A27 96y , .e
�Q
ra
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
� I Owner: _
0
pq Location:
a
�
�
Contractor: � k � � t���
Water Supplp: Private —T�, Public
• � _ ._. _
•
Sewage Dis i
washing machine,
Size of tank: —
s: No. bedrooms .pL� Dishwashe Disposal,
autom tic appliances
�� Nitrification line:
�� ` �s " i "' I �
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 owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF TH STALLATION IS COV-
ERED ANB PUT INTO USE.
Date approved: — Si ed
Sanitarian
Well:
Sewage Disposal:
By
Counter-
signed
(Owner or his representative)
Ceriiiicaie of Completion • �
Date Approved: /���J By:
S nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
su�;�lies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
pt later date. Note location of water supplies on adjacent lots.
' ` }�►� �,.T �-e !i? � • w�et! �2�
�
Aaaiication Date: -O�
, Amfir�nt Paid•
Receipt #:
�
� �
Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Maa #:
Parcel #•
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CNANGED OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Pertnit requested by: OwneNagentlprospective owner): � � e Y'
Home Phone: 4� Address: O
Business Phone: - ,,?�
2) Name and address of current owner. u� � �. e
n
3) Property Descriptiom �ot s�ze: Toumship:
Directions to the property (Induding road names and
4) Proposed Use and Structure Description: answe� each of the following questions:
a) Proposed 0, Existing CC3�
b) Sticic Built�; Modular ❑, Singfe Wde ❑, Double Wide �
c) Number of Bedrooms: � d) Number of occupants or people to be served:
e) Basement: Yes ❑, No e�if yes, # of basement fixtures:
� Garbage Disposal: Yes �, No m
g) Dimensions of Proposed Structure: Width: Depth:
S7 Water Supply Type: Private C9'(new ❑ or existing ❑), Public 0, Community �, Spring 0
Are any welis on adjoining property? Yes ❑ No 0 If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
_Conventional _Modified 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 APPLlCATION
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 faaGties to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shail become invalid. I understand
that as applicant, I am responsibie for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health Department if my property contains any wetlands as designated by the Army Corps of Engineers.
Owner or Legal Representative
Date
PCHD, rev. 10/12l99
0
�� _ _.._-- ' � / �
�Vv�L/`� ----
_�.� lll�(�
�
t
� ,1
�
. � '•
6
. , • : . !, , '
. . . . , ..., . .,. . . .. ... .... �.�.,.� • �
� : � � ... . � . , . �, .. ,� 6 �-,. ;
� � � ' � � ,. . �/ ,
, �
. . • . , � � • . _ ' ' � • . . ' ' 'µ
. ' . . � . . . � `�\
. . . . . � . � , h �1.; . � , � �. •
.�5� ..�' '�' � � � ti ? ..
� � � ��'e`.� ,
',/ '!r1 e I� J .
3 . ,
r¢F.� � �-�
,114 . 7 � � �e i
J SS � 4q � 'r �.���s � � 34'3 .
/�*. e' � � � • .
. �, �
� � • �
. � . Q
, ' `♦
./ �I ' _ ' . " � � , ,
.,SS!'.�t' r �. ` �: �
sri.� i �� �"�'� �
�' . . . � \
, ��
.� y
c ♦3. z'�1, ��`. . ��� � .
s � � � � ��: . js .
.ss'C �
:o � . : . � . . . ,s s °' �, � ,
w . � . /` . ,
. ,
� ,. � � � y✓r,� � .
. S� �'
. � �• , ,
' ' S `3 egst,s . �1 r .
� , �E p��� . , '
�
. r� � ._
. 3h� . �. .
' �+'' � � � , �
� � � "
� o. . . � . � � ' .
, � � . ,
� •
.•_� . .
A�o �.�•e' �
�� � �', �.�'.�r�'�
� c��a �_��s � �.w . „
.S✓r+'•y"� �r �
iQ✓� /1 �9 '�'�
��� � Z 0 d' AJ.C.
�j Ca �� ��� %✓H �e r'!� r. l e.
� � �
p /. � t
,Go ea�� �ti / , .
, ' ,
,
NORTN . CAROUNJI � . � : , ! � • � n� a . '
PERSON COIfNN .. , . . • � ' .
W
.�i. CATES. 1R. Bf1HG OUIY SWOnN Sfi�S THAf �TNI���PUIt OR IA��',
HCAEOK 1S 1�1 All RESP�CTS CORRECT TO THE 6EST����?�ofGBY NOME a Nt
BELIEf AKD WAS PREPAREO fR M AN ACSUAI. ����
COl�P�EIED v -
, ,.
REGISTRA?ION; �NO. L•555 •
; . .
