A28 157The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and
IMPROV MENTS
t'4,n,ua.S��ear � . , �
Owner: _
Location:
Sewage Disposai
, .--
� Contractor: —� �y�P�' ,��
� Water Supplp: Private � Public
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal�
washing machine, other at tomatic appliances
Size of tank: � Nitriflcation line: 4oc� �c
�
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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PITT INTO USE.
Date approved:
Well:
Sewage Disposal: J � �
By:
\
Signe
S itarian
Counter �
aigne
'�( wner or his representativ
_,��
Ces3iCcate of Compietion �.._
Date Approved: �J� By: .�
Sani rian
(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
s�pplies, etc. Note special problems existing on lot. Wrate in measurements in order that installations may be located
at`•]ater date. Note location of water supplies on adjacent lots.
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WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE IS ED: ��� I ATE DR
OWNER-
ADDRESS:
DRILLING CONTRACTOR:
WELL CONSTRUCTION
Distance fro Nearest Property Line Distance from Source of
Pollution�
Total Depth: Ft. Yield:_�GPM Static Water Level: Ft.
Water Bearing ones: D�{ h: Ft. F Ft.
Casing: Depth: From (� to �Ft. Di�ter: �nches
TYPE: Steel Galvanized Steel
If Steel, does owner appr � Yes No
Weight: Thickness: Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: _�
Grout: Type: Neat Sand C ent: Concrete
Annular Space Width Inches
Water in Annular Space: Yes No ✓
Method: Pumped/�� ssure Poured
Depth: From L✓ to Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand,�ravel, cuttings) - Ratio: to
ID Plates: Yes No Chlorination: Yes No
4 x 4 slab Yes�_ No
De th
From to ormatio Descri tion
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORREC AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE T REGULATIONS S FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. H EPf
Signature of Contrac r Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO INSPECTION:
Sanitarian's Signature Date
Sketch well location on reverse Us� establi�d �erence
points. n U<
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� Pers�n County Healih Dep;
A m o u n t p a i d j � �, 325 S. Morgan Street ,
R e c e i p t�� � ac� � a ROxbOrO, N.C. 27�% ��'` L�/ 30, �9
+ Gourier �2•�3-=5 a t e
� � � `3� � � APPLICATION FOR SERVICES
'["��.. i.+.�snY*.x.. .�Y"3t=�t .k�.tl k'}r4^ a �-�ir',s�'t -s.f;�tl;+f�",'AS.`r.'•�{S�i",wYi["�'wt:tf��(� `"" -�f . !�?� n�*� �•��1."1S3 ��'
,�u � �'�.�i":e iFS ..,.kY�`a� . ....�.4l�.se�tiY3�� 2 �'--G••�Sr_�;`� .Ser-viaes�l\C(� uW�� s r`�'3`SY �/.6 `f:.;,x�� wjfi't / � .i.�'1_}',� i� i'�""i_(�CI
..: :'%+.�...� : i'�'�.. ..L.,�S.'.i'�:a.:.wtwyc2e..i�.v �t.:j!�. �r�Iw.�.,'y"�� ....t-.... .`....Y.w � : .:,.s.. 5�...Tiw._K as...., �CJF�"��. 1ow7
Improvements Permit. (Established/Recorded L.ot) ._ Reinspection of Existing System (Loan Closing
_ Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace)
rovements Permit (Addition)
Permic foc New Well
_ Replace Existing Well
Bacteria l Chemical I _ Petroleum I _ Pesticide I _ Lead
Permit requested by: . 7. Dimensions or Proposed S[ructure:
,�n� prospective owner/agent:�%lQm�s �• �e�.�s Width: .32 � — Ga t-�i�
ddress: �.�� QAir �iL..�.�d �� Depth: .Zd''
/��,�ha� o, �G ,�95�3 What type (if any, additions, expansions, or
r'� teplacement is anticipated to the structure or facility
�� 6- Y�� that this sewage disposal system is intended to serve?
ome Phone �: SY9� 1�/� ' L G ^/p,J'�, No ��u,�,�� ct��r /"20P+ �l,s ,✓��
usiness Pho�e r: �oS� :s2 '- ���2�S�uqri-s s'�A�c�a.ea
Name and addre$s of current owne:: 9. Water supply t}'pe:
� o�,,q� ,�. �.�A2s t ..���� p �S�ns private �'. public ❑ cor,v-nunity ❑ spring ❑
,Z.y,y Ws�,iz,,l�,v�C 2d Are any wells on adjoining property?Yes (�No�
t�a,r�o�o_ __�/� ����3 If so, identify location:
. Property Description: Lot size: /. �3 F�e
. Tax Ma�: /�- Z�
Parcel�: / S 7 .
Township: �L,�r� . /�,,ii
. Directions to propercy: State Road T& Road
iames,gtc. �/
/S� /,c%LS: L�f1 0�/ L�,(/r,/Lou� 0��2✓ /ld.
L.
Number of occupants or people to be served:
10. Type�of structurelfacility: Proposed: ❑Exist:ng: Q
Type of dwelling:
House: C�Mobile Ho:ne: [� Business: ❑
Type of business: Nf�
Number of Employees: N�/�+
Number of bedrooms: .3
Garbage Disposal? Yes ❑ No C�
Basement? Yes ❑ No�If so, n of basement fixtures:
CLEARLY STAKE ALL COR�IERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
'"'� I hereby make applicacion co che Person County Health Department for a site evaluation foc the on-site
� se�vage disposal system for the above d�scribed 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 invaIid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the propeRy to the Health Dept. I understand that in the event I have not
� delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
,►,� the site by the Health Dept., this application shall become void and all fees paid forfeited.
W � � /�.
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z Signc
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Owner or Authorized Agent
�
0
Person County Health Department
Existing SeNage System Report For: Hobile Home Replacement
1/A d d i t i o n-- �n�p'7i�-
Requestee: �1�5 c�� �"� Home Phone# �(�
�� ^ Businessn S��O��a-
Location Uirections:
�-1 � �� < < ,
, , ,►nn,.
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�� ar • i�ii
, (� . � ��- �.. �r��
Original Per:ait Located ..
Septic Systera Uesigned Eor: _ _
itesidential F3usiness Other {specify}
# f3edrooms � � Employees Other
llate lnstalled �J "� �� Water supply C�
Type o t Sys tem �n ��'1��i� �
Nitrification Line ��Z���
Tank Size
� Certified Operator Required ( Y �
On site �rastewater disposal system sliowes no visually apparent
malfunction on o I �ICta
Yermission is granted to:
Accordinq to the attached site plan. �
Comments:
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S-86 -00-:4-E
ISS. 65
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