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A29 71►� The District� Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. �i�i,'�'" ' � ,V D t , !;> _ �(, 71- Owner: `' `' �r r� �` � Location: .' r r�l; �:�,. , - �;' ; � ' r: , .- . �--T -_:z-_T!_ �— Contractor: � �/ � Water Supply: Private —�c— Public Sewage Disposal Facililies: No. bedrooms -� Dishwashe , Disposal, �--�- -----� r — - washing machine, +other autom tic.,appliances -- ---�-----._.._;,' J ;,� �� • : � _ ;, f � .� . Size of tank:` •' � �._ �'�- ` _, Nitrification line: `. ` � 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 INSPECTED AND AP- ... PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE �NSTALLATION IS i OV- ERED AND PUT INTO USE. ,/, � /'� Date approved: Well: Sewage Disposal: � Counter-' By; signed (Owner or his �prese— n— tative) CerYificate of Completion ` � 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 house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Wr.ite in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. Application.Date: � /�-D ff � Amc,�►'i �►a�d: I . � O Rece �k#: �1(� � 1 q � # �.,�-,�.5�� I�I�IE�.� ��T ' � � ZLT�'I�� 1 �- 6 � ��.��n=r�:a,,��-,�.�n-,��:.�.0 ��.�.�.u.�:�a. Application for Services (Septic Systems and Wells) Services Reauested ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0'Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Nlap: � � °� Parcel #: % � u ,��-t ` �„} a i �- � ��� N�X� a� -�v �� ❑ Construction Authorization (Fee is dependent on the type of sy: 0 Permit Revision $75.00 ❑ Repair of Ezisting Septic System No Char�e Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altererl, then tlze Improvement Permit and t/ie Authorization to Construci shal[ beco`ne invalid 1) Services Req ted by: Name: a.� o n i c. Address: 2 3 n r ox �-.� -G• Z7S7 �j Phone # (home): �%1�– yZ � % (work/cell): S-�'1 �Y -- 2 y 9' y 2)Name and address of current owner if d' erent than applicant): Name: �'c�i�.-� .it� /�.�. Address: /$ 7.3 t f'ri J fo �-c- �oxl4�►o� .c%�. 27s � y c.• 3) Property Description: Lot Size:y.�/(o Subdivision: •— Lot #: �– Address and/or directions to Property: ^ C,I�G- S. _ u.-r•- �'q f o 1-�. __ ��jls %4►�J G 2+�- ��!• �� h. ! G. S. Oh �G 7`-f -- 4) Proposed Use and Type of Structure: �+��-� Residential Business/Type: i�e�a�e� Other ✓ Number of bedrooms � / Number of people served (seats/employees): (�_ Basement: Yes No �/(with plumbing: Yes _ No � Garbage disposal: Yes _ No � Approzimate size of building foundation: I,ength Z�/ � Width /�o � 5) Water Supply: Private Well � (Proposed E�cisting _) Community Well: Public Water System: Are there wells on the adjoining properties? No � Yes (please show location on site plan) Note: A cnm�le%d application must also include: ➢ A plat/site plan o. f'the property that shows property dimensiorxs and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properiy is ready to be evalu�ted I am submitting this application to request services $'rom the Person County Health Department. 'The information provided is accurate. I understand that if any site is altered or the intenderl use changes, all permits shall become invalid. / Signature (Owner/Legal Representative): f ��-- �ate: %// o d' 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-�97-1790) � � � , � `��,�� � � ) , � � �., 4�1�� ; . �,,� � � � �J ���� I�:�.��<m�.�.<���.�.Il �.�-���,�1�.�. �u��fl��aa� ���a�oa��! PVg��gflce �t��ne ����������n�� Tax Map #:�_ Parcel#: 7 � Approval Requested for: �,,l lYlobile Home Replacement ✓ Building Addition Applicant Name: � i .� arcl /-4T��� Address: _T 13 fks�eYs S�%re � . _ a���,�ro , �fG 2'7S7 Phone #'s: Pemut Located: � Yes No Installation Date: 3— �q — �� Design flow: 3(� O(gpd) Current Contract with Certified Operator on file (if required): Water Supply: ,/ Well Public or Communiiy Wastewater system shows no visual evidence of failure on: R—��—(,� (date) (Applicant's signature if sit� visit is not required) Comments: e�- Aa�a�a�a ��}�1������� ��a���d�� � 9-- �-og Enviro ental Health Specialist Date 1 ? /15/OS '���,J� .l.7.. ����� • ! /�y ��p -� V `/ �� .LL. IE���-�„a,r,..,, ��.�.11 ]HL��.][� SI'I'E S�'I"C�3 Name i ehar� ���t � Subdivisio _ Au o�ized Sta.te Agent Tag lYYap # l� 29 . Pa:�cel #�_ Section/Lot# �—/g�04' . 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