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A28 70The District Heolth Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. Date � � � - k� � Owner: ( �" �; Location: �� '� % '� '; ' �-� (� v' �� d� ii» t !� { ( � � a � .y�`�4, y�.. �,(� �=7f_ ' � � Contractor: ' Water Supplp: Private Public � J ^ �� � � i . � � ; -� �--- , . �: � >r .. � a���, �-;�' � Sewage Disposal Faeilities: No. washing machine; o he/r auto Size of tank: �i ���l,�l�� Dishwasher, Disposal, � appliances NitriBcation 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 and 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- PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE II�TSTA�LA�'IIqN IS COV- ERED AND PUT INTO USE. if • � f 1 f l '� l� t i!.i I� � r,l`ti _ �l,`' �(�;�t��:�.Y ;� � �.� '� .�r --� : ;� Date approved: Signecl' � � ! ;J Sanitarian� �� Well: /: Sewage Disposal: Counter- � aigne - '-f B3'� (O ne his representative) ✓ � Certiiicate of Completion r � Date Approved: ,.�� By: S itarian (OVER) Location oi well and sewage disposal facilities sketched on back. Appiication Date: .1 � 3`� � • Tax Mao #: /"�"� d Amount Paid- U n Rec�Qt �: -� Parea! #: % V �� � ��_ _ _ � ���� �� - - _ -.� � � �C.Ti�''Zi' �' `�C� ���-.m— ----- m��.a �e.o.�.� � �1Q , I � �� APPUCA710N FOR S�iVIC� IF THE INFaRMATiaN IN THE APPL]CAT10N F�R AN IMPROVEiV1E�iT P�If1R IS INCORRE�T FALSIF�� CNANG�. OR THE 31'fE IS ALTERE�. THE3d THE IMPROVEiIAEi�IT P�fIA1T AND AUTHORfZd�►TION TO CON9STRUCT SHALL BE�ME IN�/AL1D. - � 1) Perntii raquested by: (Owned�erttlprospective owrie�: �� �� Hcme Phone: � S��'— 7� > Addres� 33� � �.�o �o ,. Business Pt�nn� Sy� - 6a4g` ,�'z� �� ti v: �v� z� s�3 2) Na�te aAd addr�ss of curr+ent owner: �.-e_ � h�v�S ' � v ,ci iJ• �vnC cvo , v.., C� . � � j � 3) ProQerty Des�iptian; L.�t s�e: Tawr�shtp: Subd'msion: �0 �u, 0.�L�� 1� Directions to the property (Induding rvad names and numbers): � 4) l�raposed Use and Struciure Descrip�ion: answesi eaci� af the fiollawing questions: .• a) P*oPosed _,,, Existing , Type of Struct�me: Wid#i�: � Depth: • '� b) Number of �Bedrooms Num�er of �pants or people to be served: •' c) Baseme� Yes , No Wiit there be plumbing in tt�e 6asernent? � d) 6arbage Dtspasal: Ye.s No _ . 5) Wabar SuQPhI '1'YPe: Private _(new _ or existing_), Pubi�c_, Commun�y� . Spring -, Are any wells on adjoinin9 P�Q�Y`� Y�_ Na _ tf yes, piease indicabe aQQroodmate locatiori an the .si� pian. b� � D�s your pr+op�ty c�ntain previ�usiy identifl� jurisdtctionai wetfands? Yes_ No,_, PL�ASE NOT'E THE FaLLOWING: � ➢ A Pl.AT OF THE PROPEi�1Y OR S1TE PLAN MUST 9E SUBMRTE� YVITH TH13 ApALiCAT10N. ➢ PROP'�7Y L1NES AN� CaRNEi�S MUST BE Ci.FARLY NARKED.. , � THE PROPQS� LOCATION OF ALi STRUCTUR� IyIUST BE STA� OR F�AG�m. ➢ THE S1TE MUST BE RFADILY ACL'��S1BLE FflR AN EVALUATION 8Y THE HE,4LTH DE3�ART�+IT STAF�. � 1 her�by maice aQpiicatioc� to the Person Caunty Heaith Departrne��t fior a siie evaivatIort for the on-siie se�nrage disgnsal system for the above-described proQeriy. I agree that the car�tents of this a�plica�on are true and repr�.sent the maximum faaiiiies to he pla�d on the property- I undersiand if the siie is aitered a- the irr�ended use ct�anges, the permii sha11 became it�va�id. . � � or Laga! Rep�ve // � Q PC.4D.lev U627102 .