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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES '
Water Supply and Sewage Disposal
IMPAOVEMENTS PERMIT No.
.- Date ��-_?L-�i
__._.-
Owner: ��rk"'+�� � '�T /F.'
Location: _ � J
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ro Contractor: � �o �7�r� �, � Cv� cr
� Water Supply: Private �,.�— Public
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Sewage ' po�acililies: No. bedrooms .�� Dishwasher, Disposal,
washing machin other autor�atic appliances
Size of tank: ���L14,� �t:' �T Nitrification line: C���� ��
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 an3 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 INSPEGTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT H�ALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE:INSTALLATIQN IS COV-
ERED AND PUT INTO USE. ; �" � n/:
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Date approved: — Signed � ! %LI'". �'�� f f % � ,�~,� ;` '
• 'J' Sanit2rianN�����
Well:
,
Sewage Disposal:
By:
Counter-
signed
(Owner cr his representative)
Certificate of Comple2ion / � f
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Date Approved: �� By,:
� nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
• NOTE: Make sketch of installation showing lot size and shape, location of hous 1 Apti�
� supplies, etc. Note special problems existing on lot. Write in measurements in order th , inst<
at later date. Note location of water supplies on adjacent lots. '�"
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tanks, privies, water
ations may be located
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�'C,�O�`D��L W�TI-I IZEGULATTO
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Aapiication Date: p (
Amc::nt Paid: ,OlO
� �tecaipt#: � 2�LQ
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P�erson Countv Heaith Department
Environmentai Health Section
APPLICATION FOR SERVICES
Tax Mao #: � � o
Parcal #: �9
o�� l��'�s.��
1) Permit requested by: (Owner/agent/prospective owner): �^J
Home Phone: Address: _,�__�
Business Phone: �
2) Name and address of current owner: ��
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3) Property Descriptiom �ot size:� Township: �����
Directions to the Nro'erty ncludi g road na es and numbers): S i
,9__.I'_,. .�_ _ . �_� _
O �i �9 S ���� M
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�}��. 7�'�3
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4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed ❑, Existing ❑
b) Stick Built ❑, Modular �, Single Wide �, Double Wide ❑
c� Number of Bedrooms: d) Number of occupants or people to be served:
e) Basement: Yes 0, No � If yes, # of basement fixtures: �
fl Garbage Disposal: Yes �, No ❑
g) Dimensions of Proposed Structure: Width: Depth:
5) Water Supply Type: Private �(new 0 orexisting �), Pubiic ❑, Community �, Spring ❑
Are any wells on adjoining property? Yes ❑ No ❑ If yes, location
6) Piease Indlcate Desired System i ype: (systems can be ranked in order of your preference)
_Conventional _Modified Conventional _ Altemative _Innovative
Other (specify):
CL�4RLY STAKE ALL CORNERS APID LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAiV TO THIS APPLICATION
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I hereby make application 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 facilities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as appiicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
person I of the Person County Healt De artment to conduct their evaluations. I understand that I m responsible for notifying the
Heal partment if property ' s an ds as designated by the Army Corps of Engi ers.
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Owner or Legal Representative Date
PCHD, rev. 10/12/99
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Tax MaQ #:
Zoning _
AppllcanC
LoGatlon:,
PERSON COUNTY ENVIRONMENTAL HEALTH
,SE SEE ATTACHED PLAN FOR WELL SiTE �LA'
3ubdlvislon: Sectlon: �
� Well Permit '
Tvae of Water Supalv: Individuat Community Public
Requirements•
� /� a / /� /
Stte Approved by �
Grouting Approved by
Well Log n ( .
Well Tag '
Air Vent
Hose Bib �
Concrete. Slab
Well Driller: � �%�i � �
Well Approved By:
Date: �
'"""`See Attacfied Sits Sketch'"`�°
Weiis must he 10 feet from �property fines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any buiiding foundation.
Other conditions
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PCHD, tsv. 11/29/99 '
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Application #:
Tax Map #:
Parcel #•
Person County Health Department
Environmental Health Section
SITE SKETCH
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Applicant's Name
S � D
horized State Agent
SubdivisioNSection/Lot#
a o
Date
System components represent approximate contours only. The contractor must flag the system
nrior to beginnin� the installation to insure that proper �rade is maintained
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PCHD, rev. 7011Z/99