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The District Health Department
CASWELL - C�iATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPAOVEMENTS PERMIT No.
ate - '
owner: �� �� 1 1 ti�(1, � z.`
Location: '
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Contractor: J l �,.��g l t� i ��
Water Supplp: Private Public
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal,
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washing machine, her sutomatic appliances
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Size of tank: Nitrification line: —
Other disposal facility:
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.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DE ARTMENT
STAFF BEFORE ANY PORTION OF THE INS TI IS COV-
ERED AND PUT INTO USE.
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Date approved: Signe / � {��'
Well:
V a ri ''
Sewage Disposal: I Counter-
By. signed
(Owner or his representative)
Cerfi�cate of Completion ,J
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Date Approved: � B : �
a " arian
(OVER)
Location of well and sewage disposal facilities sketched on back.
Application Date: j � "� "� �
'���:ount Paid: j �p , Od
Receipt#: -��0 .3 I � _
T� Map: ���
Parcel #: �
� # � ���"�� � � ��Jl�..d.:j ��
1 � � --_ � � �.7� � �' �
IE-" :�ca -v- si u<ca ita 7.-,.-�• <i� �in 4:: �n. 71 �C 3.0 <c _,.mn. 11 Q l�a.
Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization -
$200.00/$300.00 (if > 600 d) (Fee is de endent on the e of system ermitted)
Mobile Home Replacement or Building Addition I� Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
1) Services Requested by:
Name: �c�LHnfd.� �OJSE
Address: C�o c1,�-�- , [i �'Erc.S J2c.� •
���C�ip�Za Il.r -L.
Phone # (home):
(work/cell): .S�l � - Z 2.3 �
2)Name and address of current owner (if different than applicant):
Name: `�"i M 4 C( � c�J ��i EQS
Address:
3) Property Description: Lot Size: �.�_ Subdivision: Lot #:
Address and/or directions to Property: /.( ✓r2.d /� IK� l�s Qc�. �S'c�vA � i2. ��t3 � pti �•
l.v i t�O �v � C' r, � v k•�. N C
4) Proposed Use and Type of Structure:
Residential � Business/Type: ��' Other
Number of bedrooms 3 / Number of people served (seats/employees): ?
Basement: Yes No ✓ (with plumbing: Yes ✓ No �
Garbage disposal: Yes No v
5) Water Supply:
Private Well � (Proposed Existing �
Community Well: Public Water System: /
Are there wells on the adjoining properties? No Yes t� (please show location on site plan)
Note: A completerl application must also iizclude:
➢ A plat/site plan of tlze property that sltows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of tlte `Lot Preparation' form verifying t/tat the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): te :
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�� u�n tv-u � �c� rt� Ji-�n ce; �rn. tL.�,.� � � <� .�n. � t��n.
�aaild'ang 1�dditions/ 19�obile Horne 12eplacements
Tax Map #:�'�� Parcel#:� Address: -�� �g�� Ils '� �
Approval Requested for: Mobile Home Replacement
Building Addition
Applicant Name: "ji�.t -} � u�.E�.V l�s.�^2 � �• �..��'��5�
Address: ��,.r�� Z� 3$/
Phone #'s:
Permit Located: ✓ Yes No
Installation Date: �' za Design flow: �(gpd)
Current Contract with Certified Operator on file (if required): ��
Water Supply: �� Well Public or Community
Wastewater system shows no visual evidence of failure on: ���t ��� (date)
(Applicant's signature if site visit is not required)
Addiiion/�2eplacement Approved
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Enviromm �tal He Specialist
z
Date
Person County Environmental Health, 325 S. Vlorgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 «nvw.personcount��.net
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21Y S L�M�R STREET - PO BOX 1268
R0X90R0 NONiN GROIJNA Y7573
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PLA7 OF SURVEY
C.J. WHITE
BUSITY FORK TWP.. PERSON COUN7Y, N.C.
OECEMBER 1998, HAMLETT-JENNINGS d ASSOCIATES
212 S. LAMAR STREET, ROXBORO, N.C. 27573
NEAL C. HAMLETT L-2465
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