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A29 121.w �:e"' air-� - .... ..... . . ........_�..,. _ ...._.�.>..... . _ _ .... . . . . ./ . . . . . ...�..r...�.. , :,,;:.�:. �! he disfricf Heolfn L���ar�tnEnl� ~ ��•• 1 � CASWELL - CHATHAM -•LEE - PERSON COUNTIES �' ' � w ��afer Suppfy and Sevrage Disposa! I1•fPROVE2;ENTS PERMIT No � ��, Date�-�� � Owner: -�G �� � �Gz`s:Y Loc�t' n: rY.� �g�t,�l�c��^T- ii � ' ._' ICo tractor. � We.tez Supp�y: private .—,� �� Public _ L . � • _ � �- , P�l�l� � en • Seuage Dis,xsal Facitiiies: No. bedrooms Dishwasher, Dispo�al, u•ashing machine, other sutomatic appliances Size of tank: J�'itrification line: ��� Other disposal facility: Water supply and seu•age disposal tacilities location, installatioa 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 II�ISPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMEN'!' STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. ,� n � i; ` , � : . �',�.Jj , t�� r ,� 1:'• Date approved • Si ened �' �� l.,� f ;• r`�, , f r I • " Sanitarian' —'—'" Weli: Sewage Disposai: unter- B3�� �ner or his represe ative) .. ^ Ceriificaie of Camplefion i� • Date Approved: ' B • Sanitarian (OVER) . LocaEion of well and sewage disposal facilities sketched on hack. , I` � � k r ' �� -.(1_ � �I °� �I �3 5�- �Re �y�J�- 3. Z ( � _ Improvements Permit. (Established/Recorded Lot) pPPLICA'�ION �OR SERVICES � O a Impxovements Permit (Unrecorded Lot) ,�_��2-�� � : .. ..::� i . .n.:.:... .:.... :. . ...... . _ Retnspection of Existing System (Loan Closing) _ RepaidReplace existing Septic System Improvements Permit (Mobile Home Replace) _ Permit for New Well �Improvements Permit (Addition) _ Replace Existing Well ::: :: �-:� .� i ;_ ,� :�. . ' ; . ( � .Sh �S Y Y� ,aterSample to be Collecfed � _ ....� ...�,. >:. . � :.�. ....,... � . , . ... �,> .. <.. ,. : x f. _ B acteria Chemical _ Petroleum _ Pesticide c� w � z t requested by: .(i ;��N PEK�(�� RS�� ospective owner/agent: �. � 5�6 T/� � i sn. � :.o�.6.dno ,� �. ��s�3 Home Phone #: S~97- ��-79 usiness Phone #:5��� !?�SJ Name and addre�s of_current owner: SA-� E' . Property Description: Lot size: 1� q�c2�S . Tax Map#: �� � °�' �5 * Parcel#: �'i1� �-r= �-5 ' « Township: o � ; �� . r L �. Directions to property: State Road #& Road Zames,�tc. . „., --rn '�-b ca.� CIc S�- � i 8�/'¢r i` � �Y Lv.�` - .y ¢(G�� 7. Dimensions or Proposed Structure: Width: !� t-Su1�.aori.. aF-atc' 1 5` Depth: � a� J 1�`-�S�t.ro� b�. � Yr� -5 . _ Lead 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? � a�� 9. Water supply type: private �j . public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No j�. �If so, identify location: 10. Type of structure/facility: Proposed•.,1Existing: f� Type of dwelling: House: �Mobile Home: L� Business: ❑ Type of business: Number of Employees: Number of bedrooms: 3 Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No�l If so, # of basement fixtures: 6 Number of occupants or people to be served: � ' � CLEARLY STAKE ALL.CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'SOn COunty Health Depat'tment 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 before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shali become void and all fees paid forfeited. Si�nc� Owner or Ayl�iorized Agent � w � a � � "B 1075 PERSON COUNTY HEALTH DEPARTMENT WBLL AND SEWAGE SITE, LOCATION INIPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � � Owner/Contractor Location/A drgss 3,- � h��� Subdivision Name SFD Parcel # � Township ' ,' p e �j�_ Date — — y (o � s r�sti � .. ��� , ;�,� u✓ % ,n � �� S.R.