����,� / JS.. f.l...[j V�.� V� V � _ �' � `� ��� �:���'n��T'll �TfiT t� 'j��Jl �1(r�.J�1�}[� ...- I �. ... .. �,.�� �«. �,a� ., � .1.� i // . ,, /i � ... -. •�•-. S� 1 Y. V Y3�L.l� V�. Tag lYlap # r,� Pascel #_� Seciion/Lot# � � �1�11`0 Date . System components represent approximate�contours only. Tlie contractr►r must, flag the system prior to begr.'nning idre instaAatz'on to insure that propergrade zs maintained �---- -}� � Ly���s ���j . -� � �� �.���: ,�,�,��� � scale:- . � 1 E� ��� � � �-40�,��. • �a�, � � v�2,�� ���e� � ��� , a � N �ev� �� �� V�'� `�. a,� �em � ID(�-• �� �r 'p'�� � � PGI�, �ev. 09/12/Ol � - .> 3 .:� � T• . ..•., t �.. P ,'.'r"4 "'.1Fs z d-."' ''" .✓ 54 .�r � , � n �-c9.mt � �.' �� '_ _. .. . ' - . =+a.. _ t s., ct 'raa.i. t.ue+e.}a�M Mz.i-_vt.� -...rr-�a .ii...Ktue'�..at.-nS %�+...a...4v� aFn��-i afYJ%�1kr:ir�a"s�....a2C.a+a' �i.�ac�weZab�53'�aefi8-w.le�rrG^.YeTi6#:sXaRi..�.:�iNprr.:�z.vi2�aKis..' _ ilt�i -�.'et�`hL'-E�EL'L-`i `��Y�ie:s��Y� PERSON COUNTY HEALT'H DEPARTMENT 325 SOUTH MORGAN STREET ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGIGAL WATER SAMPLEANALYSIS � .. �q�/j . .w � ••�Name of Owner or Tenant � i Address �� G�0.-✓� '�'` � County t� �� � _ Q � Collected By _ . � Date Collected '�`��1 �� Time Collected ���• 31 ��'� Source: �ell ❑ Spring O Other Location: LJHouse Tap ❑Well Tap O Other IIdY'�o Charge ❑Charge � '�2 *�***�***********************�************�**************************�******** *******�***�**�******************�**�*�*�*******�***************�***,�********* Total Coliform Fecal/E. Coli Results Absent . ❑ � Reported By P i ��.��p �� �- T� bactreport . . . . . . . . .. ... .. . .. :�`..�:.�::...:�..::..:�.`:'. '':;:.'..`,.'..' �.:'. ,.:..: :�....;'. � : .:..::.:::..', ..:;�:.c.:..^� �';;..� . . `,� y ,��. ���� �.� �V . •.�+.+'�Y. �:.�. �� :��::::.�,.'.:. �:':...:.7��`m . �Jl:ai?`P.71i�]L?.�lCll;'T':'!`.�,�"1.17k'IL�'�.i��` :���'r�l-JL'�CA �. WELL PERNIIT PLEASE SEE ATTACHED PLAN FOR WELL 5ITE LAYOUT Townslup: _ (> ���� i, � � �, � Lot # l � Type of Water Supply: _ dividual ltequirements: Site Approved By: �ls �1 �2���_ Grouting Approved By: _ I�ZT/��1 Well Log: 'IS ��_�ib�' — Pump Tag: � _ — Well Tag: � Air Vent: � Hose Bib: Casing Height: � Concrete Slab: � Well Driller: �vG'h5 Well Approved by: ****See Attached 5ite 5ketch**** Community 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 � •� � � �'1 "•� � 'T �ny�i1_ . �i � i1 �� i r / D_S_N_[��. 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