A29 97�����7
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
. t
Water Supply and �ewage Disposal
IMPROVEMENTS PERM�T No.
Dat �' �' �
Owner: �% rn �
Location:
C�.a� I I � Z
�
C`nntrartnr• c �. X/w�
Water Supplp: Private � Public
��
Sewage Disposal Facilities: No. bedrooms ,2
washing machine, other automatic appliances
Size of tank: �� � � NitriBcation
Other disposal facility:
Dishwasher, Disposal,
,
1►vJlh�
�i�l
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 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 INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
' ,:
� • �� /���/ /
r
Counter- f �
aigne �f ��-
(O ner or his representative)
Certificate of Complelion ,�
(�' ' _ �
Date Approved: �'��0� By: I
Sanitarian
(OVEB)
Location of well and sewage disposal facilities sketched on back.
.. ..__ .._ 9.�a
Aaplieaiion• Date: �C ��% r' O a-- . . . T�c flAaa�
�kmour�lyaid: . .. .. . : .
�l�c2i ' ' • � �. . ��#k
��.��. �� _ 1�'I�I����T . .
. - � �--oE�-��- .
� . . . . ��.-�.�,..,.,.-,.,..��.� ��:,� ..
� � a�uc�noN Fo� s�ac�s - .
sHau.. ac�o� arvauo. _ ,,�
'1) Pemdt r�uemted �ay: (Owneda9ent/Prosg�ec�ve ownerY..,� -�/ri2<� � � � `-
Home Phone: :�'�-r�-- i 7�� , Adctre� �.�-�a.��c� R.�
flusiness Phcne: , . -�d� ``'��G�—
2) Name and address vf curne�rt o�vnec ,i� ��
�� J I.? �'--�►�✓
.
3) Proper#y �'esc�iption: Lct sizs: Tow�ship: ����� Su6division: Lot�:
Directions tio th� property (]ndud'ing road. names and nu ): '
4)
�
Proposed Ues and �re Descri�rtlon: answer af �following ques�ons: �
a) �P�� _,�9 _, TYPe af Struc�ure: � 1Mdth:. Deptfi:
b) Number of Bedraom� .�_ Number of cca�pants PeoPle �o t�e �rved: , --
c) Base�nen� Yes _, No �there be ptwn6ing tn the basement'�
d) Gautiage Dispasak Yes _, No �^ '
Waber S'uPPh/ �IP� P�� �� _ ar e�astin9 �� Pu�ic_, Communiiy _, SP�9 —Iocatlan aa the s�e
Are�any w�tis on adla�9 P�PeKY? Yes,_„ No �tf"yes, ptease indkabe aPP� . P�-
6) Doea ti�e proparty c�ntain p'eviously tde� jur�ai �? Yes _ No �
PlEASE NOTE THE FOLLOWING•
' 9 A P�AT OF'[t� PROPE37TY OR Si'�E PLo�N NUSi 8E SUBIA�iiF� �fEi THts �1i'PLlC.A►'I'K�ia:
� i3ROPERT! L1NES AND CORN�S NU3T BE CL�RLY NARL�.
➢ THE pROPOS� LOCATtON OF ALL STRUCTURES I�T BE STAitE� OR FiAG��. • �
� THE SiTE �iU3T BE READILY ACG�SSiBI.E FOR }�1A! Ei/ALUAT�N BY THE EiE�1LTH DE��►�9616�iT STAF�.
i• her{eb� m�ae �ton ta the Pe�son Cow�ty H�tlt �epartment foc a s�e evaivaBon far the oc�-siie sewage disPosai
sYst�'m far the above-descr�bed property. 1 agree that the corrtents af this app6ca�on are true and repre�nt the ma�dmum
faai�Ies ta be plac�si on the ro eriy. ! under�tand ifi the s% is aitered ar the intended use changes, the permii shait
becarr►e invaliat,.
or Legai Represenfattve
�02/-0�-
ate
pC�p, �u iN17/01
_ '��'�!�` t, {�- � �
���5 �� ������
` 1 � ,� J.ldJ �� �� . '
�`. ' � � ���� 0 0 �g
��cn.�ng-�►aa�.aa�.�saa��a.Il. �'��.cfl.�.��n. � � Q
Applicanl
Location:
. Improvement Permit
Permit Valid for ✓ F ve Years No Ezpiration ���, cz.
