A28 77� a
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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water_Supply an.d Sewage Disposal
IMPROVEMENTg..pERMIT No
/� Date-- . : I t�_ . '
f U- 8S s
�WII@T: �Ya� ✓ tl� �.1 x �� e�/
Location: �
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M� �. � G✓ ,✓ h_��� S�1 �.�Vlf
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Contractor: "`�'� "
Water .SuPP1Ye Private -� L� Public .
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Sewage Disposal Facilities: 'No� bedrooms ��.Dishwasher, Disposal,
wa�hing machine, other autom�natic applianCes •
Size of tank: � � �K• Nitrification line: . ' � �
_ v�
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
_protectian•-must-�meet' state•�and local regulations.
Septic tank should be puiriped out every 3 to 5 years and shall be main-
tained by:owner iri such� a manner as not to create a publiC he8lth 1T8zaTd. '
� Septie� t8nk and nitrification line MUST BE INSPECTEI? AND AP-
_-' PRQ4EI3;BY �A:NlENIBERiOF THE DISTRICT HEALTH DEPARTMENT
�STAFF BEFORE'ANY PORTION OF TIiE TALLATION IS COV-
- �RED AN73. PUT. INTO USE.
Date approved• Sig e
Well: -Sanitarian
�Sewag'e Disposal• •
� ' Counter �, �
�BY: ' . �--eign .��iGa.�._
., tvwner or
- = Certi�cate .o� Cc_.. letion '
.. ' .. i . . . . .... ... . .. . .
Date- Approved ;� . -`• � "
By: ,�
' anit rian -- .
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Location :of:;well-and sewage disposal-facilities sketched oa back.
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Auoiir.atton Date: • 16�a6 "6 � . Tax Man �: /�o� �
AmourK �aid•
Rec� . •. Pan�! �: � 7
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APPt1CAT10P1 r-0R SeiY1C� �
IF THE INFaRMAT10N IN THE APPLICATtON FaR AN IIIAP420�E�iT P�ZAAIT 13 INCaRRE�T FALSiF9EE�,
CNANG�. OR THE SiTE IS ALTERE�. THEiHI THE IMPROVE3VIEi�IT P�iiMIT AND AUTHaRfZATiON TO
COPISTRUGT SHALL BE�DME iNa/ALID.. - . �� � � ��
1) Pern�ii raquested by: (�wnedagerYtlprospe�ive ownerj:�. � Q L�� �(�� �
Home Phone: � Addr�ss: 3 � � �
Business Pt�on� Sa3 - lSl � o � Z S� .
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2) Name and .address of caur8nt owner. �ryi � E .
3j ProQerty D�Qtlon; �at size:
Direciions to the pro �- � �-�
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Towr�st�tp: Subdivisio�: �'o ��.Iqr Lot� � g
4) ptoposed Use �d Struciure Descri�Hon: ar�swere�c�'� af e fidlovy�ng questions: /
.• a) proposed ,v, Existing . Type af Strudure: ��tJ P/�� d� Width:� Depth:�' �
b� Numher of �Bedraoms 3 Numt�er of ocr�Q or peopte #o be s�v�: � •'
c) Basemer� Yes . No �Wiil there be piumbing i� the tiasemerrt?
� d) 6arbage Disposai: Yes . No _ .
5) Waier SupP�'Y rlPe: Private �ew _ or existin �, Pubiic . Commundy- , Spring
, Are any wells on ad�oinin9 P�P� Y��No _ If yes, piease indicate apQroocimate loc�tiori on the
'stfia plan- .
6� � D�s your praperty c�ntain previ�usiy identift� jurisdictiortai wetlands? Y�_ No � .
'� PIF�►5E NOTE THE FOLLOWING:
➢ A PLAT OF THE PROP�T`f OR SiTE PLAN NUST BE SUBMTfiE� WfTH THIS APl�LlC.�►71aN.
➢ PROP�iTY L1NES AND CaRNEi�S MUST BE Ci.�1RLY AiARl�.. , �
9. THE PROPOS� LOCATIOM OF ALL STRUCTUR� MUST BE STAi� OR F�G��.
➢ THE SiTE DAUST 8E RE�►DILY ACt�ESSIBLE FflR AN Ei/ALUATIOIV 8Y THE �1E�41.TH DE�ART��i'i'
3TAF�. �
1 her�by maic8 appiication to the Person Caurtty Hesith De�artrnent for a siie evaivation for the on-srie sewage dis�aosai
system far the above-described prope�ty. I agree tfiat the carrtents of this aQpiiration are true and represent the ma�imum
faciliiies to be pla�d on the property. I u�ersiand ii the siie is aitered or the irrtended us� cfianges, the permii shail
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