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A28 113� � A I� The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. �D�at� �' ' �7 Owner: U/i nS�'c� � � �r.S•�i�• Location: 0 Contractor: Wates 3upplp: Private Public Sewage Dis�osal Facilities: No. bedrooms I washing machine, other auto atic appliances — Size of tank: Nitriflcation line: / Other disposal facility: j/Gtr��es ��.. �� � -� � 3 .� 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 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- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE I ALLATIOld IS COV- ERED AND PUT INTO USE. Date approved: Signe wp�i • Sanita i Sewage Disposal: By: Counter- oign (Owner or his repre entative ermi� y01D after 3 �t�F� Certiiicate o� Completion Date Approved: v<� v B: Sanitarian (OVEii) -� ocation of well and sewage disposal facilities sketched on back. �^ � � NOTE: Make sketch of installat� �owing lot size and shape, location of house, septic tanks, privies, water f supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located ' at later date. Note location of water supplies on adjacent lots. � � ,_� ,,. � „ _ _r, ,�, Y f� SR� 11.5� TJ �.. Person County Health Department � � . � Well Permit � Date: '-�' � This Permit Void After 3 Owner: n,�n w� �� l,� ),` v� c,�e � Subdivision Name: Drilling Contractor: � sR#I1S�''� Lot # b Distance fro earest Line�,�,L Distance from Source of � Polludon � w �' � Total Depth:� G Yeld: _L � GPM Static Water I.evel FG � Water Bearing Zones: Depth /SSFG Ft. FG FG Casing: Depth: From �_ to ,..�2 �FG Diameter: dy Inches TYPE: Steel � Galvanized Steel -�� If Steel, does owner approve: Yes No Weight .1,�_ Thiclrness: eight Above Groiu►d: �/'� Inches Drive Shce: Yes �� No Were Problems Encountered in Setting the Casing? Yes No •�-' If "yes" give reason: ''ti Grout Type: Neat Sand/Cement Concrete � Annular Space Width � Inches Water in Annular Space: Yes No � Method: Pumped Pressure Poured v Depth: Fmm � to � FG Mat ' Used: No. Bags Portland Cement �_ Weight of 1 bag lbs. ff mixture (sand, gr�vel, cuttings) - Ratio: _�_ to �__ ID Plates: Yes � No ►b 4 z 4 slab Yes � No � - - LIN - � De th I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. Sanitarians Signature Date Completed Sketch well location on reverse side. � �� 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 mea� ��se�ts in order that installations may be located at later date. Note 1 'on of er supplies on adjacent lots.Q` /�l cl� �X�U.r2� �(�-�-�Q s�a-�P � (OD l�'�-�%P"„-^� ac�� c�cS�.��'`� � �J � v v � � — � Application Date: —� 7—v , Tax Ma :#: Amount� Paid: -. _. . , - l � � i�ecaipt#: � � � . ParcEi�#- . ����4�� �iijl ii �i.�l./ � �� . � � ��� � ' ' �'Sa@�a: '�O'7l:9.r�x'n'�7Ca:��.� ���� � APPLICATION FOR SERI�ICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT. FALSIFiED, CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agent/prospective owner): �t o qf- �E'rcl l�l ��e- .�u n �a� Home Phone: .�3 - 97- q8 Address: .� ! o c. r d Business Phone: �'/ 9- �/� - o� 3S � 2) Name and address of current owner: ot �e ���� ��U ne cr h �Rox �h t�ro �, ri1 C� �C S�OG,9� J e �•��� 3) Properly Description: Lot size: /06.5% Tawnship: o I i Subdivision: Lot #: �� Directions to the prope (Inciuding road names and numbers): � �.,., � � � � ► _� _ �. , _ . m � 4) Proposed Use and Structure Descripdon: answer each of the foilov�ring questions: a) Proposed _, Existing _, Type of Structure: .