A32 178� The District Health Departmenfi
�` �..
' Orange, Person, Caswell, Chaiham, Lee Counties
0
�' Water Supply and Sewage Disposal
Date 9 "'�T '�
� Owner: jq �
° _��Ir� I')'I,'l/s
p� Location: �
s����r
� Contractor: �T�rn�� pG�'� S
� Wafer Supply: Private .�� Public
Sewage Disposal Facilities: No. bedrooms �,� Dishwasher, Disposal,
^��',�.�� ' �*+P other automatic appliances
%/�O CL� �� Nitrification line: S� �� � s�• �(-
Size of tank: � � ,
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use.
Date approved:
Well:
Signe�l
Sanitarian
�`--- -•_.-..__. . . . .
✓'� _ -
(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
�;�lies, etc. Note special problems existing on lot. Write in measurements in order that instailations may be located
later date.
Amount paid �OO,OC
Receipt .IP ' � � �� ��
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Date
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Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
�mprovements Permit (Mobile Home Replace) ,_ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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;, n F Y f � y, y�aterySample`to be: Collected.
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Bacteria Chemical Petroleum _ Pesticide _ Lead
1. Permit requested by: .
owner/prospective owner/a er
Ar�r�rPcc• `,�O�f� ��(`Q,�C'��_
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W
�Home Phone #: ?
usiness Phone #:
a
7. Dimensions or Proposed Structure:
C.�R.� � Width: ���
Depth: 3 �
�S4 � 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewa e disposal system is intended to serve?
ho� � � c.C� I`Y�� (,C�Q c--
c�ob��e p _
. Name and addre&s of current owner: `-�� � 9. Water sup ly ty pe:
� ` private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ��
If so, identify location:
Description: Lot size: � • � �
. Tax Map#: R 3 �
Parcel#: 11 �
Township: �� h � �'
�
. Directions to property: State Road #& Road
ames
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c� C
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: DExisting: Q�
Type of dwelling:
House: ❑ Mobile Hvme: �usiness: ❑
Type of business:
�Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No ��
Basement? Yes ❑ No�so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person COunty Health Department 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 bc•
issued, I must present a survey plat of [he 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 af[er the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
♦ �/��' �-
Si�nc� Owner or Auti�orized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature
Date � ,
:�an �> „� yaFXCIORS�STIEEVALUA710T7; r :8A1tF�SI, ARfJtZ.� �.� +�..'AREh3 A1LEAd z
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1. 5[APE (%) S S S S
PS PS PS PS
U U U � U
2 SOII.I'IX7VRE(12-361N.) S S S S
(SANDY, LOAMY. CIJ+YEY. NOTE 2:1 CL.�Y) PS PS PS PS
U U U U
3. SOILSiTtUCIVRE(12•161N.) S S S S
(CL.AYEY SOI1.S) PS PS PS PS
u u u u.
4. SOILDEPf}[(IN.) S S S S
PS PS PS PS
u v u u
3. RESTAICI7VEHORIZONS(M.) S 5 S 5
(II.tYERVIOUS STRATA. ROCK) PS PS PS PS
u v v u
6. SOILDRAINAG&GROUNDWATER S S S S
IFXiERNAL k IN7ERNAL) PS PS PS PS
U U U U
7. SOILPERMEABILTi'Y S S S S
(PERCOLAAT70N RATE7 PS PS PS PS
U U U U
E. AVAILABI.ESPACE 5 S S S
PS PS PS ps
U U U U
9. Sti'ECLASSiF7CA770N(SEEBELOW)
SO1L SER)ES
S•SUITAIILE PSPROVISIONALLYSUfiAIII,E U-UNSUTfABLE
RECOMMENDATIONS/COMMENTS:
STI'E CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems� e�C.� C:WF1fPR01DOCS�APPSEC.S�1 FINANCE.PC
�.
V
Person County Healtll Department
Existing Sewage System Report For: v Mobile Home Replacement
Addition
Requestee: I i `-� Home L'hone# �'� /��� ` r
1 ��� � C�(''1;f N`fl��,�G. Business# �9' ��� ��lJ��
��l o�l �J� I`e- 1►' �' I�J, !� l i���Pax Map# �_���
Location/Uirections: S� � f1 �/ T I L `}-C/L�-� �� P Mo(( k.
� I�. ; n�� I��"' �.� .r�.��,s� hQ�h s r� er, o�
Original Permit Located �
Septic System Uesig ed For:
ttesidential Business
# E3edrooms � # �;mployees
Other (speciFy)
Other
Uate lnstalled ��—� 3 Water supply
`Pype ot System
Nitrification Line
'Pank Size
Certified Operator Required /�1 d
�� �
On site wasL-ewater disposal system showes no visually apparent
malfunction on �I O
Yermission is granted to: �a- .� � l�l� �
According to the attached site plan.
� � .
Comments:
Environmental Health .$�G..
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