A27 68�r ----�--- _
Person County Health Department
Sewa e System Improvements Permit �-
,,. ,
Date: '` ' i� Per�it Void After 3 �ears
Owner: T� t�J rZ�Y su 1..P �� `/If
Location/Direcdons: ' � r;. , - ' .,.,, %'j i
Subdivision Name: (C.�G,%�;'.:..�=�f �! I h r' j SI�' )
Lot Size: �r,z, �� ��`;:,% i� TYPe of��welling:
Water Supply� lsrivate: �`' `� Pubiic: r
Semi Private: If not Private Tax Map#
Parcel # of Water Supply or Name; of `
Supplier# �
Bedrooms:� Gazbage Disposal ' :�
Basement � �� W Basement Fixtures_��'
INFORMATIQN CE TI�IED BY � � �1`��=._� .
Sanit8Ii3n: ''r;` iiR; f,, �; h��'E' �'' o e�or tepre;
REPAIR: �A ' _, s `" REEVALUATION:
Lot #
�
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Size of Septic Tank: --1� gallons /� �
Nitri�cadon Line: �
��Depth of Stone: 12 inches � � �„
Max Depth of Trenches:
OPERATIONAL PERMIT: yes no
Remazks: � !r`� ,
------- ------------.Ll �c.�ar
Date Well Approved: � _ f� We1' should be_100 ft, frQrri any sewer system
BY �anitarian -
Date e te A roved:
BY Sanitarian �
COMPLETION �
Contractor. �
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_�
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such manner as noC to create a public health hazard.
Septic tank and nitrification line must be inspected and approved by a member of
the Person County Health Department before any portion of the installadon is
covered and put into use. .
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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WELL PERHZS �
Caawell-Chatham-Lee-Person Countiea
DATE ZSSUED: DAT£ DRILLED�^����v COUNTY: �^'�""-
OWNER: � ' ROADLSTREET:
:lELL CONSTRUCTSON '
Distance from Neareat Property Lane ' Distance from Source of
Pollution
Total Depth: Ft. -Yie1d:LGPM Static Mater Level: Ft.
Water Bearinq 2ones: . Ft. Ft.
Casinq: Depth: Frao to PL. D�'Eemters ! inches
TYPE: ,Sieel Galvanized Steel
Zf Steel. does ovner app� Yes No
Weightz Thickness: HeigDt 1lbove Grouad: Inches
Drive SAoe: Yes: � No:
:iere Problems Encountered 1n Settiag t�e Casang?, Yes No
If 'yes• give reasons i —
Grout: Type: Naat S ementz Concete
1►aaular Space kidth IncDes
Water ia Aaaular Space: Yes , No
lietl�odz Pumped Prnasure Poured �
Depth: Froa to Pt.
MaLerials Ossds No. Bags Portlaad Ceaent lieiqht of
1 Dag lbs.
Si mixture (sm�gravel, cnttings) - Ratios to
ID Platess Yes _/No Chloriaatioa: Yes No
4 z 4 slab Yes� No
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L���L�J/ P��!' /Lt�SG• �
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I�ItEBY GERTZFY SH11T SHE 1180VE ZNFORtiAT20tt 25 CORRECT AHD Sii7lT SHZS
FJELL iJAS CONS?RUCTED IN ]►CCORDANCE ZTH REGiJLASI0K5 FORSH SY
CAS:tELL-CHASii11lf-LEE-PERSON DSST. �
. Sagnature of Con�a Date,
FOR HEALTH DEPAR4?�SE12T USE OtiLY
REASON FOE !10 I2iSPECTION:
. SaniLarian'a Sigaature Date
Sketch vell locatina oa.reverae side. Use established refeseace
poiau_
Apolication Date:
Amount Paid:
Receipt #• —
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� a���aa-�w�.-^---- .oa-a-��.IL 1�3Zr �.JL�7�a
APPUCATiOtd F�R SERVICES
Improvements Permit
:ments Permit - $150.00
Home Replacement/Addition)
System Pertnit
Well Pertnit
Construction Auti
$�so.oa$2oo.00
iax MaQ #:
Parcel #:
Systems-
IF THE IMFORMATION IN THE APPLICATION FOR Afd IMPROVEMENT PERMIT IS INCORRECT, FAL51FiED,
C�APd�GED OR THE SITE !S ALTERED THERI THE IMPROVEMEPlT PERMIT AND AUTHORIZATION TO
CONST9�UCT SHAL� BECOME IMVALID.
1) Permit requested by: (�wner/agentlprospective owner):�i �. , C � �E? � Y I i 1T
Home Phone: �S a�-q i�%D Address: i ��•
Business Phone: ��(o -�'U�( ��.'% �
2) Name and address of.current owner: �Yl�-P Q�(�� J2�
3)�::;property Descriptio�: Lot size: Township: Subdivision: Lot #
'';;''.�jr8ctions to the property (including road names and numbers):
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing �Type of Structure: Width: � Depth:
b) Number of Bedrooms: �_ Number of occupants or people�to be served: �
c). Basement: Yes . No ✓ Wiil there be plumbing in the basement?�,,,(�_
d)' � Garbage Disposal: Yes _, No ✓
5) Water.Suppiy Yype: Pr�iate v(new _ or existing��/ , Public . Community , Spring _
. Are any wells on adjoining property? Yes�No _ If yes, please indicate a�proximate location on the
� site plan.
6) Does your property contain previously ident�ed jurisdictiona! wetlands? Yes_ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITfED WITH TH1S APPLICATION.
➢� PROPE}ZTY L1NES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION aF ALL STRUCTURES MUST BE STa1KED OR FLAGGED.
➢ THE SITE�MUST BE READILY ACCESSIBLE FOR AiV EVALUATION BY THE HEALTH DEP�►RTNiENT
STAFF.
I�ereby make applicaiion to the Person 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
faciliiies to be placed on the property. I understand if the site is altered or the intended use changes, ttie permit shall
become invalid. !1 a
Owner or Legal Representative
� -�3 � -�D.�
Date
PCHD, rev. 06l27/02