A32 101The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERM T Nq, _
�� Date y
Owner:
Location: ��l�
�
Contractor: � V<, S% p ✓
Water Supplp: Private Publi
1.UGL-'�.. � L'�►+� .i'I�io"�J
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other s,u,tom�/atic appliances
Size of tank: �.i���l �� Nitrification line: �j ' -/
RCS 3� ?a7 ra 2�„-�
Other disposal facility: � - � ` `
y �'� 3�� /hSj� E�l
Water supply and sewage disposal facilities ocatidir� -installati6n and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an� 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-
PROVEI} BY A MEMBER 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
Certificate of Completion � rL�
1
Date Approved: � $Y�
nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
% � �
� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots. �
[11 rz� Lr�J'AL �zi4 � -
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Application Date: 1 —I(�-l�
Amount Paid: � 2 Do, 00 C(��c�
Receipt #:
�..��� ) ,%~ �����A. � Tax Map: � Z _
� • �,�-- Parcel#: �Q (�„„
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iLr�a-��u:r-<>�asc�3c�ua�L�.� 7C �ehan.Il3�a
tion for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
C�Well Permit (New/Replacement/Repair)
$300.00/$200.00/$ 75.00
O Construction Authorization
(Fee is dependent on the type of
0 Permit Revision
❑ Repair of Existing Septic System
Annlication: No Charee/ CA $150.00 or $300.00
1) Applicant Information ;
Name: � Kl h�- J a►�c s �I hf
Address: �I 1'1 1 I
ur � � S 4
2) Name and address of current owner (if different than applicant):
Name: (�OP � K'e,l�h Y�Yo�dShe�
Address: �p [�l Gt,Y 11� M(� Yl K_ iZCjl
Nvr \ M�IIs Nc; 2'� � y
Phone (home): G � � �.P � �-{' � Q5 `�,�
(work/cell): �jlP 5� 2 `���{-3 � e�
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �,Q�-}� ��'1(1Y 11P, Ni 01'� �C� �'iLAY � Mi 1� S t� (�
2��,�- i
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by aiiy other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
C�tesidential 2 �
❑ New Single Family Residence Maximum number of bedrooms: J / Occupants:
❑ Expansion of Existing System If expansion: Cu�rent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maacimum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: Ld"New well ❑ Existing Well ❑ Community Well ❑ Pu�bli�c Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? Ld'yes ❑ no
Please note any lrno�yn ground water restrictions or sources of contamination:
6) If applying for °Authorization to Construct', ple�se indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site i subsequently altered, or the inteyided use changes, all permits and approvals shall be invalid.
� 1 � 1�
Signature (Owner/ L ( Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form �ni�st accomp�ny any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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IC�nwn�r�ga�a��ra��o.Il lE3C�afl¢]Ea
WELI� PERNIIT
(New / Repair_) (Rcplacc�„enE-�
Tax Map: �,�Z Parcei: 1 o I
Subdivision: Lot:
ApgliCaut's Name: _ p�i G�e �4 Ja .< ; e�_
Mailing Address•
PhoneNumbers: q�a- t�i,{- 13qs 33f�- S9_� - 53+(� �Pa*;c�Q�
Location of Property: __►�,.r� le �; I1� Q J —�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulatiorrs governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.J Issuance of a permit does not arantee a potable water supply
Other Conditions/Comments: �a;,,.�-s�n all <�Q�Kc �
Perrait issued by�.,,,,�, — Date: __ I- ZK-I g
�Tew Well:
, EHS/Date
Location: - .
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Nealth
325 5. Morgan St.,Suite C
Rnvhnrn Nf 7757�
Certificate of Completion
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
t� /7cl�
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lEaa�irom�a���mll lF7Le�.fl�a
Name: I'�� c�
Subdivison:
Tax Map: A32.
Slt@ PI81? Parcel: I o �
; i ��,-� Address: L�t5 .l,orl,'t. il/(�K (L� .
Lot:
EHS:
_ _ Date: 1 � S—Ig_
tem Type:
Septic k: gallons
Pump Tank: gallons
Total Linear Feet:
Max.Trench Depth: '
Scale:
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2j C�7tltdCt PeiSOi� CvUi�tY �iiJifvfifTlEi�t3i Hs21th LVi:ii aiiy �U@.iilC^5 �.�i.�.6� ��?7-li��.
Additional Comments:
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