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The District Health Department
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal `
Owner:
Contractor: ��13
Water Supply: Private
Public
Sewa e' osal iliiies: No. bedrooms Dishwasher, Disposal,
washing machin oth r automatic appliances
-\
ize n : ' �� Nitrification line: ���
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Other disposal facility: '
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use.
Date approved: � � `�—T
ll (( tl
well:
. .. ��
". (OVEft)
Location of well and sewage disposal facilities sketched on back.
�
NOTE: Make sketch of installation sYiowing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing ori;lot;�Write in measurements in order that installations may be located
at later date,
(1) (2) ,
1, �
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Application Date: ������
.�mnant P�id:
Receipt #: /
A
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600
Mobile Home Replacement o� uilding Ad
$150.00 (if site visit required
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$ 75.00
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��,� sf ���.���,�
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on for Services
Tax 1VIsp: .
Parce!#: Z
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Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s stem ermitted)
� ❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ��f �Ot� �p�rMS 'U.•(. Phone (home): .��/,9 •�1`I•� a �
�-
Address: T/„��f �}{��,}�oif' (work/cell): _�(9-S9Z-QS�9
V�1l�o�0� �– 7 R6n !
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address: f� ���- f'� ,.
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Propetty:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
� yes ❑ no Is the site subject to approval by any other public agency?
� yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: �r,���.�.� j��
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: �/ Occupants:��
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will'there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: ❑ New well Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other 0
I certify that the information provided above is complete and correct. I also understand that if the infdrmation provided is
inaccurate, the site is subsequently altered, or th�ended use changes, all permits and approvals shall be invalid.
..—
Representative*)
* Supporting documentation required.
1 g v�
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)