A28 147Oct-31-01 10:51A
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Aaplication Date: � � �� � . Tax Map. �1: � �g
Amo�nt Paid: no • �O � ��
Receipt#: �n . Parcel #:
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APPLICATION FOR SERVICES
P.02
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IF TH� INFaRMATION IN THE APPLtCA'iION FOR AN IMpROVEM�NT PERMIT IS INCOF�RECT, FALSIFIED,
CHANGED. OR TH� 51TE IS ALT��tED. THE IMPROVEMENT PERMIT AND AUTHQFtIZATION TO CONSTRUCT
SHALL ��COME INVALI[7.
1) Permit requested by: (Owne agen rospective owner):��1C v/2/V�2
Home Phone: Address: 77 S/rJJT ff/cL (.N•
8usiness Phone: • o �V RoX r30R.o NG 2� 573
2)
3)
Name and address oT current owner: U l. J N SUS w� �
� APL '
(zuc o 2o nr� 2-� S"� 3
Property Desc�IptEon: Lot size: � Tawnship: � d; (-�1�. Subdivision:
Directions to the properry (Incfuding road names and numbel`s): F1QOM 2o�f/3o,�o i
To�20i RJrl_r.v67�� TRtGr Ll P�l„uT n�uTO Bv41�7�
Lot #:
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PA.
[�v r•� micr_7 i�vic.: � �r-� urv�� rwrci aoaa NI�Mt/J
W !T/�4 � �2 (�t2A (o r I
4) Proposed Use and Structure esc�iptlon: answer each of the following quesiion •
a) Proposed , Existing_, Type qf Structure: Ovv FrtAhE r►toov�2 ��dfh: 2g Depth: 501
b) Number of 8edrooms; 3 Number af occupants ar people to be served: �_
c) Basement: Yes , No�Nil1 ther be plumbing in the basement7
d) Garbage Disposal: Yes �, No � '
5) Water Supply Type; Private �w _ or existing �✓), P ic , Community _, Spring �
Are any wells on adjoining property? Yes ` No ` f yes, please indicate approximate (ocation on the site plan.
6) Does the property contaln prevloualy ldentlBed jurisdtctfonal wetlandsl YeS _ Np ,�
PLEA�E NOT� THE FQLLOWING:
➢ A PLAT OF TH� PRQpERTY OR SIT� PLAN MUST B� SUBMlTT�D YSA'ry TH13 APPLICATION.
Y PROP�RTY I,INES AND CORNEI7S MU$T BE CLEAFiLY MARK�D.✓
➢ THE PROPQSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR F�AGGED.✓
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUA710N BY TH� HEAL.TN D�pAR7MENT STAFF. �
! hereby make applicab to the F'erson County Health Department for a site evaluation for ihe on-site sewage disposal
system for the above- c' ed property. I agree that the contents of this application ar�: true and reprasent tha maximum
f�cilities to be p(ac t e pro erty. I understand it the site is altered or the intended use changes; the permit shall
become inval(d.
. 3 ' � 'c%a-
wna gal Representative � Date
PCHD. rov. t0117101
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Tax Map # a$ Parcel # I��
Existing Sewage System Report For. �Mobile Home Replacement
Addition Type:
Requester. ��- � � � � ��a-�l �m i �h
14� m��� c��r�L-�
Roxbora , �� ����-T3
( o cK Q� i r�� �-� Ct--
�m ��. h i 1 l(_a.v� c� �-ia L� t a,t �nd . �
Home Phone#
Busiuess #
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Original Permit Located: � Water Supply:
Septic System Designed For: �Residential Business Other
3 (rlaxirn�cM
# Bedrooms �N �, # Employees Other
. �
System Type: �4nV ut{ionc� ( 'Tank Size: � O� �`� . Nitrification Line: �� x
Date Installed: ��a "$1 Certified Operator Required: ��
On-site wastewater disposal system shows no visual signs of malfiinction on �'S-' O
Permissiott is granted to: � i�,�p ��Ct ��-t 5��� Sl� (Yl �' W� C� Yl t.cJ 2$ `>(,�
Comments: �i�hcl.t.c,�Gi_r' Y�c�nn C� �+�TOn.t 6%,.fl�c� �a rn.c, U!�'Lou- [c�
��n.�� c, -�,�,t Fra n.t �� �c.- �C � 5� ��i �n�m c i�
� o c�b,-��d no� •
Envitonmental Health Specialist
Date• �'���
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_. -. , - -.- . _. -- - 20' Easement /' p.�
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Anthony Todd H(cks prop.
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James M...Hicks prop. /
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/ Lot 33
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lld� 228.19'
Poresl 3 oi
"Anthony Todd Hicks"
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l.ot 34
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Lof 35
" Winstsod Inc. "
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240.15 •
N.Bp_�p_ Lof 36
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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIE8
Water Supply and Sewage DisposoF
IMPROVEMEI�iTB PERMIT N .
�if lIOID after 3 Y , t
Owner:
ation: !�i �-1
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Contractor:
Water Supplp: Private Public
� Sewage Dfsposel FadlWas: No. bedrooms� � Dishwasher� Disposal�
washing machine, other auto atic appliences
Size ot t8nk:-_.��;1�)�,''Ze� NitriflCstloa 1ine� �� %�
Other disposal facility: "� ' �
Wafer supply and sewage disposal facilities location, installation and
protection muat meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be maih-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitri8cation line MUST BE INSPECTED AND Ap
PROVED BY A MEMBER OF THE DISTRICT HE Tii DEPARTMENT
STAFF BEFORE ANY POftTION OF THE � L,LAT'YON IS COV-
ERED AND PL�T INTO USE.
. ,
Date approved• Signe
Well• itanaa
Sewage Disposal•
Bq•
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Counter-
aigne ,
(Owner or his representative)
�r@�iSCBZe O� �CO�I@�OA
Date Appmved: -" r �By• •
a 'tarian
(OVEA)
Location oi well and aewage disposal facilities sketched pp�baclt,
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F� M
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE I UED:�[�� DAT� DRILLED3p ��� COUNTY:
OWNER:�1'� � 1 � /✓ P_17 � �,e•� ROAD/�.STREET:
DRILLI
! WELL CONSTRUCTION
� Distance from Nearest Property Line Distance from Source of
I Pollution�
iTotal Depth• Ft. Yield: GPM Static Water 'I.9v.el: Ft.
Water Bearing 2ones: D t. Ft. �'�t�. Ft.
Casing: Depth: From�to Ft. Di�ter- Q°f1 Inches
� TYPE: Steel Galvanized Steel
' IE Steel, does ovner appr Yes No
Weight: Thickness: � Height Above Ground: Inches
, Drive Shoe: Yes: No:
' Were Problems Encountered in Settin�he Casing2 Yes_ No
Zf 'yes' give reason:
Grout: Type: Neat Sa 7�ement: Concrete
. Annular Space width C� Inches
Water in Annular Space: Yes . No
!lethod: Pumped �� ��sure Poured �
Depth: From � to s� J Ft.
!laterials Used: No. Bags Portland Cement Weight of
1 bag � lbs.
If mixture (san�ravel, euttings) - Ratio: to
ID Plates: Yes /No Chlorination: Yes No
4 x 4 slab Yes�T No
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I HEREBY CERTIFY THAT THE ASOVE ZNFORMATZON IS CORRECT ]1ND THAT THIS
iiELL WAS CONSTRUCTED IN ACCORDANCE TH GOLA ONS S FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. H
Si ature of Contrac o Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO INSPECTION:
� Sanitarian's Sigaature Date
Sketch well locatina on reverse side. ilse established reference
points.