A31 34The District Health Department
Orange, Person Chatham, Lee Counties
SEPTIC TANK PERMIT
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Date� ; - ' "
Name of owner -
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Address and Directions � ' �' - " -' � ' - ` • '
Person or firm doing installation: - °�'
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Address
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No. of persons to be served bedrooms 1, 2� 4.
Additional appliances to' be used: Disposal, dishwasher, washing •
machine �
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Minimum ftequirements: 5eptic tank ' "� �
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+
Nitrification line: ' �
Septic tank and nitrification line musf be inspected and approved by
a member of !he Healih Depariment sfaff before any portion of the
installation is covered.
Date Approved: �"'R
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� Sanitarian � .�,, , � ~'�-�'" .
By: `� .
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
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Aouiication Date: � � 1
Amourrt Paid• / �
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ParcB! #: / �
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APP�ICATION FOR SEitVIC�S �
1F THE INFORMATION IN THE APPLICATION FaR AN IMPROVEiIAAENT R�3ZMIT 1S INCORRECT. FALS1FiED.
CNANGE� OR THE Sil'E IS ALTERED THEN THE IMPROVEMEi�iT PE3ZMR AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME fNVAUD. -
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.1) � Pertnit requested by: (Ovmer/agentlprospective ownerj: '� r-�„ �/-�j
Home Phone: . y 3 6-.� 9 9- a oS� Address: jj-�`��" ��
Business Phone• " � �/ (
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2) iVame and addr�ess of currer�t owner: _.
3) Property Descripticn: Lot size: Township:
D'�rections to the property (iPdudir g raad n�r �s and,
4)
5}
l.at #
proposed Use and Struciure D cription: answer eact� of foliowing questions:
a) Propase� . Existing �pe of Strvc�ure: �/YYiSZ Width: ' Depth:
b) Number of Bedrooms: Number of accupants or people to be served:
c) . Basemer� Yes . No Wiil there be plumbing in the basement4
d) �arbage Disposal: Yes No
Waier Supply Type: Private (new _ or existin . Public_, Communiiy . Spring
Are any weiis on adjoining property? Yes�_ if yes, piease indiqte approximate ia�tion on the
'site pian. .
/6�Does your properly ca�rtain previcusly identified jurisdictional wetlands? Yes_ Na
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR S1TE PLAN MUST BE SUBMITI'Efl WITH THIS APPLlCAT1�N.
➢ PROPERTI( LINES AND CORNEiZS AAUST BE CLEARLY MARl�� •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST 8E STAi�D OR FU�GG�D.
➢ THE SITE MUST BE READILY ACCESSIBLE FaR AN EVALUATION BY THE HEALTH DEPARTMEiVT
STAFF. � �
I hereby maice appiication to the Person County Heaith Department for a siie evaluation for ttie on-site sewage disposai
system far the above-described properiy. i agree that the cantents ofi this appiication are true and represenf the ma�amum
facilfies to be piacecl on the property. I undesstand ifi the siie is altered or the intended use ct�anges, the peRnii shail
became irnalid.
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Owner or Legal Re�reserrtative
Date
PCi-ID, rev. 061Z7J02
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �3� Parcel # � Townslup: ��Qt. !'l'l:cl�
Applicant: �Q�ln, `�1c��l�r��
Subdivision: Lot #
Location: 1�1 G'lcv�r2 Lcnq �
Type of Water Supply: � id vidual
Requirements:
Site Approved By:
Grouting Appro ei
Well Log:
Pump Tag:
Well Tag:�_
Air Vent: �
Hose Bib: ✓
Casing Height: ;L
Concrete Slab: �1
Well Driller:
Community Public
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i By: �l '��
Well Approved by:
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****See Attached Site Sketch
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from property lines. .l
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date: 5—t 9�--f
PCHD rev O1/27/04
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Name �n�Co�rn ��au\� , Ta� Map #� 1 P�sc� #=
S 1 �C�rrl,� ,P�'- • � Se�ion/Lot# --
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� �uth rizeti tat:� Ag�t � . � Date � . .
S'ystern cros�rs�one�s „e�r+es�t a�m�cinr�te��rsrs osalj►. T''na �r amvr,�lag t�dia s,�rste�ss� #o�
� d�eg�tg �lia a�staJlsr��s �o �s�+s t��,g�a rs �
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SCale:
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Owner: �
Location:
Subdivision:
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Drille.r ID # ._ �
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Com����ny N�me �• � ���► -
D�t�e Dril�led � �
Grout Log
Tax Map 3 � Parcel # 3��
Lot #
Well Constrnction
Distance From nearest Property Line (Minimum 10 feet) i U
Distance from Septic System (Minimum 60 feet) � Ov
Total Depth� ft Yield: �_ GPM Static Water Level: C�.� ft
Water Bearing Zones: Depth �� ft� ft ft ft
Casing: /�
Depth: From � to �_ ft. Diameter: �? in
Type: Galvanized Steel .�
Weight: Thiclrness: �� Height above Ground: �� in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �No
If "yes" give reason•
Grout:
Neat: Sand/Cement Concrete GraveUCement �
. Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured � Depth C�. to � O F�
Materials'Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: � Yes _ No 4 x 4 slab L Yes _ No
Liner:
Depth: Date Installed: Grout: Installed by: _
Drilling Log
Location Drawing
From To Formation
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I hereby certify that the
by the Person County �
Signature of
and that this well was constructed in accordance with regulations set forth
ID #07� Date �" �� �� �i
— Pump Installment
Pump Installarion Contractor: i State Registration Number: a Z�O
Pump Depth: ft ta 'c Water Level: ft �
Pump Make & Model: Pump Size and Rating: ��`hp � gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of thi r as to the well owner. .
Pump Installer Signa ��' Date: �"1� d PCHD rev O1/27/04