� /C 11 � �%;�i�'V. , ' �. ;.' . � .. .. ' . . . . . '� , . � ' �►.`� �♦ �\��,�,.. ..
; � . , ii1/�� ' ' •�� t �i
�'r `�;'"c�<•;.' �� p ,�p , oaE �E TM�S � ' ! - -
. � *��• '`:.�''': � � `y . SU8SCRI[3ED AH �N � : � , •'
f:�r��� 1 . � /���,,,�� Y of —��-�.� - �.� � .
�'; _ . � �� �"'�"'�l - % ,�o .�RY PU l]C. � � ' _ . .t .
ty . /„�./i PfRf�--�l / � � .. ,•;
�,/��r ^f��`,Y .^.� ��. ;, F�f CO#A SSION � ,'' ,
'`.. ,; ; � �„ . . � .
, . '�•"_ .,. . � ; � . ., '
� : ,� � .
. � ,
� � � . ' . I � � . -t '� � . . . . . , � . � . � . � . .
�
�
a�
Uy
c�
a
PERSON COUNTY HEAL'TH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�IPROVEMENT PERMIT
Tax Map # A7.'� Parcel # ��'j
Zonin� __ Township
Owner/Contractor
Location/Address
Subdivision Name
Lot#
Date
S.R.#
A 1724
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site i,j' 1% �r�ed, or intended use changed.
Well and Septic Layout by„�a�___ ��d—�� /1�����
� Comments:
Date �j" ZZ-G� Installed by �/1�1' P,IVI� TJQO �./1�J(1'� Approved by
Comments:
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading infortnation rnntained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application Neither Pecson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c�amipro\peimitsam Ol/95 rev.1.0
ORIGINAL
/ � �
application Date: S'.3 �� � � TaY Ylap: �%
r�mount Paid: j �O .� rarce? #: ��
Receipt�: J' 702� L I
�(° �(; ��� `� �... � ;� .� �' � �\�' . �.
� 6 V � �'..�—' �— /�./ ;�� �.J S.. � � 1LT ����e M
f1L... �z�. �a :i s- � i�. ,.-..-„\�iT s-�,i:.�z. TL I��L .�:.--�.-�. ll 0=1`1�:z �� d,�+ �y�,!, f.1�
8
I����R������ �oE' �e�'vi��s �Septic Systems and Wells)
Se�-vic�s �e uesged
� Improvement Permit (Site Evaluation) L Constraction Authorization
�200.00/$300.00 (if> 600 g d) (Fee is dependent on the tyne of system permitted)
l�Iobile �3ome �teplacement or Building ?�ddition �J Permit Revision
$1�0.00 (if site visit re uired) $75.00 �
C�'Q31 �ermit (Ne1v/gteplacemeni/&2epair) 0 Repair of ��is€ing Septic System
$300.00/$200.00/$75.00 No Charse
�) Servic�s 3tequeste�l �y: /
Name: Y'ria..� � � �� R `�U��� �� Phone #(home): 33E� - 36'�r a�'3
Address: � �, tL (�vork1ce11): 33 ,� 5U'-I — I�Z �
� o.-�� or �d
i)l�am� a�sd a��ress o� z�nr��nt aw�er (i�' diif�r��t �han a�plFeant):
Name: ,,,,, ,,,c_�
Address: Se•� �2 , Qer���z o
3) ����esty �escrS�anon: Lot Size: � O Ac, Subdivision:
Address and/or directions to Property: 'j'� ,a �,� d S�N,a�A
) '�' ��� �2, o „� 2? �'�,-� �
4) �ropos Use and 'Type oi St�ucture:
R�sidential Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes = No (with plumbing: Yes � No __�
Garbage disposal: Yes No
5) VVater Su ly:
Private Well (Proposed Existing _�
Community WeIL• Public tiVater Systetn:
Are there wells on the adjoining properties? r10 Yes
�ot #:
�
(please show location on site plan)
1'�I,ote: � cobnpleterd rrm�lication mu�E ealso irccluc�e:
� � �lat/site �l�en of tlis �rapeyty �t,�ic¢t s�totiv� �: o�er�y �dirnensions rar�d 7he �iz� �pad �ocr�tioa� of rall
pro�osed strucfures. � .
