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A29 95
The District Health Departmenf Oraage, Persoa, Caswell, Chatham, Lee Couaties SEPTIC TANK PERMIT Date n — _3 '� � � Name of owner: Q n �� U n A. j�Q n� Name of contractor: �Address and Directions R} � "t' � Q DQ �� ' `�� � Dn "L:� oP 1-�v�u ..�I�q ��t�l%'` �( Mi ntsa- Person or firm doing installation: �1,.�� � Q Address � N�U �q ' No. of persons to be serve� Bedrooms 1, 2, 3,� Additional appliances to be used: Disposal, dishwasher, washing machine _l �F � n e Recommended• Septic tan � Nitrification line: �fl �'.� 3 '�' �`�� —,A �C� Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspecied and approved by a member of the District Health Department sfaff before any portion of the installation is covered. � Date Approved:: 8 — � '� rp By:. Signed Sattitarian O. David Garvin, M.D., M.P.H. District Health Officer Countersigned � (Over) � NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies�o� adjacent property, etc. Write in measurements in order that installations may be located at later 04/08/2004 10:12 3365997505 � �BQy � � . HORNER FINANCIAL PAGE 02 : �. �—��� . � ,��-���+i:��.���T��T �:r�*�,Lare��es, ��b��^��� � _ a� , _ t •�. ��.. - i,1, ,�. 1j P�nnk nqt�f�d bY% (Ow�n �yfprosp�tiv� avN H4R1e photwR: d G �g�: Buslnee� p►7Crw; ���fD Z 7� N� �d ad�trrs� ol aurt+�rt ownir. : 1' �_ }{�pr � r �_ r J,,c �5a5 �� � . J�'.5s Gss+� �''� to7 4 � 3j Prop�rh► D�sadptbn: tot �la: �� T�p; � g�bdh4ion: Lot � DU'�di0tis b Ihb (Iridlldi�l�f �i11ne0 n • r ��, � 4) ��t�� U� �nd �q�tx�u� DNorip�ion: anawrrr �aah d�e fdlowrr�p queitlons: ' 'j Pr°po�d 6ct�np TYpf ai'Jtru�urec wldth; p�►;��. h) Numbe�r Of eCA'cort►e: � Ntmbr of acoup*nbt ar pwpt� bo be s�rvrd: �) � Y�s,, Np � 1M� 1l�ee� b� plumbinp h th� �e� d) �Q� D4Po�1�l: Yss ,_, No _, sj Wabr �+PPhr '�IP+� Prlvate ✓(r��w � cr a(s�n��, Ru�ik,,,, Cammun�r,,,, 8P�p i At+e �nY wdl� on idjalnl�q prQpett� Yss Na _ It y�s� pl�aa� 4�c� �ppr� 1ao�tlori m t,hs .s1� plrrs. �I � Y�aar prop�rty cor�taln p�+�loushr ld�tllMd;uthdldion�l �ds? Y� Nv�„�C � _ ,�•11 �. • •1.,�,.� > � Pc�T of TMe P�atrr aa sn� puw .�u�r e� sue�urren wrtH �t�a ��c�►noN. � Paoa��r�r �t�s�o ca�uw�rte wua't�e c�.�r���. , � THE PROPO�lD LOCATION OR ALI. STRUCTU� IA118T � s'T�0 QR I�L,AOtAED. � �HE arrE ww�r e� �►oa.Y �►cc�s�a�.E I�oR Al� ev�u.u�►no�i r�ttr r� �u„TM n���xr �T11P�. I h�nby m�ioe �ppiicatlot� to !he Perbon County h4e�ith Dap�rtrnent tio� s ei4e e�voduatlon fbr ihs an-sit� � df�pa��l syahrn 1`ar ths �bvve-da�xib�d propart�t. i�pr�� th� � oo�tanbi of t}d� appAvaifon at+s trus end repro�nt the maxlmum far�li��s to b� ploced on ths �xoparty. i wkl�smnd ff th� �iE� 1� alb�r�d or it�s ir�t.nded uee deanQes. �a p+emit shsU bs�oom� invaild. � ' � y� �'- o . ow�,er or I..Qa, Rspr�t�.�e "" p� PCHp� �v. Od1�/07 2/2 �1101(���!! Y1�1�Y I�IY�Wui���uv ew u����� 0 •����'.)'� ������ •��ti ii�_ ���'��n� �.��^S7C��r*,�.O��JL ���'�.