A31 46_._,.
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The� District Health Deparf�enf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date � `' �/� � � /
Name of owner: �
Name of contractor:
� . _ � , �
Address and Directions
t.,� �Ii7�' _i
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Person or firm doing installation: ^�—� ��� ��___�_r! �'�� ���� R��
Address ��., � '� � TC �� � ���� �. . l
No. of persons to be serve� Bedrooms 1, 2, 3, .
Additional appliances to be used: Disposal, dishwasher, washing
�
machine
..�.�—
Recommended:.
Nitrification line:
Septic ta !� 1 1
�, , . �. _ , i !
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line musi be inspected and
approved by a member of the District Healih Deparfinent siaff before
any portion of the installation is covered.
Date Approved: �.- �,Tl-- �
By:
Countersigned
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(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. �
BUGGESTED INSTALLATION (Date' ) FINAL INSTALLATION (Date
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B 1620
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issaed until Authorization for waste water system construction
has been issued.
Tax Map # q 3/ Pazcel # �s�
Zoning Township r3��, N� Fozr
Owner/Contractor L�► R R y a. D o,,,, t �� Date y_ z y_ �-,
Location/Address �/�,.,,• is� � � y� ,�.,.��s r;z�r� .zax,av�o
v�i ,z�b-y � S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /. 99 A� Size of Tank �x i s T��v 4-
SFD ✓ Mobile Home Size of Pump Tank -
Business # of Bedrooms �x� ��.0 Nitrification Line � x. s�r�,.r �>-
Max Depth Trenches -
Permits may be voided if site is�tered or intended use cha
� �
Well and Septic Layout by,
Comments: A o �„� 4
5`(57
���
Installed by r_ x i� r, n! �- _ Approved by
ell Permit Paid ❑
Site
Comments:
WELL SYSTEM SPECIFICATIQNS
Date Installed by
�quired Slab
r Vent
;quired Well Log
ell Tag
Approved by
Ex � s �� �J Cr-
NA N�
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This report is based in part on in�ormation provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:lamipro\permit.sam O1/95 rev.l.l
�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: z
TAX MAP #: A3�
Il1�PROVEMENT PERMIT #: 13 �b zn
PARCEL #: 'y6
OWNER/OWNER'S REPRESENTATIVE: � A�►t�( A, Dni,.� E �L
LOCATION/ADDRESS:
�Iwy /s'y _S �'. y90 ��c� s F�2o.�-1 �2ox[3ozv
ON �Z14N i
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
� G�
AUTHORIZATION CONDITIONS
LOT #:
�
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # . The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
A DOJ N Lr �1 Zo f X Z6 � CA/�?/���T
R/O C�lA�llr� %� �E �l L S�S 1 C i�Y
Person Requesting: