A28 110-112s•
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The District Heolth Depart�ment�
. CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supp(y. and Sewage Disposal
IMPROVEMENTS PERM T No.
Date t` .� � �' ;: �
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Owner: � . .�;� ��,;� , �- �;
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Location: �
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Contractor.� I l ' �'`� _ N , �, , '
Waler Supplps Private � Public
Sewage Disposal Facilitiea: No. bedrooms •'' Dishwasher, Disposal�
; wasiiing machin other autonratic appliances
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Size of tank: �f����%: ' s� NitriBcation line ��;_ ��
✓
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 and shall be maln-
tained by owner in such a mannet as not to create a public health hazard. :
Septic tank and nitrification line MUST BE INSPECTED AND AP•
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLi�tTION IS COV-
ERED AND PUT INTO USE. ;,- ;�. �
. � � j'� ,� ��' F., y�
.� �.��-� t�� $
Date approved; Signe � �"�-���
Sanitarian
Well:
Sewage Disposal•
By
Certificat� oi
Counter-
ai�necL
Date Approved:
sanitanan i �� �
(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
�supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
A�oiicat!on Date: �i'-o26 -U � .
� atmourrt Pa�d: � .
Ret�i �:
P�rson �auntv �leaith �eoartrnent
�mrironmentai Heaith Section
APQUCA710N FaR Sfl4VIC�5
i'ax �ao �
IF THE INFORMATtON IN TNE APPI.lCAT10N FOR AN IMPROVE�IAE3�IT PERMIT 15 FALSIFiED�CHAPIGEi3. OR Ti-lE S1TE IS
ALTERED. THEAi THE IMPROVE�AEiVT PE3�MIT AND AUTHORIZATfON TO CONSTRUCT SHALL BECOME lNVALID. .
1) Permit requested by: (Ownedager�prospective owner): �-�'�_ ��--SL���.� `-e.
Home Phone: 3��� 5'�� ��� Address: � o_ o � L i�_ o;� l2-G�
Busi�ss Phone: �3 c�, ��i �' �°l a-� o l�l L- S��
2) Plame and address of curnent ovmer. ��� ���--�'�'�0. � C�-C_.
3) Property De�ription: t�t slze: Townshi� C �0 2�1 i��
Dlredions to the prope� (lnduding cnad names and numbers): �� -e L
IL,d '-F-o v.�a ��� s Lensh�t rG. -� r� . �ax
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-' � ` i S,t- � p v� � ✓� �� � �s �
4) Proposed Use and Structure Description: answer eacf� of the foilowing questions:
a) Proposed �, Existing � �
b) � Sbdc 8uilt � Moduiar 0. Singfe Wide �. Double Wide 0 '
c) Number cf Bedrooms: � � Number of o«,�upanfs ar peopie to be served: �7 .
e) : Basetnsr� Yes'�,. No Cl If yes, # of basemerit i�ctu.res: __ _.•_ : -. _
fl Gsrbage Disposai: Yes Q No�,
� Dimensions of Prnposed Struc�ure: Wdth: Qepth:
5) Water Supply Type: Prhrate Q(new Q or�existlng`�, Public �, Community ❑. Spring �
. Are arry wells an adjoining property? Yes �_ Plo � If yes, lar.a�on
6) Please Indlcate Desired Sys#em .Type: (systems can be ranked in order of your preferencsj
� Comrerrtlor�l _Modified Cornrentionai _ Aitemative lnnowative
Other (sP�Y)�
CL�ARLY STAKE ALL CORNERS AND UNES aF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPaSED STRUC'fURE�.
