A30 62Y
M
The Distr�ct Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEM�'NTS �ERMIT No.�_
r Date - j -
Owner: �v C� 1 ' ' � �
Location:
<L�-=-' ���_
, �-T�c-�
Contractor: '
Water Supplp: Private � �f Public
:.�:�wr) �
Sewage Disposal Facilities: No. bedrooms' Dishwasher, Disposal,
washing machine, other autqmatic appliances
rf � 1 ,. . ,r
Size of tank: � � • - � � � �'� � � Nitrification line: � 3
�
Other disposal facility:
Water supply and sewage disposal facilities lncation, . 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 BEF�RE ANY PORTION OF THE. INSTALLATION IS COV-
ERED AND PUT INTO USE. n`� � /�
di� �, ,���`�,�/�. .
Date approved: Signe
Sanitarian
Well:
Sewage Disposal: '
By: . -
Counter- '
signed �
_ (Owner or his representative)
Certificat� of Completion ' � .
Date Approved: `� �1 By: t �`
a itaria
(OV
. 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. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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�pllcatlon Date: � I��
Amou Pa�d.' l 0.0
1) PermR r+eqctssbod by:
Home Phone: ��
BUslness Phorte: ��i''
� .:.. �..�) Nams and addrass
' f.sw�s.
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3) Propstiy Deac�i
__ Dlrecttons to the
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size: Tovynship:
�duding road names and
syabe�ns-
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4) Proposod Use and 3'' ure De�xlpt[on: answer each �ihQ foiltiwinp �esBons: �
a) Proposad�, F�cii� g . Type af Strucfure:��nu aGft,�xn<ai !,�►�+�- Width: � Depth: %in :...
b) Number dfi �edrooms � Number of occupants ar people to be served:
c) 8asement Yes___; ;No �( �ere be pwmbing in the basement? o�
d) 6atbage Dispoaal: Y�s �D �. , -
5) Wa�vr Seipph/ TYPe:
Ate arry r
'site plan.
8) Doa� your pmper�y
➢ A PU1T OF THE I
- ➢ PROPERTY L1NE
➢ TNE PRQPOSED
D THE 3iTE MUST I
STAFF.
I hereby make applica�on
system for tFtQ atrove-desc
fadlitles to be piaced on
become-Invalid. � �
ate,_,_ {new or eodsting,.�,'Pubttc� Canmunity . 3prin9 _
on adjoirting praperty? Yes_, No ,_, (f yes, pleaae tndk�be approodmate locattori on the
proWott�ly identtH�ed jurEsdictional w�etlsrnis? Y� No�,
� . �
r1►II�IVi: �� . .
... , - ,
7PEi4TY C�R SIT� PLAN MIIIJST BE 8UBMITTED WITH TH19 APPUCATION.
►ND CORNER3 MUST BE CLEARLY MARl�D. •, �
�CATION OF Al18TRUCTURE9 !YtlJST BE STAF�D OR FLAGGED.
READIl.YACCESSIBLE FORAN EYALUATION 8Y'THE•HEALTH DEPARTMENT'
the P�son Courrty Health Department for a a�e evaluaHon iw the on-site sawage dLsposal
3d property. t agree that the cantent� of th(s appik�tton ane true and represent the maxlrnum
property. 1 understand ii tha site is altered or the intertded use changes, the' permit shall
�
or L;eS3al Rapresentative
Date
PC1i0. rev. �Bt27/02
t/t ROA[L699SE 4lI�oH I�I;ilawuo��nu3 �op uos�ad Wd L1�60 500L/0£/90
I �`��e.�� �����.i' ��
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I���.�-��,4-,�-,4 ����.]l I��iC��.]l�]�
Applicant:
�Loca#ion:
����� �Ja�d �oa� � �'iv� ��
Type of Facility: ��
# of Occupants a # of
Proposed 4Vastewater System:
Proposed Repair:
Pernut Conditions:
Owner or Legal Represe
Authorizerl State Agent:
T�.x M:�p j_ � P��-cel # �,
S Ulh�f:i�l V'IS�i O �1
Ph:�;s�eaSe-ction Lot :
��roveffie�at Per��
l�d� E�iragao�a l�X���'h�
g'
New � Addition �a¢er �ea�aply �<<
Projected Daily Flow � (Qo g.p.d. �
� Type: �
�w Type: _��
�
I3ate: �°2-6���
Date: � roS
The issuanca vf this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in swre that all Person County Planning and Zoning and Building.Inspections requirements aze met. Thia
�aprovenaesat �ermtit is gubje�t to revocation af tlte site pla�, plat or the untendecl use ehange�. Tlae Improve�ae�t Par�eat is not a#fee2ed
by a change in ownership of the property. Tlaas permit �vas i�sued 'ua comyslianc� with the provisaons of tlae 1�Torth Carolana `Laws a�d
Itules for Sebvage ireataaaent and �isposral �vsterrYs' (1SA I�iCAC ��A 1900). l�either Persoan Couatty noa� tlne �nvironment�l �ea�fHa
S�eeialist warrants that tH�e septec tank systeata w�ill continue to fnnctfion satisiactorily in the fuiure or that tlae ��ter supply �av� Peffiain
potable. �
�A�tl&�.�'i���ao3� �� Co�s�'uCt ��S�ew�te�' �y�teffi ��qanareai for �aaildang Per�ait) .
* See site plan and additionad attachments (_).
Proposed Wastewater System: �1�° t, ��a I Type� Wastewater Flow �6� �.p.d.
New Repair Ex ansion� Soal I;T�B: ��O g.p.d./ ft 2
Type of Facility: o`��� � `� � � ,��' - Basement _ Yes �10
.c�i4 s�+ �
Tank Size: �eptac'I'aaa�s: �� gal
�aste�vater Sy�#�na Reqiairements
P�p 'T��: g� Grease Trap: ga1
Drainfield: Total Area: �D sq ft 'I'ot� L�ng�a �D ft 1VIa��'I'rench Dep� �P a�a
'�geaae�a �idth � ft ' aaaaa �o� Cover: �� Mi.nimum Trench Separation: ( ft �� C�
Distribution Box
A�t9ao�a�esi Stat� Ag�nt: __�
Permit Exnu�atr Date:
� Seria1 Distribution
�� �- �� ��
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Pressure Nlanifold
5 n�. �(' S4'7 � l'7�a.
Date: �l ��� S
The typ,e of system permitterl is � Conven ' na1 Innovative Alternative. I accept the spe�ifications of
the permit: �
��vner/]C:eg�l �e�resent���e: �i �- Date; I °2 - � ��
� �— PCI3D7/30/2002 :
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7���a-o� � �sa�.Il ' IE-Tm�Il¢l�a
STTE PLAN
Nameli�"`� {'I�� ` � ��C�C � �� " –'r1� l Taz Map #� Parcel # �
Sub n_ �j Section/Lot# �
,� '�S
�� Authosized State Ageut D� �
System cnmpoaeats trpasenr appraximatr c,vamurs onlp. TTie coatrauormuss9ag rhe sysrem paor m begraarag the iasr�stron ta
in�,.�- thatpmpergrade is matatained .
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