A32 25:L
,. The Districf F�ealth Department
Orange, Person, Caswell, Chaiham, Lee Counties
SEPTIC TANK PERMIT
Date `�/ � �� v �J �
Name of owner: �YI C-� 1''G � Y� �� r��1 1'1
�
Name of contractor: ��� �� 1 G
Address and Directions .��3t�LI C�� � v! � I(� (
_ �� s^� t � .� � f � . . : � � e �.
r �
Person or fum doing installation:
Address
No. of persons to be servee Bedrooms 1,'�y , 4.
Additional appliances to be used: Disposal, dishwasher, w�
machine
Recommended• Septic ta �
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line musf be inspecfed and
approved by a member of the District Health Departmen! sta.ff before
any portion of the installation is covered.
Date Approved: �— (,� —
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.Ii.
District Health Officer
Countersigned
(Over)
�
� � �
OTE: Make sketch� of installation showing locati oiQ�iouse, septic tanks, privies, water supplies on
. f adjacent property, etc. Write in measuremen�•i4iorder that installations may be located at later
� ^': �
date. .
. .� .
'i�JGGESTED INSTALLATION (Date ) • FINAL INSTAId.ATION (Date )
(Road or Street)- (xoad or street) /
� . . � ! [
�
�
■���I��■���M■■
■���������N��
■�1�1���'ii��r��l�■
■��1��������1���
■��11���■�■���1l:�
■������s���'��II
■�li�������rr��
■���������: �■
��■��s■��■�s
■��■���■����■
■���■■■■��■ ■
�������!�!���
��
Amount paid �i�. i�� C�� � �_o� �'' I�
Rece��pt f! �►p''j"►n Date
� .
I . permit requested by: . � ,
owner/prospective owner/agent: MQ2c�5 J�f�pa�?.
Address: Z2 � -�! � bLQ Q� ���� �a
t..(�2ocE -!�llcc.S N C- 2�`��
�
�
w
U
�
a
�
a
Q
�
d
H
ome Phone #: 36y—a.65`1 ��t� a O1�Q $9 g
usiness Phone #:5a`i--7�735 M�KL�S la�
W
�
z
ame and address of,current owner;
� ocp � P/�IrvT"
(.� /Vbt LLS /
. Property Description: L,ot size:
. Tax Map#:
Parcel#: �
Township: -�d �Q� �� -� 1 G L S
Directions to property: State Road #& Road
ames,�tc.
� S T p� � � �d.�P bN G�
PA s�- �vQOc.E �-t!C_cS ��
7. Dimensions or Proposed Structure:
W idth:
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the stcucture or facility
ithat this sewage disposal system is�intended to serve?
9. Water supply t}•pe:
private�,• public ❑ community ❑ spring ❑
' Are any wells on adjoining property?Yes ❑ I`io [�
IIf so, identify location:
10. Type of structure/facility: Froposed: DExisting: (� �
Type of dwelling: �
House: �Mobile Home: C� Business: ❑
Type of business: !
Number of Employees: ;
I�Iumber of bedrooms: _ _— :
Garbage Disposal? Yes O No � �
Basement? Yes ❑ No,f �If so, # of basement fixtures: ;
6 I�Iumber of occupants or people to be served' t �
CLEARI;Y STAKE ALL CORNERS OF THE P�tOPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUC�'i7�tES•
I hereby make application to the Pet'SOn COun�y �ealth Uepaxtmellt for a site evaluation for the on-si:��
sewage disposal system for the above described property. I agree that the contencs of this application are true
and represent the maximum facilities to be placed on the propercy• I understand if the si[e is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can �-•
issued, I must present a survey plat of the property to the Health Dept. I understand that in the evenc I have nc �
delivered a survey plat of the property lo-lhe Health Dept. wichin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become vo[d and all fees paid forfeited.
SiQnc� Owner or Authorizcd Agent
�errriit Issued ❑
�ermit Denied ❑
�lat ObseNed❑
S ignature
�
�
�
Date
� , . . . .
� �
,... �,_ ., ��
� � .. . . ; _ ,
. , . �. . , �
`�„• . t~^���lcrb�$i"tEE�u.v� �" � '�' �`'� ��� ���.l�Y� "��r,'Y ��" ��"�
, :
. �a�` .���nt.a .. ,.. . . . _.-...��.� .'�'ht,��"� xr� . �z a� s� ,1�i1_ " . �:. �"a.,
.
s..,t! c,. _ . . x^!s:J� ' .t'�k_ � � .�r
..2: �;� �` � +a
,�,.. . : . . .. . .._ , . . <-,. < , .y... -
1. SIAPE (9�) S S � S S
PS PS PS PS
U U U U
2 SOII.7FX7URE(t2•361N.) "� S S S� � 'S
(SANDY.LOAMY.MYEY.NOTE 2:1 CV�l7 PS PS PS PS �
� U U ' U U '
3. SOi[.SiRUCTURE(12-)6IN.) S S = $ •
��1��O�LSi PS PS ?S PS •
U U. ' �, U i
L SOILDFYi}{(W.) S 5 S S
, pS . ps i , K . , , PS
U U U U: -
S. RES'IRICT1VEy0RTLONS(M.) S S S - S•
(B�iPFRVIOVS ST1tATA, ROCIC) PS PS K PS
U U tl V
6. SOILDRAINAGFIGROVNDWATER S S S S
cFxrrxxuanrrnexu� PS � PS K PS
� • u u u
�. soa.r�t�anmr s s s s
crQtcowAnox sur� rs rs es es
� � � u v v
E. AVAII,ABfESPACE S S S S,
� PS K PS
� U U . U
9. SfIEQASS►}7G1770N{SEEBELOV�
SOILSE7t1ES • . '
. }
SSVITADLE pSTR0YLS10NALLYSUITAIII.E l�tRtSUfIADLL
�LUMMENDATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include: Soil azeas, property lines, roads, streams, gullies, wet areas, f11
areas, wells, water bodies, slope patterns, etc.) � C1AMtPRUDOCMPPSEC.S1�1F1NANCEPC
,
�
. �+�� � � ',
�� �
� � - PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map #_�-� � Parcel # i�
Zonins __ Township
Owner/Contractor
Location/Address
Subdivision Name
� ��
�;�n�r
A 001233
Date 7-�� �-1-�'7
S.R.# � o FJ�
LOt# � � �� z _
SEWAGE SYSTEM SPECIFICATIONS
�air Lot Area
) Mobile Home_
iness # of Bedrooms
Permit Void after 60 months.
Permits may be voided if s:
Well ��t� Layout by
Comments:
Size of Tank
Size of Pump Tank_
Nitrification Line
Max Depth Trenches.
Permit Void if not in compliance with zoning regulations.
Date Installed by
Approved by
`� �a �� WELL SYSTEM SPECIFICATIONS
Individual �/ Semi-Public Required Slab
Public Replacement Air Vent
Site Approved i/ Required Well Lo�
Well Head Approved Well Tag
Grouting Approved _ _
Date
Installed by,
by
This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this penniG The
environmental health specialist is not responsible for faise or misleading infocmation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the propeRy or for statements in this report that may have resulted from false or misleading
statements provided to him in the application Neither Pecson County nor the environmental health specialist watrants that ihe septic tank system will
continue to fundion satisfactorily in the future or that the water supply will remain potable. c:�amipco\pc,7mit.sam O 1/95 rev.1.0