�O t;c � l� ��� f d�. Width: Depth: b) Number of Bedrooms: �_ Number of occupants or peapie to be served: �_ c) Basement Yes _, No �/ Wiil there be plumbing in the basement't d) Garbage Disposal: Yes _, Na � 5) Water Supply Type: Private �new _ or existing �, Public_, Community _, Spring _ Are any wells on adjoining property? Yes � No _ If yes, please indicate approximate location on the site plan. 6) Does the property contaln previousty identlfted jurisdictional wetlands? Yes _ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR StTE PLAN MUST BE SUBMITTED WfTH THIS APPLlCATION. ➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARI�D. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. � ➢ THE SiTE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department foc a site evaluation for the an-site sewage disposal system for the above-described p�operty. 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 b��Qme in�Jva��lid. (/�J � � ,� D � Xsf�1 ��C-ar.c� 7�.� IiIG�L! a�/ Owner or Legal Representative � Date PCNo, re�. �a�7�o� > � , � . �= J- . .. �. � a r� p ' �. bth+ ,� y. � `i l p �; � � a ,r i�: x , �1 i <t :��. y ! IS � .�.' » � ) � - r ' . �. t k � 1 � j � v. l� +s i s . � r �i� � a zF M1 � t � Z y ��L.. �t < .;. T � 4 + 6 .. C � � ` I 1 . � t ` �r f .F� } tY yr:� '4�.� } f ��1+'��r:. �c � ^' A � . � � 1 ....... . ... . r .... . .1;.. . . ' � .4 .,, . I + : .� ' � �. y r � ��i xWt�d' n.'1 f_..�— � . :,� 1 ty? s v�� r s�J'. ��� r f . '. 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T.� c .2- 3 .t. . � �.. ✓ :�I ���-�,��.s�- ������� V+. ' � .! �, �✓ � � .b. V � � ���a�-��„-,�-�. ����Il �E—ZI��u.Il�� Tax Map # �� Parcel # �� Existiug Sewage System Report For. —y� Mobile Home Replacement V Addition Type: ru � Requester. � 0. �0 r1 �i' � e iZ�. � d(r� c. pi.�.n �cc,n Home Phone# �q ��`� �� ��� ^�Jq lo�k f�;i.irY l�d� , Busittess # �I�I �{'l�1 "�$� �.nxl�r-c�. I�C o�15"-13 _ � � q� Original Permit Located: LS Water Suppl3r. ��' I va-t �� t- �� Septic System Designed For: �Residential Business Other �l OT # Bedrooms �S7rtT�0 # Employees Other System Type: �'n�Ln�� 0�� Tank Size: ����Q Nitrification Line: �.QS� X Z 3 �`'��c Date Installed: l� a��� � Certified Operator Required: �� On-site wastewater disposal system shows no visual signs of malfunction on � 0�07'�0� Permission is granted N�T� C� � �C�.� C'l�f.lGt-�l � � it�aq �- � D�K (,Jt rc, GZ dc�cd rCG�{Uin� 0��1 En� ��nmu�.fi� t�ca. f{I� o e r mi `� .�araa c Fou-n.�(a-h'bn i 5�' T� I ( -�nc. �.X,�S-�.i�W W� 1 I. � c� �cK GJ�S i�ta,t (� �� i � �s� OF -�.� c,ac,( (� 7�c-�.ni �I �y �ni5 i5 �10-� �n a. Fo�n�da-h' on �-�c,n n�tb� r��,,,�,(�.�cd �v CnU1 rOnmtn�� �ca l�. Mo�„�c�zr� Fo� t�ea I-�!, rcasonS, � I� ��I��Y rc c.omm�l�.d '�a-� n� Environmental Health Specialist + Date: S o�o�'Oo� Pts{i�idc� G.c,rbtcid� J o� Pr�scr���f.ion �r�a.-E,mcr�.�S bz Pc.�Form�d � Or a�o�v�d �c. deck clt�.c �:o '�c �-St �n l,J�.�c� ConfaMinu.�cs `�C.. WC�{ I. � �(.�Ovr(,O i�G,Gvrnr++CF� MOV enct �� �i�f�uC 1�.3• �'1�(l� C.U�,t(,r" U r-�1 ��{�cr �„,��aS Pinc,-trcc.s to Fc-c�crtit da���.�� �iyStc.r dc�c.f� fr-a.Fti'c. �J Ol�1t�5 S�o�,�.Id I�e. rd�.,,-�cd ��- O�c� ���c oF ��� driv� Gtfso