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The District Health Department
WELL - CHAT AM - LEE - PERSON COUNTIES
y and Sewage Disposal
IMPROVEMENTS PE IT
Dat -" "
Owner:
Location:
.�
Contractor: �_, �,ry,t' n
Water Supply: Private Public
Sewage Disposal Facilities: No. bedrooms Dishwa�her�Disposal,
washing machine, other t�omatic appliances �-� ---�
Size of tank: Nitrification line:
_ . , . . , <,
Other disposal facility:
w
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 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-
PROVED 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
Signe `
Sanita ian
Cs u n�__C�2�t'-�:.aC1�',.�� �
g �
(Owner or his representative)
Certif'ica2e of Com leli n/ -
� .
Date Approved: � B '
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
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
AQaiicatton Datie: ��3-0 b Tax Man#: /�3�
Amoum Patd•
Recst , Parcal �: �
. . ���'?� � ���� �� . .
� � - � ��v'�'�� �_ C�I �
�sa.Ta.a.m-�--- �-^--- aeaa��.71. ��ro....1I.��a -
�. aPQucAnoN r-oR s�ncEs . . � t'`� e'�`�2- � l
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1) Psrmit requested 6y: Owner/�ent/PrnsPedtve ownsr): i�,l D C r-. ,� Y'c� �5 � �-'
Home Phone: 3 6' - 7� 8 � � Address� -
8usiness Phone: ' ! 3 � � '
CJe�c�el�`5 �ell- �336- 5�y- �� IS .
2) Name and address of carnent cwner: � �' �� v
� L uc— /� c, .. ._ : ,� . .�,f,... i
3) -Prcperty D�lption: Lut size: c� Township: /Q 3
Dir�ttons to the property (tn�ding roai� njames and numbers)T�
�
u r Z � r . � /1 P�lr !'�
houS.e ov� r• 4`�4✓ Jo n✓�y ItauSe: ,
4) Proposed Use and Str�r� pescr(p�On: answer each of the following qusstions: � r
_. aj- Pro� ��, Ex�sdng ✓, Tj/pe of�Struc�ure: /� n c! 5� :`
..• b) Number �f Bedrooms: . 2- Number of oc�pants or peopie to 6e served: �
. •� C) Baseme� Yes_,_,�No�� WUI there be plumbing in #he basement? �
• . . d) l5a�tiage Disposai: lr`es . Na ✓ . � �
�
�
;
>_.� �� 1,�- =
p�th• C� 0 '
Water SW�P�Y �IPe: Private �/(new _ or existi�q ✓ 1, Pui�lic . CommuniiY . SP�9
� Are any wells on ad�jointng prope�ty? Yes No ✓ tf yes, please indicafie approximate locatiori on the
site pian. . —
Does ycur property cantatn previousfy identlflad jurisdlcttonal w�lands? Y No
PLEASE NOTE THE FOLL0IMNG• ' '
➢ A PIAT OF THE PROPSiTY OR SiTE PIAN MUST BE SUBMiTfED WlTti THIS APPL.ICATiON.
➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MARKED. •,
➢ THE.PROPOSED LOCATION OF ALL SiRUCTURE3 MUST 8E STAkED OR FiAGG�. �
D THE SITE MUS'� �E READILY ACCESSIBLE FOR AN EI/ALUA7i0N BY THE HEALTH DEPAR7AAEi�if
STAFF. ' '
I hereby make appllc�ti�n.ta �the Person Caunty Health Department for a siie evaivation far the on-siie sewage disPosal
system for the above-described proQerty. 1 agree-that the cantertts of this appiication are true and represerit the maairnum
faciiities to be piac�d on the property. 1 wderstand ifi the siie is aitered ar the irrtended use ct�anges, the permit shaU
hecome invalid.
� c 1-�—� �PT /v c7� 1 '�/�u�iSG�L� . '(� % 3 � � �
or Lsgal Represerrtative � Date
or�un .ou t16127102
- -- ---__ _ . _
— ��' I . � � : ' �� � T�x Map i , �rcel �
_ � �� t � � � � - S�u�bdivision
1 _ , . �. � , ., , , , ,., � , � , I I I , I I.. Fh��se Sect,iom:'Lot �
P�rnnit Valid for
Type of Facility: .
# of Occupants p�
Proposed Wasteu
Proposed Repair:
Y
I�provemen�t �ermit
I�To E�iration
New Addition �Vater Supp�y �e 1!
Projected Daily Flow zY� g.p.d.
� Type: q
� Type: �
# of Bedrooms
ystem: �v�
..
Owner or Legal Represen ignature: Date: %� t� -0 G
Authorized State Agen�,��. � Date: �-Il �D"lo
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Ymprovement Permit is subject to revocation if the site plan;'plat'or the intended use changes. The Lnprovement'Permit is not
aifected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Lv�ws and Rules for Sewa�e Trentment and 1)isposal Svstems' (15A NCAC 18A .1900). Neither Person �oun,ty ; nor''the.
Environmeutal Health Specialist warrants that the segtic tank system will continue to function satisfactorily in the future or�t6af
the water supply will remain potable.
?suthorization to Construct V�astewater Sysiem (Required for �uilding Permat)
* See site plan and additional attachments (_J. .
Proposed Wastewater S tem: DnV n ono � � Type 1�A Wastewater Flow Z�a g.p.d.
New Repair Expansion _ � SQiI LTAlt: � 27S g.p.d./ ft 2
Type of Faciliiy: l� Basement _ Yes �
�asi�vva�er Syst�� Requireffients .
Tank Size: Septic Tank: �0(�gai Pnmp Tank:--�' gal Gre�se Trap: '-�ag 1
Drainfield: Total Area: ��� sq ft Total I.ength 2�o ft 1Vla�mus� Trench IDept9i � an
p.C•
Trench Width � 1V�inimnm Soil C �er: �_ in 1Vliniffium Trench Separation: � ft
I)istx�ibution: �/ I)istribution �os v Serial �Distributaon Pressure 1�Ianifold
5pecifications:
�uthorized State Ag Date: '7-//-DU
Permit Expira on Date: -- - /
The type of system pernutted is Conventional Accepted Altemative. I accept the specifications of the
pemiit. ,�( �
Owne�/�egai �t�pres8a�tative: liV Date: 7- �2 4- 0-G
� ��—� PCHD rev. 11/10/O5.-
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