PLE�SE ATTAC1i SURVEY Pi_.Q►T OR SiTE PLAN TO T�IIS APPLCATI�N
a� 1e-�'�
1 hereby make appiication to the Person Caurrty Heattl� Departrnerrt for a site evaluaflon for the cn-site sewage dtsposa! �system %r
the abo�e-desr,ribed property. I agree that the corrter�ts of this application are true and represent the maximum faaTities to be
ptaced on the property. I understand if the site is altered ar the iritended use changes, the permit shall become invatid. I understand
that as appiicarrt. I am responsibte for identifying and marking proQerty lines, camers and making the sita acc�ssibie for the
personne! of the Pessan Cautriy Health Deparimerrt to condud their avaivations: I understand that I am responsibfe for notiiying the
Hea�h Departmerrt ifi my property cantains any wetlands as designa#ed by the Army Corps of Engineers. �
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OW�II�'! OC LL'g2I RP,E7�2S8l1f'dtlV@ . r D2�
•PCHD, tev.10h12198
Tax Map #:
ApPucartC
Locatlon:
�,� �e-� �`� %
PE9�S�N C�l9id�l E3VVlROiVMENTAL HE�LTH
�� ,�,# I Ib-! II-I��p
T �_ �
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PIN
w�aselsecSon
� �i? 7
Lot�
��- � Imarovemeni Permit .
New Addition Type of Structure 7' ` �` l Water Supplji W
# of Occupants � # Sedrooms ` Other System Type
Projected Daily Fiow: � g.p.d. , Permif Valid For. ❑ Five Years ❑ No Expiration
Proposed Wastewater System:
Pmnnce�ri Re+nair '
Owner or Legal Represecrtative Signature: Date:
Authorized S#ate Agent: Date: � /d
The issuance of this permit by e Health Department in no way guaraMees the issuance of other permits. The pertnit hoider is
responsible for checidng with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site plan, plat, or the intended use changes. The Improvemerrt Permit shail not be af�ected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposa! Systems of the North Carolina Administrative Code. �
Wastewater System Description: F �/1 (�P_�1 f� a,..0 F�*sf«'1 Wastewater Flow: Q.p.d. Type:
Facility Description: S�i G va ��� New ❑ Repair Expansion ❑
Basement? O Yes � No Basement Fixtures? � Yes O Na
Wastewater Svstem Requirements � 1� 1�J �� � � 0� O
�
Tankage: Septic Tank size �gal. Pump Tank size gal. Grease Trap size gal.
Trenches: Total length ft. Trench Width ft. Total Area sq. ft.
Max. Trench Depth: in. Aggregate Depth: in. Soil Cover. in. Trench Separation ft. on cenfer
Permit Expiration Dafe:
Authorized State Agent J f Date: ✓�� %�l
' 1
*Ses athached site plan and ad ndum pages for additional permit conditions.
The type of system permitted a does ❑ does not differ trom the type spec�ed on the application. ! accept the
specifications of this pertnit.
OwnertLegal Represerrtative Signature: Date:
O�eration Permit
System 7ype (in accordance with Table Va)
This system has been installed in compliance with appltcable North Caroli� General Statutes, laws and Rules for 5ewage Treatrnerrt
and Disposal, and all conditions of the Improvemerrt Permit and Construction Autlwriza6on. Issuance of this permit implies no
guaramee That the system installed wifl function property for arry given period of time.
Authorized State Agent Date
PCHD, rev. 03/07/01
Application #:
Tax Map #:
Parcel #:
Person County Health Department
Environmentai Health Section
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Applicant's Name
�
Authorized State Agent
SITE SKETCH
Subdivision/Section/Lot#
s�, /o /
Date
System components represent approximate contours only. The contractor must flag the system
nrior tn beQinninQ the installation to insure thatproper grade is maintained
sca�e:
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PCHD, rev. 90/12199
� Person Caimty t1�Htt Deparimerit
Eanriranmentat Heaiti� Sectiort..
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Qpefation��Permit � --
� Sj�em Type c�n �u�nce v1l�n Tabie ve): -'�
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TI�HS BYSTF�11 HAS BEEi�1 IN.STALLED IN COMPW1Ni� 1ARTH APPLIGABLE NORTH
CpROLINq GEl�IFRAL STATUTES, RULES FOR SEWAL3E TREATYENT AND DISPOSAL;
.�IND ALL CONDRIONS OF 7HE IYPRWE7IENT F6iYR � AND CONSTRUCi10N
AU1i�lORIZATION. �
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