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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
J� /` IMPROVEMENT3 PERMI No.
Y J�1�jh� Date �—T�'-.���_
Owner:
Location: �
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�1�� �. 7�'�� ,:��''�fi��! � `�- ,
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Contractor: � ' 1��v��
Water Supplp: Private — �� Public "
Sewage Disposal Facilitiea: No. bedrooms � � Dishwasher, Disposai,
washing machin other auto tic appliances
i
Size of tank: ��� ' Nitriflcation line: . �� 3
Other disposal facility: " '� %
i
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.
SepEic tank and nitrification line MUST BE INSPECTED 'AND AP-
PRQVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE I1�JS ALLATION IS COV-
ERED AND PUT INTO USE. ��
f `n ��,�--
Date approved: Sig
' �/U��1
Sar�i ian
Well•
Sewage Disposal: Counter-
BY: oigned_ �
(Owner or his epresen�tat� .
�,�erm� V4(D after 3 years
ca��. � co�ianon
Date Approved: �—��$� By:��� ��.-.-�.
� Sanitarian
(OVER)
Location oi weII and sewage �disposal facilities aketched on back.
�j NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
-. s��plies, etc. Note special problems existing on lot. Wrzte in measurements in order that installations may be located
: at later date. Note location of water supplies on adjacent lots.,. ;,,' ' i; _
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PERSON COUNTY HEALTH DEPARTMENT
� � WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map #_��� O Parcel # 7y
Zoning Township l3� � k
Owner/Contractor � " � ate �-_3- �I
Location/Address � n �
_ S.R.#
5ubdivision Name Lot#.
Layout
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,� .�, �� ��,�,�, S� s-�
As Installed
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SEWAGE SYSTEM SPECIFICATIONS
.epair Lot Area � G{ Gt/L' Size of Tank ///Ul/ �!' '—
FD Mobile Home ✓ Size of Pump Tank
�usiness # of Bedrooms � Nitrification Line �� () ��3 (��S �
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
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S�'gs�
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This report is based in part on information provided the homeowne�r his/her representative in the applicatibn 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 applicaeon. 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\permitsam Ol/95 rev.1.0
A�niicaiion �ate: �"-%�'� �
�mourat Paid• t
�ecsipt #:
�prson Caun�tv Health De�artmen�
- �nvironra��nta1 Heaith Section
� . ' �': APPLICATION FOR SEiiVICES
Tax Ma�o #: �� � '
Parc2! �: (� ��
! �ermit requesie b : ( �gr agerrt/prospective owner): �`�� � � � ` ' ) ,, r � c /�
' Home Phone: � -�"! -S7b,� Address: d �ft% �d �
,
Business Phone: - "-� a� 7 << a 7�75
��'� Z) Name and address oi current owner. � e—
3) Property Descripticn: Lot s�ze: / 4bc� Township: �5 � �j �� S' '�Gl i�1�( � ��"
Directions to the property (In�lut�ing r4ad �art�es aRd n}�mbgrs) a, r`-,r � I� S
4) Proposed Use and Structure Descriptlon: answer eacl� af the following questions:
a) Proposed �. Existing ❑
b) Stidc Built Q, Madutar �, Single Wide �, Double Wide ❑ �
c) Number af Bedrooms: � d) Number of occupants or people to be served:
... .
e). ..Basement: . Yes �, No �7 !f yes, # of basement fixtures: � � � � � - _ - �
� � Garb,aae_ Di��c�al: Yes �; �y:, ❑ .;.. . _ . .�:., _ . _.. ,: . _,.. ,. .. _ . , . _ y �_ ..--v.. ._. _ . _ . _ :...
