Loading...
A31 15� � The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Woter Supply and���Sewage Disposal IMpROVEMENTS PERMIT No. � Date � � �'---� Owner: � Location: , , ... . . . _ . . .... . : ... �:... - . : . : . . Contractor: ' Water Supply: Private Public �=: Sevira ' 1 Faciliiies: No. bedrooms �Dishwasher, Disposal, : washing machine, ther automatic appliances ` Size • of tank:. Nitrification line: - �:i ; p: 1r :. - '�` � � � .... _ Q ._. /' V � ��-: :. ' .. . ? Other disposal facility: .: •- - - - _. , ;s.�,,�;,,;,�`' � d*�L.... Water supply and sewage disposal facilities location, installation and ';; protection must meet state sand: local regulations. � � � ' �� Septic tank should be pumped out every�3 to 5 years.and�shall be�;main- . tained by owner in such a manrier as not to create a publ'ic, �H"eaTth haiard. , - ; Septic tank and nitrification line MUST BE INSPECTED AND AP=� �� PROVEI} BY A MEMBER-OF-THE-DISTRICT HEALTH-DEPAR,TMENT •. _-�. STAFF BEF�RE ANY ,PORTION OF TIiE ALLATION IS � CO�T- " �:; ERED AND PUT INTO USE. - -% Date approved: Sign " Sanitari Well: '�'• �ewage Disposal• . By� Counter- signed (Owner or his represenYative) : Certifica2e :of Compleiion � - `• Date Approved: . �� B . - . . . �. . _ itarian (OVEit) . Location of well-and� sewage disposal �facilities sketched on back: "' x ,�. . � ��z ..� o ��� ti � �n a � �o � � � � z `° o�� m fD r: �' b � w �. o ..: w '� o'� � �s � � � � � � � � w w �'. � y � K � t fA �'. fp C vi � b � o � � aq y � �Q � o ° N " � � y � �. �. ��a o � ;� � �' w ¢7 � � � m �. 0 �°' � � � � o y � c. � y � G � A m' � y �b � � r. :: � ai r. �« � y N w � � � a� � y o � 0 w � � � O. .Y iZ/07/200{ 04:�9 PM Aaolicaticn Date; � Amau t nid• Recsi� ? l�' 3�2�- Peraon Co. Envlrenmsntal H�alth 7365877808 1/2 ���-,� .. s I�"I�,1I�� �1� � = . . aC � v�?�T'IC' � �.sa�aa-ua�a.�c�cs�ea��.d� �.e,.�.7i��a .:1• •- -_►/ '"�l Tax Mao #• .� -3 I � � p�,._retl #: 1j Parmlt roque�ted by ; Ownerl entlprospective awr�r):�1�� �-3 � ����.t Hame Phane:.33� c Z Addreas: _ z d� .S;r�- «�� �<-� � 6usinesa Phare: _ 5,�y -.3 i �i _��,��1/� �h_'i� r��. z�s-� i 2) N�mo and address of aurt�ent owtter: T.� �5 f- fio%. � S !J� :r � 7ov Sa rl`+. •�/.•/ /Z.-/ /-�u r,_// .�1. %� /�� � ��. � 3) Property Dascription: Lot size: /�� 3S,¢�Township: ���uDdivi3ion: Lot # Dire�iions ta the property (!ncludtng road names and numbers): /_��� /�Zs�Go.., r��� /-/�►•1,, is �.SoK fs _Td SQtrr.� ���..i �4 .als,R. //��;) � s�` S��r� �,...�� �,�, i� � 4j proposed Us� anc! 3tructura,@eacrlptlon: answe� eech of th�faliowing questions: a) Proposed _, ExisUn� ����e �f Structure: �In�� � y o�-� Width: DeptP�: !,� c x� s: f-� b) Number of Bedrootns: /VtA-N Number of occupa tn s or peopie io be sarved: Z c) B�sement: Yes ✓ No WIII there be plumbing in the basament? �/o /✓�-. d) �arb�ge Disposal: Yes _, No ✓ � �} WateT Suppiy 7ype: Prfirate ��new � or exis�ng_ ✓, Publ�C� Community,, Spring _„ � Are any weil� on adjoining properfy7 Yes_ No �yes, please indicate appraxiRtate IocatIan on the . site pian. 8j Doss your property co�sln previoualy identffled juriadictianal w�tiand�? Yas,_ No � f�_ ► • • •1�1 ➢ A PI.AT OF 7H� PROPERTY OR SiTS PLAN MUST BE SiJ9MITfED WiTH THl3 AE�Pt.lCA'f10N. ➢ PROPERT1f UNE9 AND CORNER$ MUST BE CLEARLY MARI�D. > THE PROPOSED LOCdlTION OF ALL 8TRl1CTURES MUST BE Si'AiCED OR FI.AGG�D. ➢ THE SIl'E MUST BE liSADILY ACCE8SI9LE FOR AN EVALUATiON BY THE HEALTH D@PARTMEN7 STAFF. I hereby make applkatlon ta the Person County Health Department for a site evaluatiort for the on-site sevuage disposai system for the above-described property. I agree that the contents of this appGcatlon ere true and represent the maximum fa iities to be placsd an the property. 