�3 SI'�. ��.'��' ' � f I ' Nam,e 1'/� it I � it� 1�Dm� , Ta� Ma}� #� P�ce3. #�f � -r/� . . Se�ion/Lot# � �/-l�i�C� � �utho e.d Ageat - . � Date � . . s . ,S'.�►s�em unm�o� �� u�raxia►�s`r�rs'rs o�r. T.Sie co�r a,sr.st tdfe s�rste»s�va�- a�r ��aeg�mg tlia a�stst��s #o iatsas�sa tl�t�iro�rargsiade as ma�isd . . ��- . • �hS n� c�r� � G `��P`�c� �'iX, _ � .�.�'r-�1�. �`P — �� e�,.t f-,'��+ �S �� c� c�•.h�t�, � (�J�`i'� � �c�.� C,�T-�. QXiS.4:� �9� ��iu. '- iJ ��- �l —���c�,� �. �-� � �c� , —1�,�-;h cQ.�� . ��- --- �il�� 5�..� . a,, r�o �*� ;s Cl��. o� �1u-•, . '�.'�^ �` `� %�-�v�-� , Cb, Q. � � � � p �� ���� ^"�'�-� c.•x�1�, f,� . �' s �ai- � C�� L -� � c�t � �q� �� � ,o �x�..� - ��.�� a9��z��z _ ._. __. . _ _ . _.__. . �� )� ���� `l.J�� ��,, � ������ IE��.��� � ��.�.11 IE3L��.]l� i��x ful�� ' , P�.rc�el � S�uhci!ivi�5�ioii Ph��se Sec�t�io�� Lot r Applicarrt:l�;\\�.o...,. �c�Qr � Location: 5�1 �; � � O�eration: Permit System Type (in Accordance With Table Va): . � � THiS SYSTEM HAS BEEN INS?ALLED - IN COMPLlAPICE WITH APPLICABLE NORTH � CAROL1Nia► GENERAL STATUTES, RULES .FOR� SEWAG� �:TREATMEMT AND� �DISPOSAL, AND ALL CONDIl'IONS OF THE IMPROVEMENT � PERMIT . AND CONSTRUCTION AUTHORIZA ON. � � � . _ . . . . .� . . . . . _.....:: t%d���i .. .. . Authorized ta e Ag fi � � . . � � � � � : � Date � • . . installed By: J -v�, �s�,.�.'� Date: �l -0 7r �/ . . . . . . . . - . . .. . . � � � . ' . : . . . _.. . _ . . - ._ _. . �.�,. • ��.. � � . : . � J •. � _ -7,�o,�a e • . � c � �'�'(a � . � � �j,, �IO S��G �'� 1� �� � �.a��s. - �`1� , ��_ 1 ' �e.�c c:y,�1-c�crv� r�c>. z 1 � i � � �lu %c.c t -�'kv� L �f'� � � � pt; l � . -1-� l,�u� �z h�!- �. � �� , �'j I oCj�dtP: �,,.��v �,�s.� . i ���� �� • . t PCHD, rev. 07/29/02 ❑ S��'iiC �'AiV9t t1VS€�ECT1O(V CNE��4.IST (Type i� -1� Tax 1Vlap # Parcel # System Type {Tabie Va) OwnedAp�licant� Subdivision Address/Location � SeclPhase Lot # � St�te ID/date Capac�ty. Tee and Fiter Bafi�e • Sealarrt Riser if ap licable Tank Outiet�. Seai Permaner�t Marker � Pump Tank /Sealant Riser � . .....,�.. �heck Valve/Gate Valve . . t�-sip on o e : . Floats/Switches � � � � � � Alarm visable and audible � Electrical Comoonerits Rate m Ap roved Pum Mode! B(ocic Under Pum Pum Removal Ro e/Chain Dis�tribution System Seriai Distribution ' ressure an o Low Pressure Pi e • A r. Pipe Material and Grade Valves Trench Width ft, Trench. Depth rn. Trench Length ft, Trenct� Grade Trench S acing . Rodc De th and Quality � Dams/Ste owns etc. � Pressure Laterals � Hole Spacing o e �ze � Pipe Sleeve . � � - � � � � Tum-upsfProtectors � �Required Setbaclss From Wells �. � � From Property lines � � � -- : .Strvctures/Basements.:: � �. . . � �t es rama � e ays � . . . . . . : : . _ . �SurFace` Waters - . _ . . . . . Public Water Suppiies Vertical Cuts (>2 ft. . Water Lines � � Vehicle Traff'ic EasementslRight of W� Other Easements Recorded . Comments� � � � . pcf�d rev. 3113/01