A31 15�
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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: -
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p:
1r :. -
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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:
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iZ/07/200{ 04:�9 PM
Aaolicaticn Date; �
Amau t nid•
Recsi� ?
l�'
3�2�-
Peraon Co. Envlrenmsntal H�alth 7365877808 1/2
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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.-/
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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
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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 #:
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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)
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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) •
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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:
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