The URL can be used to link to this page

A30 67The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. Dat ��(.�,� t � Owner: P � % Location: !f � . ,- � ,� _+�. � i/I �— k, , � / A • � Contractor: � � � Waier Supplp: Private , �G Public �� Sewaqe Disposal Facililies: No. bedrooms Dishwasher, Disposal, washing machine, other sutomatic appliances Size of tank: .�'�\Y�� ,,.d NitriBcation line: ,�� Other disposal facility: ° Water supply and sewage disposal facilities loca£ion, 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- PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. �..-'' - Date approved: 5igne � �f� a'aian Well: Sewage Disposal: By: Counter- �� 9igned— �'l � (Owne �r�iiS p Z�'3�--" � Certif'ica�e of Comple2ion - � J . , �� Date Approved: i � By. anitarian (OVER) Location of well and sewage disposal facilities sketched on back. NOTE: - sketch of installation showing lot size shape, location of house, septic tanks, es, water sttppli�s, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located at �ater date. Note location of water supplies on adjacent lots. � ,�i� . _ -. ' �2� I —7 n ��'1 ___ 'J T� �\��( �� " �-� ��\\�"�- �r' �17� ��,,, �u � ,� -�i , � �. �� .�� -J L� � A�;�lication Date: �� q� � v • Ar:�ount Paid• 10 a• � D , � � Recejpt #: � I 1 � y C�� _; Tax Maa #: '�3 � Parcel #: � / Person CountY Heaith Department Environmentai Health Section . APPLICATION FOR SERVICES - 1) Permit requested b:(Ownedagentlprospective owner): r�q n�� d d�2/ n, Home Phone: 59� 3�-11 Address:� v� � �� 1 < ��rt Business Phone: S9�- 3�-�7 oX��d ,✓ � `L.�y �] Z) Name and address of current owner: � 11 � O» 1 L Q Gh n� r yl 1 � � � G 3) Property Descriptiom �ot size: ,� Township: �vi�Y F.a' �C Oirections to the property (Including road names and numbers): 4) Proposed Use and Structu e Description: answer each of the following questions: a) Proposed O, �isting � b) Stick Built �7!Modular �, Single Wide �7, Double Wde G c) Number of Bedrooms: 3 d) Number of occupants or people to be served: � e) Basement: Yes ❑, No f yes, # of baseme � Garbage Disposal: Yes ❑, No 6� � � g) Dimensions of Proposed Structure• Wid • 3g Depth: %� �ec� 1 0 oM � bcz �� 5) Water Supply Type: Private new � or existing �), Public �. Community�, Spring ❑ Are any wells on adjoining property? Yes 0 No 9�if yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) �Conventional Modified Conventional _ Altemative Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make applica6on to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are tn�e and represent the maximum facilities to be placed on the property. I understand ff the site is altered or the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Heaith Department to conduct their evaluations. I understand that I am responsible for notifying the Health D rtment if my property contains any wetlands as designated by the Army Corps of Engineers. � ? - �� Owner or Legal Representative Date PCHD, rev. 10/12/99 � � `<<� A 1526 . ��e� .�, PERSON COUN"I,Y HEAL`l,H DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map #_� �0 Parcel # �p -7 Zoning Township �v ForK Owner/Contractor �.r Date� aGL'�O �Q�{ation/Address�wT _.y��_Q on you�►.9 ' C'.�,a�� c.�rcG� X'aac,(• / K ) r._ lf1Ur S.R.# � � � a Subdivision Name LOt# as Insta��ea I,ayout � � Hc�mc. owncr nceds -�o marK � �c �ra�er� corners �- l�a.uc arc� U e r� F�`ed by E�-ES, .�2 �u,nP ,57-' be Fare b e�inn i`n� �kj addi��'a� 3Qa�ol �3S'x3'oF 1�-�� Q-=n�S�al1 Zy �� cf c e�, Q,Stc�y �p' o�� pn pc rty �� un d r o0 '� 'o FF a/I G�e !(S , SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /, �� AC Size of Tank �x i S� � n9. SFD Mobile Home Size of Pump Tank_ N/ft _ Business__`�� # of Bedrooms�__�d��' Nitrification Line fldd �3s � x�' a �-E1, Max Depth Trenches �y" Permit Void after 60 months. Permits may be voided if sit� Well and Septic Layout by ` Comments: � Permit Void if not in compliance with zorung regutanons. � aIt�ed pr inter�ed use changed. Date � 7-Do Installed by � j �. p cA� ��_Approved by WELL SYSTEM SPECIFICATIONS re Approved ell Head Approved �outing Approved_ Comments: Date Semi-Public w Installed by_ Required Slab _ Air Vent Required Well Lo� Well Tag Approved by �ti�� w/�-�P --� 5/�7� �%] This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Petson County nor the environmental health specialist wazrants that the septic tank system will continue to fundion satisfadorily in the future or that the water supply will retnaut potable. c�amipro\pemrit.sam O1/95 rev.1.0 ORIGINAL 8 Person County Health Oepartment Existing Sewage System Report For: Mobile Home iteplacement � Addition Requestee: �cl�� {-�orne� 104�' �lDunqs C�a.p�! �� r�� pxlo�rp� n1G o� 75�3 Hone Phone# �7�8�Y� Businessx 'Pax MaPn I � J�� cc( (�% Locatlon/Uirections. �i�'S -�urn L on � o�,�.r� ' �h� •1 CC,urc,� oad `1� c�.-� � o�s' 0riginal Permit Located �� , Septic System Uesiqned For: _ Kesidential _�_ E3usiness Other (specify) TM Bedrooms `7 # Employees Other _ llate '1'nstalled �1' a��$� Water supply Ur��Q-� L.�C.�� Type ot System CC)�1U2(1't� pr10. � Nitrification Line ��Xc3� G�d� �c��x3��a"7-00� �c�7 �x�� Tank Size �� O�� G�� O�l Certified Operator Required p�� On site wasL•ewater disposal system showes no visuaily apparent malfunction on � ��r��%� Yermission is granted to: �}�Id a��r00M ��a� Accordinq to the attached site plan. Comments: Environmental Health $�G.. . �� . �S�M1 .' �r ..t..i" f�.+'..r:i:.�r"✓�9. .-_. . _ . . a-�-�� DATE 0 � Person County Health Department � 2 Environmental Health Section � � �Tax Map #: � J D Parcel #: � Zoning: Township: ��: �C1f��— Subdivision• Section: Lot: _ Applicant• f�°�/��n �'!J � - Location• � r C�� l% ` 6�� Operation Permit S stem T e In Accordance With Table Va): �G-- �i� ��_�a�-L Y Yp � THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPRO EMENT PERMIT AND CONSTRUCTION TH RIZATIO . �,� . G�� --7�-�0 � �� Authorized State Agent h Date Tax Map #: Parcel #: PCHD, rev. 10/12/99