# I . C Lot# SEWAGE SYSTEM SPECIFICATIONS Lot Area cl cvts' Size of Tank_�j S� � h° '"' e � L r N w Mobile Home Size of Pump Tank # of Bedrooms Nitrification Line L j� i S,� �o �(�c�",.o � n�� -� n,�.� �,.�� Max Depth Trenches ��d �.; �.�� ,�e� �l P�k q' x � o� Permits m� be voided ii Well and Septic Layout by Comments: Date ell Comments: Date Installed by ' aid ❑ ELL SYSTEM Semi-Publ' ement v Approved Installed by Approved by �'II'ICATI ired Slab Air Vent Requi ell Log ell Tag _,� Approved by_ This report is based in part on inforrhation provided the �iomeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam Ol/95 rev.l.l AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DAT'E: — — � IlVIPROVEMENT PERNIIT #: TAX MAP #: PARCEL #: OWNER/OWNER'S REPRESENTATIVE: P�Y eYSa� LOCATION/ADDRESS: � : . . . , ; . , L�:�:_ ,_ � SECTION OR BLOCK: AUTHORIZATION FOR CONSTRUC'�ON I„SSLT�D B AUTHORIZATION CONDITIONS .��-� ���- ��' �.�,� 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifications as set forth in Improvements Pernut # D'7,S• The construction and installation must also meet all applicable rules and laws. 2. No portion of the Wastewater system shall be covered or placed into use until inspected and approved by the Person County Health Department. 3. Any alterations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specified in the associated improvement permit and application, may void this authorization and associated permits. 4. Conditions: �i �lJ ►� {� c� orv� I.v t� u e c— � ' QZt,�-�c— �.� � e�f _ �� Y �w �� Person Requesting: , a �e a�r ��Y�►�f • Oy6l PERSON CO�TY HEALTH DEPARTMENT ` WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT . Tax Map # � � � Parcel # /�-/ � . Zoning Township ��i�ve l�; ll T Owner/Contractor_� � G� Pe �� ��so �l Date �� 7- 9� Location/Address �-�1 S-ho c�� I( 2 �-,6 src�- / IS5 .�,� lc��-�- Z��e U � P�� C e�y Subdivision Name c� SQ v r . Lavour s2� I� 5 1 >-� `f�s Q� ts ��. �-a�� m�� � �,, �% ��� � n W °J�.n '� � � eck roork �-� S ,b�e b�'IFI�e/L . fa� ��:.� �Q,,,, ��Op ns (.� � l_ �. �� �r S.R.# Lot# II ` As Instailed �1�{�; S� n r�o�, -� be b�►!f �vP►- �r;s�i"� s� � �(�t..� 4�,Ff��f �ly.c�",�fii e/d SEWAGE SYSTEM SPECIFICATIONS pes�{'rv o� Repair Lot Area I,�r �t �'� Size of Tank ��'� N� ld�U�� SFD Mobile Home Size of Pump Tank -�� Business # of Bedrooms Nitri�eation Line Ac�� Sv �X ���tu r�,al�ce � Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered o tend e ch ged. Well and Septic Layout by Comments: Date Installed by, Vell Permit Paid ❑ �dividual ubl ic ite roved ell Head An ved Comments: by TIONS Required Sla _ Air equired Well Log Well Tag �� Date Installed by Approved by� This re rt is based in part on informati provided the homeowner or his/her representative in the application submit# for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have tesulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wa�rants that the septic tank system will continue to func[ion satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0 _. � .�::'h!..!.i-'5.:..:.�. J'�w. .r..w.��u, sr:.:+_4 .�'.' ... ... ..... .... . . . . ..... � .� —.. , . . � r i ��• S fj� �N�i �U rX 3 � !o rf' PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant E�� Address ?� � lv Tls�-�� �t-��T� �- County Collected By --���`Z. _ v Date Collected 4� �7f,�'�)� J_ Time Collected � �%' �� Source: �ell ❑ Spring ❑ Other Location: House Tap ❑ Well Tap ❑ Other � No Charge Charge ........................................................................� ******�*******************�*******************�x**�x*************�******** Total Coliform FecaVE. Coli Present � ❑ Results . � Reported By �� �-' Date Reported � � l a-� l� � io`� �h�� Absent ❑ `�.