5�1 sagned capy af fdie `��t.�r���sration',,i'orraa veri.fya�a� ihat ldae propeYry �� r�ady io be. evalurate�
� a��a sa�bmittin� ft�cs �pDlncatioib #o �'e�aae�t ��rvzc�s �'roa� t'�e �Qrsota �ousnty ?3eaith i�epa�-tnne�ni. � uttd�rs#asad tha�
i�' #h�e infms-�nation �rovider� is a�,e��-r�st oa- i�' #he ��#e :s sui�s�que�nt3y �l�ere�, or ii #;�Q �ntenc�ea1 u�e ct�arg�es, a�9
per��#s a�d app�avais sha➢1 became ia�valid. -
�ab�a�.i�-� {Cwner/Legal Representative): ��r� : g'3"��
10i08 Person County Lnvironme�tai Health, 3?5 S. iiior?an St., �uite C; R��boro, NG �757� (336-�Q7-1?00)
�� : � ; � '; ;} �1 � t� ,' `� � i
� \ � �� '� � ( I � ��. ; � �;�, �
'�, , �..� � � �,,� � �
� ' �i A
� ����`� � �� � �� ��. �' "�
�. ;- ,
�.!s.Z.-v-;�.�•��>>�xr.�<e��.tL.�,� .�� �.�����n..l ��..1�
�a����l��a� ��s��#�m��/ I���b��� ���a�n� �e������a��ss
Tax IVIap �:� Parcel#:�� �,ddress:
Approval Requested for: �� obile Home Replacement
✓ Building Addition
��
Applicant Name: of�rz L�7al✓ c�
Address: F�Q C' ia s'I d.
T
Phone �#'s:
Permii Located: �/ _�es Tlo
Installaiion Date: g-ZZ-04T�3-p� Besign flow: �( �(gpd)
Cunent Contract with Certified Ope:ator on file (if required):
Water Supply: v Well �ublic or Community
Wastewater system shows no visual evidence ef failure on: 2-�'�`� (date
(Applicant's signature if site visit is not required)
��1������/���������r�t ��p�-����1
Enviro ental Heaith Spe�iaiist
/z" �"°�
Date
Person C��nr� Environmentai =, eaith, 325 S. y:or?an St., Suite C, RoYboro, N� 27� ; 3
Fhcne: ��6-�97-??9C/ ra,.: ��6-�9�-750� � �-v�:�,,t�.�,ersor�countv.i,er
��-r �. ���,�:� � -�- -��� o►� �.
�
; ��� �� ���� � �
�� ��� ������ �
'�� ,.�
� �d-��- � �-t-r--� �m�.Ii I� � �.II��
�t�plicani
Location:
�� �� ..�_ ���� � � 9 [�
� o o �B�
�,^�t��o�r��� W
�c�L� ao �
. Syst�m Type (ln Accor�ance Wiih i�ble Va): �
THES SYST�� F��,S �E:..�! i�4ST.�.LLE� 11°! C�f�lIF'LIr�Pl�� 1d1lti'H AP�'�lCA�LE . NORTH
GA�OLINA GE�E�L4L SiATilTES, RU��� FOR Sc'�VAGE TR�ATME3�T �IVD DISPOSAL,
AND - e�,LL CONDITI(�NS OF � T}-3� 3IViPR�V�?VfElVT PE�tVII? �►�D CONSTRL]CTIO(�
AtlTHO�Ci�.�T10N. � wGl � - �
. _ . �1n�
-�iec� Qr .
�� d - �a,,y�.S . y,c r�
�" � !'T va n0 0 /� W�
cIB
Date: S � 3 -0 9
�e � �
S�
.��--
1 `�� i
�
�
� �hs�,ech�U� o� sYs�►r� u;�s .�
-�r �ur�uvPc,�es o�►lt�� ��u5e sKe+�l� 1
a5 t'�e�renc2 � n Case Sc�S��vt -t-ct, S
i,�, '� Wi f � KnouJ po55r�jr� Prr��EtxS ancl
I�"�M�1�S I ,
�C�-iC�. r=V. 07/2�l'C���
���'�3� '�'�s�?� ��9��'��"�d�� ��E���..aS a �d��e �8 � 1�
Tax Ni�p ��� Parcz! ��_ Sys�e� Type (Tabde Va)
Owr�e�,A�plicant � � � Subd�visio�
AddresslLo��fiaon R'� �lem C�n,�.{�r �R�. SeclPnas� Lofi � ��
ve��a�. �°�ra� ��i�e�tl���� �lo��ar����ora i�� Ini�a d�� �
� State�(D/da�� � rencfi Wid#h� � 3�t. 5. --cf
Ca aci p �-;�� �,v ,��,�_��. � i
.. . .
- . ��, �yw :- _. _ t . .::. ,., ; Trenc� Lsn �fi �.:�:: , ; �,� � .
Tee and Fiitef
� Baffle Trenct� Grade . ._ �"�.`� .
Sealant Tre�ch S acin �
.� � Riser (ifi ap�licabie � � Roc�C De th and Quali
• � Tanic Outlet Sesl � � Dams/Ste downs e#c. - .
Permanent 1Vlarker Pressure Laterais � ' �
. Paamp Tank � � Hole Spacing � .
