A29 9..
The Distr�ct Health Department
�• �� , _ Orang rson, Caswell, Chath m, Lee Coun2ies
s\ Water up I a d ewage �'isposal
Date '
� Owner:
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pq Location: � '�
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�,, Contractor:
�n ;
� Water Supply: Private Public
No. bedrooms '� Dishwasher, Disposal,
wec ' ' o er ti appliances `/
Size of tank: �� itrification line:
�
Other disposal facility: "
Water supply and sewage disposal facilities� location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. 5eptic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PAftTMENT STAFF before any portion of the installation is covered
and put into use.
Date approved: � � S J� /
Well: ;j
Sewage i saL• � Sign �d
� S � itarian
By:
Countersigned
(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
suppiies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at�later date.
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" PERSON COUN HEALTH DEPARTMENT
�� � WELL SEWAGE SI� E, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # - 2 �j' �arcel #
Zonin� __ _ Townstup .�� � y ork
Owner/Contractor
Location/Address
Subdivision Name
Lot#
Date Z- /O-
.R.#
A 001050
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is altered o'n nd use anged.
Well and Septic Layout by
Comments:
Date �-/-2� �►'� Installed by� �,,,��,(�� Approved b� ���� _
WELL SYSTEM SPECIFICATION5
Individual Semi-Public Required Slab _
Public Replacement ' Air Vent
Site Approved � Required Well Lo�
Well Head Approved -� Well Tag
Grouting Approved
Comments:
Date Installed by
Approved by
��
0�+�� v1i ti`�
This report is based in pazt on information provided the homeowner or his/her representative in the application submitted for this permit The �'
environmenW heahh specialist is not responsible for false or misleading infoTmation contained in the applicatioa The environmec►tal health specialist �
is also not responsibte for concealed conditions on the propeRy or for statements in this repoR that may havc resulted from false or misleading j;.
statements provided to him in the application. Neither Person Coutrty nor the environmental health specialist wacrants that the septic tank system will ;�
conLinue to function satisfac[orily in the future or that the water supply will remain potable.• c:latnipro�pe�nitsam Ol/95 rev.1.0 j�
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Tax Map #� Parcel # �� %
Existing Sewage System Report For: Mobile Home Replacement
�C _ Addition Type• t�,_��v.s��
�- �
Requester. ����r� Hom Phone#
��Tc/ _ .�u.c/Ds<a �i�. Business # � Z�'S�Y�7
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,�u/c.�t.,�s
Location•
Original Pernut Located: � Water Supply: G��CI'
Septic System Designed For: �Residential Business Other
# Bedrooms � # Employees Other
Systern Type: C�:��.�/�ien/.f C Tank Size: /adn Nitrification Line: Z� �
Date Installed: � Certified Operator Required:
�,����-.,�) .
On-site wastewater disposal system shows no visual signs of malfunction on l -
Permission is granted to: ���'i r.�o�o,�.�%� .� .4�2c���� l�
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Environmental Health Specialist Date: d�
�4 oiicatlon Daie: 3� a b'
,�mount Paid• ,
Recai �: _� �
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P�rson Cauntv Healtfi Deaartment
Fnvironmentai Heaith Section
APPLICATION FOR SEi�VIC�S
i'ax �ao �• �o��
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Pares! #• 1
IF THE INFORMATTON IN THE APPLlCATiON FOR AN IflAPROVEMEIN7 PERMIT IS F,4LSIFiED. Ci�IANGED. OR THE Sii'E 1S
ALTERED, THE�I THE IMIPROVE�IAEiVT PERMIT;AND AUTNORIZATiON TO CONSTRUCT SHALL BECOME iNVALlD .
1) Permit r+equested by: (Owner/agerrtJprospe�.�tive owne�: �� g• �� �( d�, 7� .
Home Phone: �q -9 7�3� Address: t� d-� �c{%
Business Phone: v O�'0 7 s`7
,.,
2) Name and address ofi current owner.
3) PropertyDescriptlon: �otstze:144' Township: �1�.��/ ��'�< .
Direcfions to the property (Induiiing road names and numbers):
4) Proposed Use and Structure Desaription: answer each of the following questions:
a) Proposed �, Existing ❑ �
b) � Sbcic Built 0;1Gloduiar �, Single Wide q�ouble Wide ❑ Z
c) Number of Bedrooms: � d) Number of occupants ar people to be served:
.. e) Besement Yes �,. No � If es, # of basement fixtures. �
.
Y ' _
_ _ ... ._ ... . ._.. _., .... . _ _ . _ . .
fl Garbage Disposal: Yes �, No ❑ .
g) Dimensions of Proposed Structure: Width: Depth:
5� Water Supply Type: Prlvate�(new � orexisting �, Pubitc Q, Cammunity �, Spring ❑
. Are at�y�vells on adjoining property? Yes ❑ No � If yes, loca�on
6) Please lndlcate Desired System , i ype: (systems can 6e ranked in order of your preferenca)
Conventiorral ,_Modffted Conventional _,Altemative _Innovative
Other (speciiy): .
CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CCRNERS OF'ALL PROPOSED STRUCTURES.
PLE�►SE ATTACH SUFtVEY PLAT OR SITE PLAN TO THIS APPLICATION
i hereby make appiication to the Persan County Health Depariment for a site evalua�on for the on-site sewage disposal �system for
the above-described property. i agres that the �cnnter�ts of this appGcation are true and represent the maximum faa�ties to be
placed on the property. I understand if the siie is altered or the irttended use ct�anges, the permit shall became invaUd. I understand
that as applicant, 1 am responsib(e for identtfyin�:. and marking property lines, camers and making the siie accassibfe far the
personnel of the Persan Courrty Health Departm to condud thear evaluations. I understand that I am responsibie for notifying the
Neatth Depa ent if my property cor�iains an iiu tlands as designaied by the Army Corps of Engineers.
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er Legal Represe ' e Date
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'''See ktEaclied 3ite Sta�ch'*
- .= WeAs must be 10 feet from propecl�/ tines-
� WeiLs must be 100 feet fi'om septic s�ls�ems. . '.
Wells must be at (e,�st 25 fie� from arry- buiiding foundation.
Other ca�d'rdans: �
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