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`The'District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
ate � -.—;____? _,� �
Owner: - � '' � ( � �
Location: _ �
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Contractor: � � , � 'L Q.
Wa2er Supplp: Private ���; i'ti Public
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Sewage Disposal Facililies: No. bedrooms ' Dishwasher, Disposal,
washing machine, other auto�aatic appliances —
Size of tank: �� � �"J Nitrification line:
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Other disposal facility: � � iit�ti�'
�ater 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 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-
PftOVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IN$TALLATION IS COV-
ERED AND PUT INTO USE. // { _:� j
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Date approved: Signeci� ��� - .
Sanitarian .Jtr�cn� Cali�ns
Well:
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Sewage Disposal: Ca �nter� ;� i� t,i' j�;�v�G''
BY� (Owner or his represent� e)
�CerYificate of Completion
I y� s� ��U' o�vaP DE'N'e.�
�ate Approved: BY:
Sanitaria
(OVER)
Location of well and sewage disposal facilities sketched on back.
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zN0 : 1�--r sketch of installation showing lot size an�ape, location of house, septic tanks, p� water
su lies, .-�7ote special problems existing on lot. Write m measurements in order that installations may be located
� at later date. Note location of water supplies on adjacent lots.
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^:aftn t paid ^"
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Receipt li �
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Da te
Permit requested by: .
ner/pros ective o er/agen • _
dress: ��'�' � i � e. :
�1t�RDL� Mills N• •
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UHome Phone #: v
� usiness Phone #:
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5�9.7/$9
7. Dimensions or Proposed Structure:
Width:
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facili[y
t�this sewage disposal system is intended to secve?
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Name and address of current owner: 9. Water supply t}pe:
. � private f�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No (�(
If so, identify location:
. Property Description: Lot size:
Tax Map#: � : j6
Parcel#: ` �1./
Township: _
Directions to property: State Road #& Road
,�tc.
�et�.T�._ To l�
I�Iumber of occupants or people to be served:
10. Type of structureJfacility: Proposed: DExisting: Q
Type of dwelling:
House: f�Mobile Home: �Business: ❑
Type of busii►ess:
Number of Empioyees: �
Number of bedrooms: _ 3
Garbage Disposal? Yes � No �
�asement? Yes❑ NoQ If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTIJRES.
I hereby make application to the PeI'SOII COL1Il�y �ealt�i Depar�IrieIIt for a site evaluation for the on-site
sewage disposat system for the above described property. I agree that ihe contencs of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is aitered or the
intended use changes, the permit shall become invaiid. I understand that before an Improvements Permit can bc:
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�iin 60 DAYS after the date oP the evaluation of
the site by the Health Dept., this application shall become voit� and all fees paid forfeited.
Signc� Owner or Authorized
Pecmi� Issued ❑
Permit.Denied ❑
plat Observed ❑
S ignature
Dale
RECOMMENDATIONS/COMMENTS: � �
SITE CLASSTFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, ri��
• C.'�AMiPAUDOCS�APPSEG.S�f �ANCEPC
areas, wells, water bodies, slope pattems, etc.�
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # /`�- 3 6 Parcel #
Zoning Township r'�,4 i�l U��
Owner/Contractor �'qND2,q Lon1C� Date �T /S �
Location/Address c.� � i/L c�s � u. ��� � ��✓
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�; � «� a�c.,,� '�6�,..,�x�;z i� S.R.#
Subdivision Name _ Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area y, Z� s�` Size of Tank �X is i i� tr �vo d c'i-.� L
SFD - Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line ��s i�,v� �oo'x?
Max Depth Trenches
Permits may be voided if site�
Well and Septic Layout by_�
Comments: �e�,�/a �� A
or intended use ch�nged.
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f�f�� E ' � J �"�!C 7�'ti�T �
Date Installed by ,�,��Sr �it�Y� Approved by,
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS --
Well -l�e�d
Grouting �
� Comments:
C�
�, Date
Semi-Public
Installed by.
Required Slab
Air ent
Requir Well
Well Tag
Approved by.
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 Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: l�
TAx � #: 3 0
IlVIPROVEMENT PERNIIT #:
PARCEL #: %
OWNER/OWNER'S REPRESENTATIVE: ��N �zA � ►J Ct—
LOCATION/ADDRESS:
� S //�- I-� A S S-E L L ��.,� �� �Z J7 .
� � �i c r-+'i' c� vs � .R�i o2� ��nr �E-k � �
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SUBDIVISION NAME:
LOT #:
SECTION OR BLOCK:
AUTHORIZA�ION FOR CONSTRUCTION ISSUED BY:
CONDITIONS
l. The Wastewater system constn.iction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #�. The
construction and instal(ation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any aiterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
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Person Requesting: