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A28 29AThe Districf f-lealfh Department� Orange, Person, Caswell, Chatham, Lee Counties SEPTIC TANK PERMIT DatP g� G � — j.%��. Name of owner: ` � 1�� � �/a� �ti �� Name of contractor: � �'';,��T_ /-+,�j r'..q1� IAddress and Directions •�, o�,� Q- .�i'� �2T'' !/ s' l r� � t Q.�L�-�T �' � '�r�v� �r��z,. ��s Person or firm doing installation: .L,� 1` � � Address -���2i�'�Nf� No. of persons to be serve� . Bedrooms 1, 2 3, . Additional appliances to be used: Disposal, dishwasher, avY shinQ _m�chine Re moc mended• Septic ta p� Nitrification line: �� Q � / � % / Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspecied and approved by a member of the District Health Departmeni staff before any portion of the installation is covered. Date Approved: � (ei - �Z Countersigned Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer (Over) � NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. SUGGESTED INSTALLATION (Date ) FINAL INSTAI.LATION (Date ) (Road or Street) (Aoad or Street) �s������■��■������� ■■���■■ ■���������■����.���� ■�����■ ■���■�������■��� J ����■�■ ■��������������� ■ ���e ■■ ������■ ■■�■�■1� ■ ■�■ �� ��■��■� ��■���f�� � ■ 0���■ ■�����������������■��■���� ����o���■����w��i�����■�■�■ ����H������r��r�����■����■ ����■�������l������������■�� ����e��■��i�i�i��■ ■ ■�����■■ ■���■���������� ■ ��■�� ■ ■����l������������I�A���_---� ---- � 4.�--� Apalication Date: �� ���''6 � Amount Paid• �� Recei pt #: ��� '# �� � ����_ � ���.� �� — — _ -- cC � �J1�'IC' � �aavaa-o��-�--- o��.eo.7L 7%�om.71.�11�_ APPLICATION FOR SERVIC�S Tax Map #: � � o Parca! #: a I � IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFiED, CHANGED OR THE SITE� IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALlD. � / /�) Permii reques ed by: Ownerlagent/prospective owner): Home Phone Q Address: � Business Ph ne: '• -dd /1 � 2) Name and .address of current ovmer: 3) Property Description: Lot Directions to the property (i l�rd�/�/�� � 75 � �� 4) proposed Use and Structure Description: answer each of the following questions: a) Proposed J Existing Type of Structure: ��4�� � c Width: � S Depth:� b) Number of Bedrooms: Number of occupants or people to be served: �i c) Basement: Yes_, N Will there be plumbing in the basement? d) 6arbage Disposal: Yes No _ 5) Water Suppiy Type: Private �new _ or existing� , PublicJ Community� . Spring _ Are any wells on adjoining property? Yes t/ No _ If yes, please indicate approximate location on the 'site plan. 6) Does your property carrtain previousiy identified jurisdlctional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SiTE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA►�D OR FLAGGED. ➢ THE S1TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT STAFF. I hereby make appiication to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum faciiities to be placed on e property. I un� tand if the site is altered or the intended use changes, the peRnit shall became invalid._ . -.���� Owner or Legal r'% _ Date PCHD. rev. 06/27/02 � `�� ?. )� ���� �� _ . . _ . � � � ���� I�aa�aa-�� � o��.]L IE 7LImm1L�71a. SITE PLAN �v Taa Map # ��� Parcel # ��� S Secrion/Lot# Authorized Srate Ageat �� � System campoaeats reptesmt nppioaiv+sm caamrms aaly. T6e canu�cmrmusr9�g t6e :rystem pdot m begranmg the insmII�oa av insrm �tPt'oPe�'Bnde ia msiaraiaed � .. • . � . ' � . � . . � - V �,V.e �( S'►`� �� � .�- ... rcfm, �. o�/Iz/oi �:� �� ���,.� .�.�. ,,,. �,-3 � , ; .. �� � ���� �� `—.._ � � . � � `"_'' -�-- � � �� � � �+ =a�r�s'C>iY�.a^a.�-��ca��.l .l���ol�u.���. ..�. t. ..��� . ....�U�..�: IlOi. .11 .{�IIJJ..YU3 Dri:`� D : _ C � �n��,� Ty ��in � s . . • +�atc� Dridieci ' �ell Log T� �,�rap��i Parcei # �2,�� Owner: 1 i � a /,�/��__.--�.� � � . Lacation: Lot # ________,. Subdivision: S�'ell Coasiraction Line _ nimum iQ feet) � — I?istance From nearest Property (� � � � Distance from Septic System (Minimu� 60 feet fi Totai Depth: � ft Yieid: � GPM Static W�'ate` Level: �_�._ Water Besruig ZoIIes: Depth ��. fr�� � --- ------- Casing: ft. Diamc.�ter: � i in . Depth: From _�_ t��--- �- Type: Galvaniz� �cl�.ess. � Hei�t above Groun.d: �v___ ln Weight: rohleTns encountered while setting casing? Y�s !--�D Drive Shoe• ��'� To �Y P If "yes>' 8�ve reasoa• r _ . Grout: Neat: _^_____ S��C��'nt ✓ Conc:ete Grave Cement " inches Water in Annular Space Yes �� pnnu1ar Space Width �y — Method oFGrout: Pumped Pressure Poured ✓ Depth �_ to �_ Ft. Materials Uaecl: Weight of 1 Bug �_. pounds No. Ba�s Portl.and ceuient � If mixture (san�, gravel, c;uttings) — Ratio �. � ., N� 4 :e 4 siab �'� �O ID plates: _�'ts _. `- _ .... . _ _ f�,ocuti�n Drawing ---_----- I hereby certify that the above informar:on is corrcct and that ttus wcll was coi�st�v�t�� � flccord.ance�tivith reguiacions set forth by the Pe:son County Heatth Department. ' �—��� ID i# ��,3..� Bate �/ G' a�-- gignatufe of Contz'actor � � pC:�D rev 01/16i02 �� � ���� �� . �� ,,, � ..._. � �'� ���� . .�' x�:;arn,�r:o,.-,. ,.�;r,. a�axn��� ��aa�o:Il.��s: : WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map � Parcel # a Township: Applicant: Subdivision: Lot # Location: Type of Water Supply: � Individual _ Community Requirements: Site Approved By: '' � �f' Grouting Approved By: — ^D � Well Log:�,,� �%j��c`� Pump Tag: Well Tag: Air Vent• Hose Bib• Casing Height: � Concrete Slab: Well Driller: Well Approved by: ****See Attached Site 5ketch**** Public Liner: Installed by: Depth set: _ Grouted: _ Date: Water Sample: Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date: PCHD rev O1/27/04