Type of Facility: o��sc, Nevt� Addition Water Supply ��.0
# of Occupants # of Bedrooms .� Projected Daily Flow � g.p.d.
Proposed Wastewater System: �i,�/�/r„/,6o,�,4.� Typ.e: ��
Proposed Repair: Type: �
Permit Conditions: ,,�j//.,, ��/ ��„/
Owner or Legal Representative
Authorized State Agent: �
Date:
Date:
The iasuarice of this petmit by the Health Department in does not gusrantee the issuance of other permits.'It is the responsibility of the
applicandproperty oycmer to in aure that all Persan County Planning and Zoning and Bullding Inapections requirements are met. Thie
Improvement Permlt is subject to revocatlon lf the eite plan, plat or the intended use changes. The Improvement Permit ie not affected
by a change In ownership of the property. Thta permit was isaued in compllance wlth the provislona of the North Carollna `Laws and
Rules for Sewage Treatment and Disposal Svstenis' (15A NCAC 18A .1900).
��� Authorization ta Construct Wastewater System (Required for Building Permit)
* See site plan and additlonal attachments (_�.
Proposed Wastewater System: �i»/j1. Type � Wastewater Flow �(�.p.d.
New Repair ✓�x ansion _ Soll LTAR: /✓�� g.p.d./ ft 2
Type of Facility: cu _ Basement _ Yes _✓1Vo
—� _.
Wastewater System Requirements �
���5�-i � �
Size: Septic Tank: � boo gal Pump Tank: gal Grease Trap: gal
field: Total Area: sq ft Total Length Zo o ft Maaimum Trench Depth �' � in
Trench Width � ft Minimum Soil Cover: /-! in Minimum Trench Separation: — ft
Distribution: Distribution Box -✓Serial Distribution Pressure Manifold
Speclfications:
Authorized State Agent: �
Permit Expiration Date:
The type of system permitted is '�Conventional
the permit.
OwnerlLegal Representative: �
Date•
Innovative Alternative. I accept the specifications of
Operation Permit
Date:
System Type (in accordance with Table Va) • .
The syatem has been installed in compliance with applicable North Carolina Qeneral Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Conatruction Authorization. Iasuanca of tlua pern►it does not guarantee that the
wastewater ayatem will function properly for any given period of time.
Authorized State Agent: Date:
PCHD rev. Ol/23/02
:����3� �Jld����
"'- � �.1� ���
I���a-�� � �mm.¢�.11 IE3L��.Il�
SI'�'E SI�TCH
Name L , Ta.g Ma.p # 1�°2 � Parcel #� 7 5
Subdivision S �( Section/Lot#
�-��-z� �
Authorized S t gent � � Date .
System componettts represent approarimate�contours only. The contractor must, fTag the system prior to
beginning the installatzon to insure Zhat�iiropergrade is maintained
�f,�7pi0 uV N
� .' N�
$�� �a�T�
� �T� /i o2Gf'�'
. —_: . I
_ ._ _ �. — — — — -- — — --�
/
1
1 � �� �� �� r��� �
\�. ��
��co�/sT2�cr
v�i�p ���1 g��2
�/�w �.�N� �s i ,��u�
Scale: ,S
N�, ��a�s
a G �oo
yo o � TbT4 t�
= —rt-��s-r��- ��-� �n . =
�2��✓c� �3orla�ys �-iln " 7��� CS,�,�a/� �1�, � ; �T ' �
/ `/�-iG.,
�" Geg✓� ���'" ���c,a,os %/ ,; �y� `
z �� o r� p•p� � ,�-� �
%�'. �� �
� , ,g„
,
�' � ��,
/ j �''' �`�'
�
��
�i
�G f
P�HD, rev. 09/12/01
��
� s��
�'
,
� �) j �� �i} � ��� � �tix N1�,p � �;r�c�l r
' � i Su:bciiivr:s�ian
�� � � t�� � � � I � � �
P�h �s �- Se �ti o���: l.a t r
� e�� r e � ��� — ��� � � � ( � �� � � ��
�
. �� / •
• _ �■ _ /
C��er'�t�or� � ��°r�'1��t
� � System Type (in Ac�ordance With Table Va): �
THIS SVS'i'�lUi H/�S� BE�N I1dSTALLE� ItV COINiPtl.�aVCE. �VITH APPLiCA�LE N�RTH
CA►ROLi(dA GEiVER�►L STATUTES, I�ULES F�R �SE�►AGE�TR�T�iER9T �ID I�iSPOSAL, .
