A31 151Size of tank:
The District Health Department
; CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply.and-Sewage Disposal
IMPROVEMENTS PEF�MIT�I�Iq
`. _. D — r- S_ C3
Owner: t ' j
s
.�
Location. ' ' �
, ,
Contractor: —���-"
Waler Suppl�y Private
Faciliiies: No. bedrooms
Other disposal facility:
1_�� - . .
�� �
�
Dishwasher, Disposal,
automatic applianc�s
Nitrification line; v
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 an3 shall be main- '
tained by owner in such a manner as not to create a public health hazard.
5eptic tank and nitrification line MUST BE INSPECTED AND 'AP-
PROVED BY A MEMBEft OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:.
By
Signed ` � `�-i • �
Sanitar'
Counter-
signed
(Owner or his representative)
Cerlificate of Completion
Date Approved: 10-,�-� BY: �
anitarian
(OVEft)
Location of weli and sewage disposal facilities sketched on back.
�
Aqplication Date: �"� �
Amount Paid: 0 � �
Receipt #: _�
Person Counfii Health Department
Environmentai Health Section
APPLICATION FOR SERVICES
Tax Map #: f�"�'
Parc�l #: � �'
IF THE INFORMATtON IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: Ownerlagentlprospective owner): :� �^� �` 7i'-" �i �,��1 Y 4'�� jGh�� �'�' � f�K
Home Phone: �' ' " �YS l ,�, Address: !� � [� �� ��� G''�; v�. G / t : ,�1,
Business Phone: '�1 t-� —�t - �� 5 `c� i�'j3 c+u �Oi. ;,r� ; I C.: 5' /UC:-,, yr y/
2) Name and address of current owner: ���
3)
Property Description� I nt ci�w• I�IT' Tnwnchin• �u�� i ("���
Directions to the
�2L1� t.oNJG i� �
� 62�d� CM. 2d,
�
4) Proposed Use and Structure Description: answer each of the foilowing questions:
a) Proposed ❑, Existing�Q
b) Stick Built� Modular ❑, S`i�gle Wde 0, Double Wide ❑
c) Number of Bedrooms: '% d) Number of occupants or people to be served:
e) Basement: Yes� No if yes, # of basement fixtures: `r
fl Garbage Disposal: Yes 0, No � � l
g) Dimensions of Proposed Structure: Width: '� Depth: �
5) Water Supply Type: Private�(new � or existing �, Public �, Community O, Spring ❑
. Are any wells on adjoining property? Yes �j No ❑ If yes, Iocation�Qdx• l�r t� �� P(2p�byZO
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
_Conventional Modi�ed Conventional _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS APID LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application 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 true and represent the maximum facilities to be
placed on the property. I understand if 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 fo� the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health Department if my property contai � any wetlands desig �ted by the Army Corps of Engineers.
�
L� <' 0-3 '�� ��/�/ ��
Owner or Legal epresentative ' Date
PCHD, rev. 10/12/99
Person County Health Department
Existing Sewage System Report For: Hobile Home Replacement
T ✓A d d i t i o n �SC��O�.
� ,
Etequestee: � � � �� Home Phone# ,3��i - �ySl
`j'cg�(,,Q,t�1 i CT�o�Ch� Businessn � -'����' 15
`��5 /1%G. � �ax Maptt
31- s � 3�3
L o c a t i o n/ D i r e c t i o n s: RU.�( i� I Y 1� ►�l5 �• -�,��� (1 i D rl -s{-Q-Y�- �-h,(�C�°,%,
� ��I �-n �� � S�B
Original Permit Located _��
Septic System Uesigned r'or:
Itesidential ✓ Business
� Bedrooms �-�
Uate
0
s
Other (specify)
# Emp loyees Other
:Cnstalled ]0 -o�" �Q
Type of System
Water supply
Nitrification Line ���,�c�� v
Tank Size 1
Certified Operator Required � ��'1- �
On site wastewater disposal syste�a sliowes no visually apparen�
malfunction on �� � ��-V 1
Yermission is granted to: .,\1�1 �� •
According to the at�ached site plan.
Comments:
Environmental Health $'�G.. �
I
TE
0
.+
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