted•
Date:
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems,
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:,
�
PCHD rev 01.�27/04
05/23/2007 09:45 3365670840 CUMMINGS PAGE 01/91
,,.. ., , .,.,. . . . _
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� c��:� .��-�°��.� �oo�� � � -�—
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�a�a��a�-��:ei��aa;�aG..�7L,� �"�c��n.I�,�C�,i�<, d D 7 �i ~I
Grout �og
Owner: P�'I �'/% %-+��%/ � S� ����r� Tax MAp � Parce1 �# �
�ocation� '!/ /�.1/
Subd'zvision• �t � -�—�-
We� Co straction
Distance �xom nearest Pra�erty Line (N�inimum 10 %et) 00 �
Dxstance frozn Septie Systena (Minianum GO feet) .<� 00____
Total ]7epth: o�r7.0 ft Xxeld: 'o2G GPM Statie Watex' Le�ea: � f�
Water Beariug Zones: ]7epth %'•1g - ft o`�oS �t ft -�
Casing: 1 � ��� in
Aepth• Froxn �" ! to � ,S ft. � Diametex•
'i�pe; �Galvan.ized Steel r
��i��: ����g�: , �� Heigb,t above Ground: %3 iuR �
Dri�ve Shoe: � Xes No Any problerns encountered wk�ile sctting casi�g'i Yes ,,� No
� "yes" �1VC ieason:
Gront: �
Neat: Sand/Cement .X Concrete CrraveUCemeaat �,�„
. �. ,Axmul�r Space Width �_ ivach,es `Watez in Annular Space ites � No
, 11�ethod of Cs�vut: Pumped �zessuYe Poured i� ]7epth d--- to 2�j-- Ft.
1V,Iaterials Used: � ,!� � g g''� poux�,ds .
No. Baga �'ortlax�d cement Wei t o£ 1 Ba
If mixiute (sand, grave�, cuttini$s) - Raho 1 to �
ID plat�s: � Yes ��o � 4 x� slab LC Xes � No
Liuer:
� Deptla: �ate Installed: �� Grout: ?natallcd by:
To
Dri�ing Log
Loca�vn Drawii�ng
Format�on► . � �,,,�; / j .
sa�� rl.�! �
�e ,
� 1,eas� �S 2��
I hcrcby certiry that the above information is Gozrect
by the �erson Cou�ty Health Dcpartment. /,
� � , y�
S�gnatare of Contractor Cr-� ��
�,ttti t}�e �y��l was constructed in �iccordance witk� regulatiox�s eet fortb
�# ��.37 vate ,S~17-a�.
�a�taUAnent
�ump Installation Contractor: C. "�'' "'�"'7-� D�"� l0^"^ ��^ ��- State Registration Number: %� $�
Puznp �eptih: % 8'd ft Static Water Level: 3 6 � J
Pump M�ilce & 1V�odel: t �c% � Pump Si�� and Ratang: �/Z hp �� gpm
Y hc�reby certify that this p�n�p w�s installed and the wel� k�ead co�Ietcd accoxding to tb,e Person County Well Rulcs in eff�ct
on tlus date aud that a copy o� tkais rccard k�as been pr ' tv the weil owner. ,
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.. � _.._��__ c+!.......a...... / • / - ' • . � llatB: �r� ! � � ( PCHA xev O1/27/04
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STTE PLAN '
• t n'
Name � I �-I'l Ll Tzz Map #�Parcd #�
S n Secu�u/I,or#
�—ZY --� 7
Au ' ed Stabe Ageat Dau
Syaum rnmP°aents �eat aPP�a�aeae cantarae anly. Tlu canuacmrmuattlag t4e sysrrmpaiar m begma�g �e�srailartau tn
�= r1�rPmoPergraderamsram�aed I+�
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. � �5����
Si�ewQ(K
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� ys1 �1"e I'�
eX�s`f�'�
�,e l�
i� �ron�f'
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Marrn�a�.n. 100 �ov�
. r � �e�vi�¢�er ry- �Z.S' ��►,
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sat� /�.��4' -% .�ea �e
oresn ..� ro 1» Im