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A28 77� a `� 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: � - �\ �q _ , M� �. � G✓ ,✓ h_��� S�1 �.�Vlf . • 5� � � �-� Contractor: "`�'� " Water .SuPP1Ye Private -� L� Public . ;_ , i 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 -- . -- �0� Location :of:;well-and sewage disposal-facilities sketched oa back. � _ - ; V y � y � r D � � : � r � fi y' � � u � �� y � s � � � 0 r. m N A w p � ]' d ,��o 0 w � 0 � 0 � x 0 C � m � � r. 0 r. � x N � e m `n � K Auoiir.atton Date: • 16�a6 "6 � . Tax Man �: /�o� � AmourK �aid• Rec� . •. Pan�! �: � 7 ���_ � ���� �� - - -� � � �CTr�i�' �' . �m.�r�,--- ,�--- m�.��.a. ��t.e���. 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� . � � �� h 2) Name and .address of caur8nt owner. �ryi � E . 3j ProQerty D�Qtlon; �at size: Direciions to the pro �- � �-� . B�� 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 � � �O � Dat� �o. ,�,►- a�rzTraz _ - :.� � �•4��• � � \ \. 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