A29 119PetS�� Coanty Healt� DepartQeut
SaQiron�eatal 8ealtb DiQisioa
Applicatioa for Yater SaQply andloi
Septic.iank Yerificatiaa
Oate P.eceived � �" �� ��� Request Give� to
Tai Hap Ho.
SR1 oT BaLe L,ov � � �� -, -� ��
Property AddresslLocztion
Direstions to Pr
Requested by �
Report to: ha�e
Nailing hddress
rtp �,�
�t_ �_ a
SubdiFision o�� / �� Lot#
Parcel No. fo�nship d�/ ��
2a � �,� �/C oZ 75 3
,_/e„ — � D/J T%�-'�
o ,� c- �
�� �� n—��-��
P6on�t —
1/ r� -q,�Lendinq �qencp VA ( j PHA t � �onv. ��.v
Closin9 Date / -
Yhoflet
Prior to satplinq aay vater sapply, t�e Qell iast 6e a6oQe qtaand and teet cartept standacds.
kater SqsteE: Individual (��blic{DBSj ( j Se�i-public (less t6an 15 connect� ( 1
pype Loan: `Rev ( � Resale (vf Kefinanciaq ( 1
Rote: Healt6 Depaiteent no longer does Refinancing �valuations.
Status of Spstee: �ev ( 1 Bzisti�g ( 1
t' Sanpliuq:
Ble_ctticity a�ailable Tes (� �o l 1
xas spsten cGloriaated Ff� ��0 ( I
� ke
Spiqct avai:able �E� � � �
CotFeots:
•keY should be c6ecked onlp if 5oase has not been previously occupied:
"Saeplin9 infoteation is needed for_individual vater systees only.
.��.�*„�.�„s,.,t„<<..����+++�,t�,..�.+.,��.+,+�t.��.�,�,tt.�.�..+__.'..�.vastins`ectee`bV'L�15'Departflent'and
fhe sevaqe disposal sgstee installed at a hor:e located �t t�e above �ddress P
tGe follotinq results found:
( l�idEIE �'cS �� si9n of �alfunction at this tiEe.
(aJ�tBE h0E4 Yd5 CeCd4L, L�IEIEfOIC LbE ZCtllcl fUUCL1001�G ib111L}' of t6e sqstei cannot b� dEtereined.
t6e s ste� ioi t6is Eoee is ealfunctioniny, ot sho�s evidence of past nalfunctions: rhe i�ealt6 Dept. should
(1 y
be contacted ior Repaic PerEit.
T6e vater supply for t6is 6oEe is_furnished 'oq �� les: than 15 connectf (�1 Ylivate/individual vell located
( � Publicicocaunity snpplp- ( 1 Seai-public supply (
n pioperty vas collected on �( `�� — C� �od test�d aegative for colifotn
( v� 6 o o fficial sauple of this Yater supplp
6act '. Yhis vatec snpply is co si dere d b a c t E r i o l o g i c o l l y s a f e f o r drinking zt t6is tiee.
llr
Date
Bnv' oneental 8ealth Specialist lication.
alse or nisleadiaq iufoteation-cootaiaed in �ILS
th15 ICQOIL l5 bZSEd ld QaLL 04 lULOI¢dL100 QTOvldea bY LEELOTEf ��er OI d1SIheT IEQIESEDLdL1YE 10 thE aee IO q
Yhe Bnvironeental Healtb Specialist is not tesponsibl
a lication. Toe Bnvironeental BEalt6 Specialist is also o��i espf lse lotf4isleaZi qEdstate�entsgpTo ided 15,5 eE
eP o tic tanY. S
or for stateeents in this ceQort that Eap hzve resulted
. •� in the iuture or that the Yater supplY kill reQai� potable.
application. Reitder Person Ceanty nc i the Bnvirontental Eealt� Specialist +atrants that t. sep
Vjj] CGULIOUE to functioa sztis.acto y
a
�e Dis�ric� l�eaf�h �epari°ment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
�a�er Suppiy ond Sewage Dispos�t
IMPROVEMEIST'3 PERM�IT N�o.�
Date— �` �5—�-�
Owner. �� �1�.G �����
Location:
� 7�
Wmier Supplp: Private � --'�� pubIic _.
S0W8 e D'is �a�r e� uu�
g posal Facilifies: No. bedrooms Dishwasher, Dispo ai,
washing machine, other automatic appliances •
Size of tank: _ �_ Nitriflcation line• �� i�
Other disposal facility:
Water supply and srwage d.isposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shali be main-
tained"by owner in such a manner.as not to create a public health hazard. '
Septic tank and nitrification Iine MUST BE INSPECTED AND AP- .
PAOVED BY A MEMBEft OF THE DISTRICT HEALTH DEPA,RTMF,NT ;
STAFE BEFORE . ANY POATION- OR .'THE INST,ALLATION IS COV-- •
ERED AND PUT INTO USE:-. •
i!3 �/t f
Date a��FBY€�:— �igne � �/ � � P l �% ` J � y'.��� �
�ts�i_ . Snniknra�
Sew�ge Disposal�
ounter-
BY� D�
- I OP L� P pP� {aiiveS
. Certifsca3e of Completion
• � Date Approved: "'�
By:
n arian !
. (OVER)
Location oi weII and sewage disposai facilities sketched on back.
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