A28 1602� 3�
The Distr�ct Health Deparfinent
CASWELL - CHATHAM - LEE - PERSON COUNTIES
' t ,
Water Supply bnd Sewage Disposal
IMPROVEMENTS PERMIT N .
� Date -
Owner: U
Location•
D
h�-�rt �� ���� .� i ,
Contractor:
Water Supplp: Private Public
�,�s�f � ��1�•-
Sewage Disposal Facilities: No. bedrooms ; Dishwasher, Disposal,
washing machine, other suto tic . appliances �,
Size of tank: __i�y��iy`�'�, Nitriflcation 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 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 DEPAftTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATIOIV IS COV- `
ERED AND PUT INTO USE.
�
Date approved: Signe
Well: Sariitari
Sewage Disposal� "a `�-7
By
CerliScate oa Conipletioa
Date Approved: By:
Counter-
aigned
(Owner or his representative)
Permit Y.O1D after 3 Yea�s
- - .— -�-= - -
-----...�
Sanitarian
(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
�
Aooiication Date: C�'') �� Tax Man #• l"S ��
Amount Paid: I�S
Recai � 9 9(�j Paresl �: �� 6
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APQLlCATION FOR SERVICES
�
� Permlt requested b• Owned ent/pnos e owner : G, `
Hame Phone• • �3� - .5��1 � D� � Addt+ess;i � �
Business Phone: 5�3- oal � '
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2) Name and address of cumeM ownec lr� �' v�,�
. \, , V .
e .
3j -Property Description: Lot size: ��� Township: O � j v l � 1� Subdivision: Lot #� �
Directions to the property (induding road names and numbers�: �
4)
5)
proposed lJse and Structure Description: answer eaci� of the following questiorrs:
�a>- Pnopo�d _,✓E�s�,g Tme of struct�,re: � ��J �rwdtl,:_ 7'� oeptn:�
b) Number of Bedrooms:' � Number af accupants or peopie to 6e s�aved: '
�) Baseme� Yes .�No �Will there be piumbing in the l�sement? :;
d) 6arbage Disposal; lfes . No ,� . ��
Waber Supply 7"ype: Private �ew _ or existing_�, Public_, Commundy . Spring
� Are any wells on adjoining property? Yes_ No _ tf yes, piease indicaba appraxImate loc�tlori on the
.sibe pian. � .
%�Daes ycur property caM�aln p�eviously ide�ifled jwisdictlonai wetlar�ds? Yes_ No
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MUST BE SUBMITTED W1TH THIS APPLICATION.
➢ PROPE�tTY L,WES AND CORNERS MUST BE CLEARLY MARKED. -,
➢ THE.PROPOSED LOCATI�N OF ALL STRUCTURES MUST BE STA�D OR FiAGG�. �
➢ THE SITE MUSfi 6E READILY ACCESSIBLE FaR AN EVALUATION 8Y THE HEALTH DEPARTMEi�'1'
STAFP. ' . �
I hereby make appiication.to �#he Person Courrty Health �epartment for a site evaluation for the on-sit+e sawage disposai
system fcr the above-described property. 1 agree that the conter�ts of this applic�tlan are true and represer�t the maximum
facii'�ties to be plac�d on the properiy. i understand ifi the siie is aitered or the irrtended use ct�anges, the permit shaD
become invaiid.
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Date
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6/14/2006
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Building Additions/ Mobile Home Replacements
Tax 1VIap #: Aoa$
Approval Requested for:
Parcel#: l ��
�_ Mobile Home Replacement
Building Addition
Applicant Name: ��T� �a Lr�rann
Address: 3�8 ��-,�,�n,b� S?�
�.�,,� �-o. �.x. Z�s�
Phone #'s: �'t�,b-'�'ia- C7�11b
Pernut Located: �_ Yes No
Installation Date: Q- a$'� Design flow: 3c�o (gpd)
Current Contract with Certified Operator on file (if required): �vc.
�VVater Supply: X Well Public or Community
Wastewater system shows no visual evidence of failure on: (o � 0'1�7 d.o (date)
(Applicant's signature if site visit is not required) (�
dition/Replacement Approved
�c-�- �--o�u
Env�ronmental Heal Special' Date
11/15/OS