A27 74V
�The. �ist�iCt Health {�epar�mea�t
�._
A CASWELL - CHATHAM - LEE - PERS�N COUNT�ES
�Wat�er-�-��p y�and�ew��e Despos�rl
IMPLqOVEMEP]TS PERMIT No._.
_ . „�.e �._ 1 s - �c.�
Owner: _
Location: .
`�
Contractor:
F`rivate
wS''�r�An.�'� ��� � v� Sti.���
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� Pli1T1IC _
�ewage Disposal Facililies: No, bedrooms �_ Dislavaasher, Dis�oaN,
washing machine, other automatic' applfiances
Size o! tank: Nltrification iine: _ �
Other disposal lacility: ��_
Water supply and sewag�e di�posal facilities location, 5nstsllation atid
protection must'"meet state and l�ocal regulations. -
Septic tank should be pumped out every 3 to 5 years and shall be ma�h-
tained. by owner in such a manner us not to create a� publqr health hazard.
Septic tank and nitriflcation line MUST BE INSPECTED AND AP
PAOVED BY A MEMBER OF �HE DISTRICT HEALTH DEPARTMF.NT
STAFF BEFORE ANY FORTfON' OF THE INSTALLATIO1�iS COV-
ERED ANl3 PUT IX1TT0 TJSE.
,� ✓ ' � � "':
Date a�proved�_��.-�� Signe ~
Well: ���
Sewage Disposal: � " Counter- ',�—`�f'
BY: �� �`V"�
--- (Owner or tcis representativ�)
, �; :
CerH6eate o� Completion � • ; �
/ , \
Date Apprqved: Hy•
. •t81s�811
., � , (OVEii) .
"��LL�cacation oi well and s�ewege dispoaal facilities alcetc�iecl pn Q�c1c,
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, . .. ,, -� (�� 1�TC- ���
�__�
WELL PERHZT
Caswell-Chatt�aen-Lee-Person Counties
��t�� f� Nnareat pr �LL CONSTRQCTIOk
Pollution�� °�ty Line Diatance from Source cf
Total Depth: FL. Yield: GPP! StaLic Yater Level-
ilater Bearing Zones= th. t� FL.
Casis�gs Depih: From�to �FL. _F��u-• � Ft.
TYPEs Steel Galvanized Stee1 � � "��--°��
Sf Steel. doss oveer app Yes ----�
fieiqhLs Thiekneaa:� beighL�Jlbove Grouad;
Drive Shoe: Yes= Iaehes
Nez'e Problema Eneountered ��=tj,p� L� ��g? Y�— H=
� '7e:' give reasoni_
Grout: Type: I`eat Sm�d./�mes3t
Aaaular Space Wiatp � J ��S Concrete��
Hatet in hnnuler Spaee: �Y� �o - /
lletAodz �` Poured v
Depths iYo�m ed to �_ YL.
Naterials Uaedi No. Bags Pertlaea Ceasat
1 paq lp�� �leight of
Zf mixt�re (aand� yrave2, cattin4s) - Ratio:
SD Plates: Yes V k� -�—,t �.��
4 z< slab YesT%- �� Chloriaatioae Yes���No
�� No��
, 1�BY CERfZFY THAT ?HE 1180VE INFORlS1lTI0N LS CORREGT THAT SH25
� UiELL iitAS CONSTRUCTED ZH ACCORDAN REGi�y�T OKS �
��''�iA?fiJ1l�l�LEE-PERSON DIST. �� b�r _ /i � T� ' -R� BY
REASON FUE II�
Sketets ve1� 1Qe�Li�y ca, r S�i=ar1°a `s Sigaature Date
poiats. evrsse side. Use eatabliahed reiereace
�ication nate: 01 � U d
Amount Pai� 166 ,
Receict #:
d�C_�- �-3 "
Person Countv Health Department
Environmentai Health Section
APPLICATION FOR SERVICES
Tax Map #:
Parcel #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Permit requested by: (Owner/agent/prospective owner): Jerome.'Rvss SEewar�
Home Phone: 331p 59i-�}�+`�T Address: l 5� Carnn;tc DnVt
Business Phone: 33Ln 599 -83� '�x1o�� �•C. a'7S'73
2) Name and address of current owner: .�e.v�.,�,� "Rt,ss S�ewar�
1Sa, Grar�i�e �rivc
`Roxb�ro n1 C ,�7 S'"i 3
al� o lo
3) Property Description: Lot size: Township: l� v� ' ��
Directions to the property (Including road names and numbers):
4�QQ-�' �'0 011J2 ��l'1� iX.ii� I�'�ri'C '�w4lF
57
S'n,� Ie � � vs�' �ivrc
r�i�IC AVi�Z.� �i
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed ❑, Existing�
b) Stick Built�; Modular �, Single Wide ❑, Double Wide ❑ �
c) Number of Bedrooms: 3 d) Number of occupants or people to be served:
e) Basement: Yes o, Nq� If yes, # of basement fixtures:
fl Garbage Disposal: Yes ❑, No�7 � �
g) Dimensions of Proposed Structure: Width: �� Depth: ��
5) Water Supply Type: Private.�'(new 0 or existing �), Public 0, Community ❑, Spring 0
Are any wells on adjoining property? Yes2�f No � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
ZC Conventional _Modifled Conventional _ Altemative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application 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 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 as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
person the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Heal Depa ment if my pr perty contains any wetlands as designated by the Army Corps of Engineers.
�
l� a
Owner or Legal Representative Date
PCHD, rev. 10/12l99
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Person County Health Oepartment
Existing Sewage System Report For: � Mobile Home Keplacement ;��`�
� Addition
Requestee: (� � `7���/���� Home Phone - ��%
� �'�/'��/fL° ,��j�'. ausiness#,�-,�I--��2)
�� /�i�� �/ V( i 2�S <� 'P a x M a p# O� � r��
Location/Directions: i,��T� dl�l ��f�"��� �{�• ��`�'� 1�
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Original Permit Located
Septic System Uesigned Eor: �_
ltesidential �� Business Other (speci�y)
# Hedrooms . � # Employees Other __`
llate Installed � Water supply �1 �%���
'Pype oi System
Nitrirication Line `t1;��X �� v -
T a n k S i z e I i�ldL(/ Gi'GC,Y •
�J (`�
Certified Operator Required �//�1 -
On site wasL-ewater disposal system showes no visually apparent
malfunction on C� �-�
Yermission is granted to: ,����/�� � V�����%��
According to the attached site plan.. -
Comments:
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