1 ur�derstand if the �ite is aitered or the Intended use changes, the petmit shall b e Irnralid. / 7-� � 3 - �ao�� Cwr+ar or Legal Represer�ative Date PCKo, ,�v. c�r2�roz e �'.. �� .. ._.� - . . _ . . . �.,. . �. . ; - ..l � �•\: `�� \� � T _ = c (� � �. � �= l: ,�. .,.�� � _!: E: i; _ f: � i:.�., / i�i. .�. , - �--� � � :�� � 'n:-ara - .-r��- hr L.. � r.t s rn�• �.�.`- wa�.i.....rt — — _ �. � ur� i,�a ' �� ` ����r r� �, � � i - r. e �. �� ���.• � '���a,�ta�.� 4e �� / 'n/ .. .�.cu,r� ... - ♦ I �/'liL� �-J � � � 1 �� ��it I.ac�l: �� Wa�es S� ' �A% �C� . S�c gystem 3�e�3 Fa� �iesir3,cat�ai �a�iae9a t�L . ��� 3 #� � � � �Yo���3� � . '�'�,C��i`L�/�T7-�•l . �3�.�C�" `�C%� 4 � 2 Z�C � C _ � . ; . r • ' � , • . . . �� Tr r��.. � �3 —f'SO " C� op�r az��- /U`� ' t�-�e �astew�s �eai spst�m sia�ws�n�o �s�it sigas ��Sinu ori '� (--t� S �� as gr�t� � . � ' . • � �'d`��`` .. , . �,,,�;,,�.�,t,�,�t �� s� t� vv-�" � �"3 (--a � _�� y'�)� � �■ ���''^{'4J�� . ... � � � �l..J T���t� . . �iaa�ls��'^r^ �a9.�.� � X ��+�4'��9. Si1�'+ rLL11r N e � � � � Taa 1�L1p # �� I'ascel #_�L S �on Searon/Lot#��_ Authorized�State Ageat D�� � Syarew compaaeacs leprrsmr apptarimaae conmws aalp. Tl�e caamcmrmuer9sg t�e ayarem pdnr m begiaaia� �e �as�dna m laenre t6etP�P�EMde is msmm�ed Scale: ��� rcfm,,�. a�/Woi Application Date: Amount Paid: Receipt#: _ Tax Map: Parcel #: ���.s.s- �I��..���T � - - � ������ IC_. �rav n u�ca aa��TM-� ��ra d�.,r,n.11 7L-�t .��, �.71 �l�a Application for Services (Septic Systems and Wells) 1) Services Requested by: `� Name: ���a�-�h �-.��u f�_�" :�'� Address: � ov S� �-�t,.,�`.�./.-/ /la �---�o�/ !yi .��15T.,/1/� Z ,�,;'� � Phone #(home): 3j �� 3 ��f —'i/ z (work/cell): � j � $ 3-�'35Z 3s e sfs_3 ��� 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: �+A �- Subdivision: Address and/or directions to Property: � a o Ss,�T �f �: <<•� � t�► #: 4) Proposed Use and Type of Structure: Residential ✓ Business/Type: Other � b' X 3/ �- Number of bedrooms / Number of people served (seats/employees): /�o �� !� Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No 5) Water Supply: Private Well Proposed Existing � Community Well: P.ublic Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comnleted application must also include: ➢ A platlsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated I am submitting this apptication to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): �% ` Date : 3 - i � � �i' 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � i- I; :; �' ). t� r `i �. i :, � � � `�� ,� � � � ` � ��� ��. j � � � �..� �. � ,� .,. ., �. � ���''� y �� � �� '�1 � � �' �� �- �� y Y j �( •t ..-l��i.'Z.`� 1�������_�l�:J�.Z.S��� � .i�����;Ti<�.� 'S..' . �a�a�d��a� ������m��/ I���b��� �-I�agn� ���fl�a���a��n�s Ta�� Iv1ap #: �?�I Parcel#: 15 �ddress: Approval Requested for: Mobile Home Replacement �C_ Building �Addition ApplicantName: J�ir�S 1.�;{�ii-2 Address: �Oo �a-ler�eld `i�! N��r�l I�e M�1��i j� ��5� 1 Phone �#'s: � a-;'�u�- 7�lla .. Permit Located: �� Yes Tlo Installation Date: Q,-�- � Design flow: �_ (gpd) Curreat CQntract with Certified Operator on file (if required): 1 .. Water Supply: �c Well Public or Community Wastewater system shows no visual evidence of failure on: � � - 2 v/� (date) (Applicant's signature if site visit is not required) • • ' . �- . Z r� � a ► ��.: ' : 1���� . ���� w �tr1������1���������e�et ��p�����1 �n �� �-, Environmental �iealth Speciaiist 3/�/�� Date Pe:son Co�nr�� Environmentai :,eaith, 3�� S. yiorgan �t., Suite C; RoYboro, NC 27� � 3 Fhcne: ��6-�97-??9C/ ra;;: �� �-�9�-750� � tv�:�^,v.�ersoncouiZtv.l,e: Y