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A32 14The Disfricf Healfh Departmenf Orange, Person, Caswell. Chatham, Lee Counties SEPTIC TANK PERMIT , �� Date � � `� � �� `� � i ' ) Name of owner: � �` ��i� '''� `� ��1�'t ilL'� �� '? I �i"<_�� Name of contractor: � �' � ! '�' r i � " " � "� ( ' +' !�� Address and Directions f� � � �'r 1 � -"'. �1 + � � `� i�) (� � --, � i ��)"1 �� f"� r� 'ri ,.; � r ;#= i `� ( - 1 `'� � Person or firm doing installation: �' � G= i<� Address - � � /t.:( , /'�"�'( ��/ , �. � ; �� -�� No. of persons to be serve� Bedrooms-1,-2,-3,-4�- Additional appliances to be used: Disposal, dishwasher, washing � machine � r �� Recommended• 5eptic ta � � ' �•' ��` � % / � , Nitrification line: � Z �� " , Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspected and approved by a member of the Disiric! Health Deparfinent staff before any portion of the installation is covered. Date Approved: � `-�(� -[,!) � Signe� �-� �j Sanitarian ', % � ��Y, "L (l�; -�� • _./� By� . �� Countersigned 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. c� a��°va.. P �� 3 _ � ��6 I � 8 � U � a z • . -�� - i ►-q� Improvements Permit (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) Permit for New Well mprovements Permit (Addition) C�hUr Replace Existing Well ; .Wafer S�rnple to be �ollected: _ Bacteria _ Chemical _ Petroleum _ Pesticide 1. Permit requested by: �wner/nrosnective own� [ome Phone #:7�/�- ' �usiness Phone #:_ . Name and ad ress , . Property Descripti . Tax Map#:_ Parcel#: Township: — . Directions to iames, etc. nN CR\ �.s _ Lead Dimensions or Proposed Structure: � 5 � eo p �f idth: G 2 '� � , ;nth: "� 2 ' � �O� 7�� ,�" < What type (if any, additions, expansions, or �lacement is anticipated to the structure or facility .t this sewage disposal system is intended to serve? owner: 9. Water sup�ly type: v_+ � private L�l public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: : Lot size: Number of occupants or Road # & Road .� S 12 I I g�I �le to be served: 10. Type of structure/facility: Proposed: DExisting: ❑ Type of dwelling: House: ❑ Mobile Home: ❑ Business: ❑ Type of business: Number of Employees: Number of bedrooms: Garbage Disposal? Yes ❑ No ❑ Basement? Yes ❑ No ❑ If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pei'SOn COunty Health Depai'tment 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 before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Signed Owner or Authorized Agent Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ Date FACI'ORS-51'i'HEYALtiAT1UN AREfIl `:: AREA2 :: i1REA3. . AREAd < _ I. SLOPE(�) S S S S PS PS PS PS U U U U 2. SOII. TEYTURE (12-36 IN.) S S S S (SANDY. L0.41.iY, CLAYEY, NOTE 2:1 CLA1� PS PS PS PS U U U U 3. SOIL S7ROC7URE (12361NJ S S S S (CLAYEY SOILS) PS PS PS PS ' U U U U J. SOIL DEP7H (IN.) S S S S PS PS PS PS U U U U 5, RESTRICTIVE HORIZONS (iN.) S S S S (IMPERViOUS STRATA. ROCK) PS PS PS PS U U U U 6. S0l[. DRAINAGFJGROUNDWA7ER S S S S (EXTERNAL & INTERNAL) PS PS PS PS U U U U 7. SOII. PERAfEABILTCY S S S S (PERCOLOATION RA7E) PS PS PS PS U U U U S. AVAII.ABLE SPACE S S S S PS PS PS PS U U U U 9. SITE C[.ASSiFICA7'ION(SEE BELOVI� SOIL SERIES 5•SUITABLE PS-PROVIStONALLY SU[TADLE U•UNSUtTABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:�AMIPRO�DOCSIAPPSEC.SMFINANCE.PC .. . :....,_.r__�:_..�_:.._..._.. . ... . rivies, water supplies on location of house, septic tanks, p be located at later NOTE: Make sketch of installation showing - 'acent roperty, etc. Write in measurements in order that installations may ) ad� P _ . _____ .�...nx roate ., / �,_... /„ 4 � � �� a� U � a � P�-�. T, �, N ` 0768 PERSON COUNTY HEALTH DEPARTMENT WEL,�, AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # � � �. Parcel # � � Zoning Townshi � ��— _�-�—� Owner/Contractor ��'�- ��.�� -�� Date IO --/ Z -9S , � . � , , . .n � ._ , Location/. Subdivision N � 1 � ��.. '�p ,/� . �� 1 �. l �� i ♦ i�� I 1 _ � / ��i i 1S Lot# S.R.# t�7C�3s��,ll g'� J s 7 70 � SEWAGE SYSTEM SPECIFICATIONS �ir ��p Lot Area .� �-�- Size of Tank_ la' Mobile Home N��'i' Size of Pump ess # of Bedrooms 'r'�� Nitriiication l Max Depth T `X(� Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is alt�red or intended use changed. Well and Septic Layout by ��-��--�-��rJ•�� Comments: D a d � �. G ` �G � G� �b t w `� Date 1 b�� v 9� Installed by ��+�-�-� Approved by I.r)..t� � �� n „ _. c�-.� _ _ � Well Per it Paid ❑ WELL SYSTEM SF Individu Semi-Pu ic Public Replace ent Site A roved Well ead Approved Grou ing Approved �o ents: Da e Insta ed by FICATIONS uired Slab Vent Well Tag Well Lo by This report is based in part on information 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 ro function satisfactorily in the future or ihat the water supply will remain potable. c:�amipro\permitsam 01/95 rev.1.0