g) Dimensions of Proposed Strudure: Wdth: Depth:
5) Water Suppiy Type: Private ❑(new ❑ o� existing �), Public 0, Community 0, Spring ❑
. • Are any weils on adjoining property? Yes ❑ No � If yes, location
6) Please Indlcate Desired System Type: (systems can be ranked in order of yonr preference�
Conventional _iVlodifled Conventional _ Alternative. _Innovative y�J� `�x �
Other (specify): ' � � �C��
��C�`�� �
CLEd1RLY STAKIE ALL CORNERS AND LINES OF TiiE PROPERTY. ��
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
1 hereby make application to the Person County Heaith Departrnent for a siie evaluatian for the on-site sewage disposal system for
the above-described property. I agree that the contents of this appiicatian are true and represent�the maximum facil"�(es to be
placed on the property. I understand if the site is aitered or the irrtended use changes, the permit shaii become invaiid. I understand
that as appiicxnt, I am responsibfe for identifying and marking property lines, camers and making the site accassible for the
personnei of the Person Courtty Health Departrnent to condud their evaluations. I understand that I am responsible for notifying the
Health D artmerrt ifi my property contai s an weUands as designated by the Army Corps of Erigineers.
�
O er or Legal Representati e . Date
PCHD, rev. 10/12/99
- l���St�R! C�I�tVTt ���11R�NME�1'�'�L HE�LT�-33
-� � ° + . p��,,; � S�� ,,��'AC}�Ei3 ��LAN ��F� '�UE�.l. S1� LAVOUT
T��� A 3� � �.�� � y . .
ZnNna - TO�p �
/►PN�t
Loratlon:
Subdivluon: �O� � .
Well Permit �
Tvae of lNater Sup�tv: Individual _ Community Public
Reauirements: .
Siie Approved
Grouting Ap ov by � � �� �
Well Log
Well Tag
Air Vent
Hose Bib
Conctete Slab _
1Nei1 Dritler:
Well Approved By: � Date:
**See Attached Site Sketch** -
Welis must be 10. feet from property lines.
N.yells must be 100 feet from septic systems.
Wells must be �at least 25 feet from any buiiding foundation.
Other condiiions: � �
PCHD, rev.11/29I99
. .. . ______.. . . __._.._�.__.___..... ..... __. .
� � � Psrson �Couitaty iiealth. DeQerlm�nt ...
- • . � �s�nviraanmentai Heaith 8ectton Tax Ma� �: � �
� � � Paresi �:
SiTE S�E'8'C�� � . _ .. . . .. .. .
... . ... � . .,..�,.... ...., r � -- - -� _ . ... .. - - �� � � � . z:�:..... �.�,.�,�.
= , . `�;: Appli s Name . �� ut��ilvi�ian/Sec�on/Lot# .
� �� . .
. Autho State Agent Date � � �
Sj,a�em con�prr� represerrt qpp�+ande�+o�e cantoWrs o�riy. Tbs contractor t� flag tba sytstem.
pr�or to ba� tbs �n�taAadow to fi�ure ttli� proper �rads is �x�in�nad
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Date
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PERSON COUNTY ENVIRONMENTAL HEALTH
� WELL LOG
Subdivision Name: Lot #
Drilling Contractor: c�e--�� f 2-�-Q.�� �.��
WELL CONSTRUC'I'ION �
Distance from Nearest Properry Line ► v Distance from Source of
Pollution t G �
Total.Dep.th:�2 ,p�_ Ft. Yield: GPM Static Water Level aZ.S—' Ft.
Water Bearing Zones: Depth2i�, .Q__F[. F� Ft� �t.
Casing: Depth: From 6 to 1�1� Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
� � Weight: Thickness:� '� Height�Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
_ If "yes" gi� e reason;
Grout: Type: Neat SandJCement / Concrete
Arinular. Space Width � Inches � .
Water in Amiular Space: Yes No
Method: Pumped - - Pr:ssure � Poured
Depth: From O to � 0 Ft.
Materials Used: No. Bags Portland Cement
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Weight of .1 ba�_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � � �
- 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C^v'vi�TY HEALTH DEPARTMENT.
