A32 16Ttie District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewoge Disposol
IMPROVEMENTS PERMIT No. r
j!� -' Dat ' �
Owner: _��- !�(l ) P �l.L� �
Location: l � t
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Contractor: � '
Water Supplp: Private Public
Sewage Disposai Facilities: No. bedrooms �� Dishwasher, Disposai,
washing machin er tom c appliances
Size of tank: � Nitriflcation line: �� � � 3�
� Other disposal fa
S �? o S
Water supply and sewage disp6§al facilities location, instajlation and
protection must meet state and local regulations.
Septic tank-should be pumped out every 3 to 5 years and 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-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY POR1'ION .OF •THE IN ALLATIOld IS COV-
ERED AND PUT INTO USE. ..� .. �
. �
,
Date approved: Signe � `
Well: C3 , �I� . . Sanitarian
Sewage Disposal:
By:.
Counter-
oigned
(Owner or his representative)
�ermlk y.Qid �ftar � Yoars
CertiSealO o� Complelion '
Date Approved: 1� BY:
Sanitarian .
(OVEB)
Location of well and sewage disposal facilities sketched on back,
.` N(�)TE: Make sketch of installation showing lot
supplies, etc. Note special problems existing on lot.
: at later ^d�tg. Note location of water supplies on a
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� of house, septic tanks, privies, water
in order that installations may be located
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Applicant:
Location:
Operation Permit
System Type (From Table Va): Product (IIIg):
Tax Map �Z— Parcel # � �
Subdivision
Phase/Section/Lot #
# of Bedrooms
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization. _
(Authorized Agent)
�C� f32Q��e�
(Licensed Contractor)
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Scale: �
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(Date)
S"— /� — IG
(Date)
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Line Length
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Total �
Tax Map: �`t 32 Parcel #: _��
Septic Tank System Checklist (Type II-I� System Type: �_
Notes:
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Boz
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV +Systems):
Notes•
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Copy of OP e-mail Date:
May 05 10 08:36p Scott's Hackhoe
05/04/2020 12:54 336597780B PERSON CDLI�ITY ENVIP.O PAGE B1
Application Date: ��"��"�� o Tax Map: � 3�
Amount Paid: __�,� Parcel ,�: �
Receipt#:
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� x�►'�.-a aa .cv aa:�.n�.c. a� 4_�n. IL �E]tC �+�, Il�14�
0 Improvemcnt Permit
S2QQ.00/$300.Q0
Q M�bik Home Reptaci
$150_OD (if site vi�
❑ Well PeratitlNew/[tei
Application fo[� Services (Septic 5ystems aud Wells)
Secyices Rc aesfed
�valuatlon) G Construdton Authorizatioe
600 d (Fee is depeadent on the tyne of
5300.pQ/5200.Q4/a75.40
�) Strvices Re ne��,ed�y
Nam�: Lt� '3 �9+G�, t St�rv .�
Add�ess; � • ,�
[r �:o
575.00
:psir of Ezi
No C e
Phone f� (home):
(warkketl): �,Ly 7'3::)--75'�'� ,
! Z)Name end addresa o ettrreot owuer ('�f dify'ere�t than applicant):
Name: E=dd ° ,J� 9
AddrEss: O zJ L ✓,'s ?)� l,(ttit Sk J�/` r�
a� �� � ��
� Yroperty Degtription: Lot Size: 7c� �c'��Subdivtsion: �t �:
Address and�or directions to Properry:
/�ropoaed Usea� Type of Stractut�e:
Rcsidencial ✓ Businessiijrpc: Other
Nurnber af bedrooms 3 I Number of pe�ple served (seats/employees):
�asement� Yes Na ✓{with plumbing: Yes Na �)
Gari�age disposal; Yes No
5) water Supply:
Private WmJI �proposed Exisiing _, j
Community Well: Public WaterSystem:
Are there wells on rhe ad}oinirsg properties? No Yes (pleasa show focation on site plan}
Note: A cvm leted liratinh ►nrest also inclwde:
D A,pladsite plan of[h� property thot sfrowc pruperiy dir�errsioru and the size and locatior� of all
proposed structur�s.