/�(yp NDiTi�NS ..OF THE InAPROVE➢�E�T F'E�IlIT �D. �COIdS�RUCTiOIV �
�AUTHO IV. � � • � � � � � .. .
. ..�.� . - . . .. . . . .. : � . � �--,2�-�� � � . �. .
. � uthorizsd State Agent � � . � . ' . • � � Date . �
lnstalied B.y: �i �' �1,�/r `� . � ._ . . � Date: `��o�-� O� . . . .
� � �o�� � ���s � �M-�
,� e����,b.�
� ...�
�,�, �, _. _.. � � �p
��`lz`` 6's Yz`,
' �� (r — — r- -r-
_ G�Q �/Z�l
!
�. ...,., o ...P. �.. +.
` � ��" r
�
. �
1 � R-- . � .r- �.�-
'�g„
r � I
F
?,r �1m
�,7�� .,
z
-.— —
<—
�( f'�"�• r� ��"zN� i��',� -,
.�---�' �0 )C h o r D
�ul( iP4.� �fa �i1�2
'SYz `� �,�e,�c� .
�'�z �� �`��
S�-2 l(o�
�-�` (l au«9�aUe�
�c.�,-� �'` ��
� � a� 5rave �
� �`"'� �
"`P'CnD, rev. �7/29f02 ��
. . ��Z�; Y
S�s�T�G �' � ��9�F��'�"dt3N �����s�' ��e al - ��
Ta; MaQ # �-c Farc�! # � System Type (Tabie Va)
OwrnedA�piicant� Subdivision �
Address/Location � Ser.lrPhase Lfli #
Stats IDldate ��,���i
Capacity. ��(rp.
Tee and Fl�ef
Trench �dth `5, ft.
Trench. Depth . 3 6 in.
Trench Length �08 ft
�
� Baffle Trench Grade L j
Sealarrt ' Tr�encli Spacing •
Riser ifi applicable) Rocic De th and Qua!'rly L
Tank Outiet�: Seal . � � �. DamslStepdowns etc.
Permanerrt Marker � � - � Pressure Laterals . - ---
� Punap Ta�aEc . . . Hole �Spacing � ��� . �
. � tate ate � . a e �zs � � -�-
� Gapaciiy � . . . � gai. . . � . Pi e Sfesve . � � -.,. ...
� . . � Waterproof 1Sealan� : � �� � Tum-upslProiectors � .�� �--- �
. .� Riser . � � . �. . Requie� Se�ac�:. . .. �
Water Tighfi . From Welis �:
Fdarrnp From Property lines �
_ �hecic Valu�/Gate Valve : � �� : Structur-es/Basemerrts .
. . ..- . . Anti-sip an o e . _ . . � . ... rt es ramage ays
_.... ... FloatslSwiic�es �: . . ...� ......: .�. _.� . _.- - �Surface��lNaters .. .
Atarm� visable and audible Pubiic Water Suppiies
Eleetricai Companents Vertical Cuts (>2 ft t/'
Rate gpm � Water Lines
Approved Pum Modei Vehicle Traffic
BIocX Under Purn� Adjacent�Systems �
Pump Removal Rope/C�tain.. Easemer�tslRight of lA/ays
� Distsib�ataon Sys$em � Other
� Seriai Distribution ' Easemenis Recarded .
ressure an' I pe or ntract
Low Presscace Pipe � Tri-Pat#ate Agreemefrt
Appr. Pipe Nlater�a! and Grade -
Valves � -
� � Gorntnents.
�
�c; td rev. 31'13I01
Q