, � ` �---
' naturc of Contractor Dac�
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Application Date: � "a -D � • � Tax Vlap: /`t 30
Amount Paid: I 0� �(�U Parcel #: �i-�
Receipt#: �yr �,T'1�-.,,��
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ZE-! : iz�. -s—:i r<c� �a „-,•�, �cT :i� �i:.za ll IE�t K:-- � 11 ti.I�a
A�plication foa- 5eryic�s (Septic Systems and Wells)
Sea�evicQs Re uested
❑ dmprovement Permit (Site Evaluation) ❑ Construction Authorization
�200.00/$300.00 (if> 600 g d) (Fee is de endent on the ty e of system ermitted)
Mobile I3ome Iteplacement or Suilding Addition �J Permit Revision
� 150.00 (if site visit re uired) �75.00
C V✓e�l �ermit (Netiv/Replacement/giepair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char2e
� rvices Re uested by
Name: C[ D �2Y'5
Address: � �!
� �
Phone # (home): �j "'� � — �`� �i " ��% b 3
(�vork/cell): �� � � � �! —.'�"o� ��
�)l�ame and address of current owner (if differ�nt than applicant):
Name:
Address:
3) �roperty �escriptnon: Lot Size: �� ��t���Subdivision: T ot #:
Address and/or directions to Property: /� O(D �b %� � lPN �
4) Proposed Use and Type of StrucyPre: �Q ��� � a a X� e
Residential Business/T e: Other
Number of bedrooms / Number of people served (seats/employees): �
Basement: Yes No (with plumbing: Yes No _� r
Garbage disposal: Yes No � l��-�L �
�Water Supply: � ui t� _
Private Well I/ (Proposed Existing �
Community Well: Public Water System: .
Are there wells on the adjoining properties? No Yes (please show location on site plan}
1°Tate: A completerl a��lication mus� adso include:
���Zat/site plan of the property t/aat show� p�o�erty dimen.sions and tl�e size rcnd docution of ull
proposed structuYes.
� A�ig�e�' copy of tdte `.�nt Preparatiofa'�'orm verifyin; that tlae property i� reacrly do �5e evaluutesd
� am submitting this application to request services �rom the i'�rson Coun9.y �iealth �epartme�at. I understand that
�f the infor�ation provided is ancorrect or if the si#e is su�seqaae�atly alterec�, or 3f the intended use changes, a�6
permits aaad approvais shall become invalid. =
�ig���;r� {Owner/Legal Representative):
D��� : � — 3 7- o �
10/08 Person County �,nvironmental Health, �25 S. �iiorjan St., Suite C, Roxboro, NC 27573 (�36-597-1790)
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�' :�.�-3.:,r�{t� �.�..rr�.�t� ��.Gt.��. � �:�,� �.�^a.
�a����s�a� r'���g�'1��fl�I P✓���D��c� ��Il�fl� 1�a��D�����IIfltBflIl�S
Tax iti�ap #:� 3b
Appr�val Req�ested for:
Parcel#: � �
= i�Iobile Home Replacement
� Building Adciition
Applicant �ame: � � �,����er5
Address: looto ,lol.� � en R�..
ox6�r� . C, 2757�
Phone #'s:�1�i�331�-SQ�-52�7 (H)�.� - 5R7 — 5`�03._
P�rrut Located: ��'es i�to
Instailation i�ate: S- 2.0 - 8$ Design flo4v: ��D (gpd)
�urrent Contract with Certified Operator on file (if required):
Water �upply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: 3' J'r'dq (date)
(Applicant's signature if sit� visit is not required)
Comments:
A�a���a��3������s�a��� �g���n���
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Enviro ental Health Spe�ialist Datz
1 ? / 15/OS
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IEua�x-�,•,�,r,•,, ��.�.]1 7F�'3i�c�.]i�
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Name �J n� rS Tag IYIap #�}3a . Pa:tcel #�_
Subdivisi -, _ � Section/Lot#
_� 3_�_�� .
tho�ized State Agent . � I�ate _
Systesar cmrr���raera� a��i�sesa� ca�i�a�xsa�ate�c�ours �aady: �'�as con�ctor rrs�, f8�� �B'e .s�+�es��r�or t� ,
begiraasing �lae Pras�crd�zors to x�r.sra�-e � p�+n��rg� as sr8cas��sas�ri
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