A A signed rvpy of !he 'Lot Prsparatfon' form verifying that th¢ properry fs rtady to be evrrluated
I am �ubmittiag this application to request service,s from t6e �ersoo County Health Departanent.l underatend that
if t�te intormation provided is incorrect or if the aite is bceg ueotJy altered, or if thc inteaded uae c6angc�, all
permih �ud app�ovals shall beoome iavaiid.
Signature (Owner/Z,egal Representa,tive): % ,L y • Date :� s r/J
10/08 Person County Environmentai Elealth, 325 5. Morgan St., Suitc C, Roxboco, NC Z7573 (336-597-1790}
p.l
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impravemeat �'srmit
��rmit Valad for _ �'ive �eaa�s _ 1To �apiration � . ,
Type �of Facility: New Addition �ate� ��ppiy .
# of Oc ants # of Bedrooms � Proje�ted Daily Flow g.p,d.
Proposed • a S stem: � Type:
Proposed Re�air: . _ � � Type:
Permit �Conditions:
Owner or Le eseatative Signature: i7ate:�
Autho ' State•Agen�r . Daxe•
The issuance of this pem�it by. the Health Deparanent m does not guarautes the issuanca af other permits. It is the responszbility of the �
applicant/pzoperty owner to in sure ti�at a11 Person Coimty Plannmg and ZAnmg :and Bnilding Inspections req�utemecats are met This .
�mQrovemeat �'ermit is subject to revoca�ion if the site pIan, plat or the intended use citanges. The Improvemeflt Psrmit is not
ai%ctesl by a c3�ange in ownership of the property. This. permit was issned in comgliance.with the provisions of the North CaroIina
`Zaws and Rules for Sewa2e Treat�nent ar�d ])isnosal Svstems' (15A NCAC 1�A .1900). Neither P�on �ounty nor ttte
Enviranmeatal �ealth Specialist' warrants ti�at the septic tank system will cantinue ta function. satisfac#or�y in the futnre or'tiiat
the water supply w9ll remain:potable. _ . .... . _ , - _
Aut�orization #m Constrac� �Vastewater Sys�em (kte�nired for B�ding Pex�ait) �
* See site plan and additional attachments� (_J• �
Proposed Wastewatei� System:�Q�itX'w-h �"� �( : Typ �G l C(` Wastewater Flow3�Og:p.d.
New R.epai� Expansion _ � � Soil LTAR: � 30 � g.p.d1$ Z . .
Type o�Facility: �� �9 Basement_Yes �No � .
, �,
� �aste�ater Sg�steffi �.equi.remen$s �
�ank Size: Se�tic �ank: G/�• g� Pnmp Tank: gal Ggease Trap: gal �'/`�� 4 S
a /
�rain�eic�:_Tot�l Area: � sq it �Total Leng#h �� ft � N$asiinnm Tranclt �ept3i C in �y� ��,y`� .
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��emc�',�VidtB� � ft tl�'s�'�uaa Soil Cmver. in 1dliniffizun Tre�ch Separatiom: ,� ft :.
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i�istribut�on: . 13i�tribn#ion �og � Serial �istri�ntion Pressnre 11�Ianifoid
�peci�catfions: �M.�i -�i l.(PS'h'i�S �,C( 33CP 5�'7^��7P� + .
; —�— .
Authorizesl State A.gQnt
Permit F�m:
The type of system permitted is � Conventionai Acc�te3 Alternative. I accrpt�the spe�ifications of tize
P��- .
�wn�/Y��bal �8�presa�ative: Date:
' pC"dD rev. l l/10lOS
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SITE PLAN
N e' � p ��� Tas Map #L� 1�arcel #�
Su ' ' on Section/Lot#
0
Authorized State Agent Dat�
System compoaenis represmt appmximate rnnrours only. The coatracsormust9ag t6e system prior m beginning the insraliarion m
insure thatpmpergrade is marntaiaed
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PCFiD, rev. 09/12/Ol
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