� S#ate D/date �� - _ . :. _: __ . _ .: . o e j �'�:.. � r: �, - . ..
- Ca aci �°''" . Pi e. Sleave���:.:� ._,� = � � _ .;� � _.� .
. . _.� --� 4:b �� . :
Wate roof ISealant � T�:rn-u slProt��i6"�`�s �� � �
Rise� Requi�d� Se�a��
Water�Ti ht � From� Weils � S 8- - �
F'��a�r From Property iines � .
CY�ec�C ValvelGate �lQlve S#ructuresBasemenis � �
�� Anti-s� on o e � i�c. es / rama e.� s �
Fioais/Swi�ches � � � Surfac� Waters .
�larm visable and audibie Public VVa#er Sup iies - •
Electrical Com onents � Verticai Cuis >2 fi.
� Rate m . 1lVaier Lines �
A rove� Pum fViode! Ve�iic3e�Traffic ��� '
Bloc� Under Pump � Adia�nt stems � -
� Pump Remava! �Ro elCnain • ��asements/Ri hf of Wa s
. � D'as�ibu�aoea: Sy��m . OQh�e�
� Serial Distribution ✓ S -3- Easements Recard� .
� �ressure i�an�roi e e perator ontract
Low Pressure Pi e � Tri-Partate A resment
Ap r. Pip� Niate�ial and Grad� - � .
\/aives �� '
Cr�me�s�n% . . .
�c:� d r�r. 3l � 3/C'1
\
; � �� � ��
; `�, �� � � � , �
� � �
�.�
: .�.. �' ,�,� r� `L..J � l�� � ��
�L_:.a:IL�'1.�'�'7i7I"{�D'.%�1..TY:iil��?L�iCL.'G'L.�L �3.�tE:.c`�.11�.J�^�
9f1
�aa����m� ���fi��a��/ I`�I���fl� ���a� fl��������ne���
Tax 1VIap #: 2� Parcel#:��
Approval Requested for: 1Ylobile Hoine Replacement
� Building Ad�iition
Applicant Name: o ,K �, ��Pn e�e
Address:
Phone #'s:
Perrut Located:
Instailation i�ate:
v Yes No
12-20 �4� d- $-2Z-oa
Design flow: 3� � (apd)
Current Contract with Ceriifi Operator on file (if required):
Water Supply: Well Public or Community
Wastewater system shows no visual evidence of failure on: �-�- Oq (date)
(Applicant's signature if site visit is not required)
Comments:
�
�i�' Q1�Il�flO�fll�����1� ��n� ����n��e�
�
_ ,�.—� 8' — �{ — o�
Environm tal Health Specialist Datz
1 ? /15/OS
._���,./ / ' �11L(�� V ���
�
+�` ������
1�,�.�a�-����..�,�.�.11 ]H[��.]l�.lh,
NaYne_ � ��,•���„ �r�,����er�� ��
Sub 's n ,� �
�—y
Au�ho�ized State Agent
��T� �1�����
Ta.g Map # ���' �� �Pa��el � �� �;.
Section/Lot#
�- �f ��,i
Date
System cnmponents nepresent approximate �contorsrs vstily. The conimmctor �rarrst fiag the syste�n�Drior �o ,
beg�nrairag the installution to insure thatpr+n�iergmde as muisvtaaned
�
� � � '
�.
�
�zs���� � �� ���
��
� 4 "
� � , �� � �Rvq
���, .. � . �� � .. . � ti . ..
� � �..
��, �K... .��n� � 4 ' ',�'1
� �,
�� � �� � �� ✓L'�
�'a ."� `v
- Y ,. �
�� .'
ti
RL>.
� ,:R ��
� 4 �, � � � r �"� � .' zs ,
�
`z �. ', i
r
� ��� �� �
� � 4� � /....
i �,r
�
� ��� . � p.:�� . � t .
4
' , � .z, , .e. , . i(: . , � �.
�r.v—•
�
�—��
� ._ . . , ., , .�
. �:, ,�. ' f. v ,: , ., ...:. . ., . .
, . , .., c. .� . , , .., .:�. : ,. , ' � �'�
S3 h 4 _
n
�
ri,, ,. �- , _.� , J.
.
�., ,,. . ' � ., %^ .,,'; r . , >^ . ,,,. '.� -.., , _
.i 'r, „.. - ,. ,.
Y., .. f „ ., � ••�... .;, .�.
�
„
-. . ,,. . ..�. , . < ,/ . ..�.
�
' . , < , v. . •� . ,i. . �,- .
, . . ,: . � " � .
� � . . - . _ . . , ,,
.,�;' ;��� , .•,• � ' ��. ,�, ':'� � �� .
�:, _ � 3300
� r.,
� � �� . _