A32 35The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PER IT o.
� —
Owner:
Location: � '
Contractor:
Water Supply: Private Public
Sewage Disposal Facilities: No.
, Disposal,
washing machine, other `utqm�tic appliances
Size of tank: �/ � Nitrification line: �_
Other disposal facility:
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 INSPE-ETED AND AP-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLA�ION IS COV-
ERED AND PUT INTO USE.
Date approved:
Weil:
Sewage Disposal:
By:
< �
Signed �
Sanitari
Counter-
signed
(Owner or his representative)
Certificate of Compleiion
Date Approved: j_ �:� g� By: ��
� itarian
(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
� at later date. Note location of water supplies on adjacent lots.
(1) (2)
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Yerson County Health Department
Existing Sewage System Report For: Mobile Home Keplacement
J�Addition
Requestee: r � Y1 l-���1 / f�v��u,c�t5av �'�ui� Home Phone#
� 90 3 l��sxr �� Business#
�u rG��c; %�%i/�S' `Pax Map# %� 3 a 3 s
Location/Directions: .�2 ///� �
Original Permit Located
Septic System Uesigned For:
kesidential
# E3edrooms
Business
# E�nployees
Other ( specity ) C`.�u��
Other
Uate rnstalled /- f S-$/ Water supply ,J�
`Pype of System C.�x,������J�
Nitrification Line /�D ` X 3 �
'Pank Size r%.SC� Z��
Certified Operator Required � �
On site wast-ewater disposal system showes no visually apparent
malfunction on �- I - � �
Yermission is granted to: �Crl� ��u-� �K�' — Nd —
p,�,u�-,�.Q�� -- �o �� �' � l� a�Q°.� - -
According o the att hed site plan.
Comments:
Environmenta:l Health SapG:
dl"- '
,���
DAT
do
Asr�aunt paid . ot � • �'a6'9'% .
Rec+ ipt Il � �0 6 Date
• �
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�23831
1. Permit requested by: . . 7. Dimensions or Proposed Structure: w 1.' n I
-.� Width: �� x �2C� (=�Ilaw•�.�,,r.1
owner/prospective owner/agent: �0.� � ���
e.���P��• .'P ��� 1�-� l.� 1� r��� : a-� V� � Dep[h: _
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w
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[�l ��-d � � � �
ome Phone #:_
usiness Phone #:
�a +' �" � 8. What type (if any, additions, expansions, or a�
�' �`� replacement is anticipated to the s[ructure or factlity �
T� C���4 � that this sewage disposal system is intended to serve?8'
Name and address of current owner: 9. Water supply t}pe:
� S0.M � � private ,�. public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ No (�
If so, identify location:
Property Description: Lot size: %Z '� �
Tax Map#: �- 3�
Parcel#: 3�
Township: (3 u��.�.� . �Or��
. Directions to property: State Road #& Road
ames,�tc.
. ��- ����
10. Type of structurelfacility: Proposed: (�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business: ►��a
Number of Employees:
Number of bedrooms: � __— °
3 S e��-� �
Garbage Disposal? Yes ❑ No 0 Cr
Basement? Yes❑ NoL If so, # of base nt fixtures:
i6 Number of occupants or people to be served: � _ '
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 invaIid. I understand that before an Improvements Permit can bc:
issued, I must present a survey plat of the property to the Health Dept. I understand tha[ in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�hin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become voic� and all fees paid forfeited. � Q��-1
�
SiQnc� Owne� or Authorized Agent
r
, permit Issued ❑ Signature Date ' ,
� Permit_ Denied �� ,
Plat Observed ❑ �.,
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SSUITAIILE p5-tROYtS10NALLYSUCfAIII,E tl-tRtSUC[ADLE
RECOMMENDATIONS/COMMENTS: - �.
STI'E CLASSIFICATION DIAGRAM (Include:•Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns� CtC.) C:V�MfPRd1DOCSAPPSfC.SA1 FINANCE.PC
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