A32 72.� ,
' � ' Tlie � District Health Department
' �• Oiange, Person, Caswell, Chalham, Lee Couniies
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'� Water Supply and Sewa�e Disposal ,j
—� -- - . �'�.,^..�-�'`��
x Owner: �
� Locatio��f.'
� Contractor: � �� .�
� Waier Supply: Private � �blic
Sewage Disposal Faciliiies:
washing machi e, other a�
Size of tank: I��
, �.
h-66fi's Dishwasher, Disposai,
: appliances �7
Nitrification line: � � )
� Ot er disposal facility: v —
.�y 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 apPro�ed: - _ ERTIFICATE OF COMPLETION
�.
Well: � -
Sewage Disposal:�7�1 Sig Sanitarian
By;�� b�1 - —
Countersigned
(OVER)
Location of well and sewage disposal facilities sketched on back.
�IOTE: Make sketch of installation showing lot size a�d sha�e, location of hoixse, septic tanks, privies, water
� �upplies, etc. Note special problems existing on lot. Write in mea rements in order that installations may be located
►� at later date. �-�'�aC.l'
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�Amount paid ���•�O
Receipt 1� �
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Pers�r� Courtty Haaith Ccrt
325 S. Morgzn S�rept
Rox�oro, N.C. 2?57�
Co::r'er u�2-�3-15
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Date
Improvements Permit. (Established/Recorded Lot) I_ Reinspection oE Existing System (Loan Closing)
1mpFovements Permit (Unrecorded Lot)
�provements Permit (Mobile Home Replace)
_ Improvements Permit (Addition)
RepaidReplace existing Septic System
Pecmit for New WeIi
_ Replace Existing Well
. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospectiv owner/agent: Width: 1� � %G
Address: � �°��-k _�-_ � Depth:
�° . What type (if any, additions, expansions, or
• ��C G�' N�� K' re lacement is antici ated to the structure or facilit
� P P y
��_� G �� � S � that this sewage disposal system is intended to serve?
; H o m e P h o n e #: 3 4� a a� q
usiness Phone #: M ���rr�e-
2. Name and addre�s of current owner: 9. Water sugply t}•pe:
� SGM private � ublic ❑ community ❑ spring ❑
Are any wells on adjoininS property?Yes ❑ No �.
If so, identify location:
3. Property Description: Lot size: ��--C..-
. Tax Map#: . 3 10. Type of structure/facility: Proposed: Existing: Q
Parcel#: Type of dwelling:
Township: � C� �% House: ❑ Mobile Home: Business: ❑
; 5. Directions to property: State Road #& Ro�d Type of business:
ames,�tc. � Number of Employees:
i �e e o� i�Q, � Number of bedrooms: �__—�/
i Garbage Disposal? Yes ❑ No�
' Basement? Yes ❑ No�o, � of basernent fixtures:
I6. Number of occupants or people to be served:
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CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF AL�....
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn 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 be
issued, I must present a survey p]at 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. within GO DAYS after the date oE the eval�iation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signeci Owner or Authorized Agent
. -- - _
_----. _ _ . ...___�T___.__ _.-- - - _..._..----�--- _ -- - - . . _
.....
. _ . . �- .�..- . . . . _ _
Yerson Coun�y Health Department
Existing Sewage System Report For: v Mobile Home Replacement
Addition
R e q u e s t e e: �Qry1 �' S��•(, /�` a/1'1
�,o. �3oxi53
1—� U. r1C� �� l%%i ll5 /V'l', Z-ZSyc
Location/Directions: '�'i �'i'� � �
Home l�hone# �6'I -�{q>C�
Business#
'rax t�lap# J 2 - % 2
� �OS .�n L 1 � � ,��a-` ( � � l�'1 b n � I� . Ti.� �' ►1 ��.1 a -�-
� � n e� i`� � I � �
Original Permit Located _�_
Septic System Uesigned For: -
Kesidential � Business Other (specify)
# Bedrooms � # Employees Other
Uate :Lnstalled � 7- 7� Water supply �
�
'Pype ot System _
Nitrification Line �`�CC� ��
.e.
Tank 5ize �� UC.
Certified Operator Required /��
On site wasL-ewater disposal system showes no visually apparent
malfunction on C��o�:%(97� , ,
Yermission is granted to:
�
According to the attached site plan.. -
�„ _ _ � � ,
• �'l�ii�i�e!�1\�Gi'�'� � ' ��1������J'�l1f[�l/'
' �1 _�u � % � /� � ,
Environmental Health S . 1 � �>- �/2�/9�
�� / DATE
. .. _ .
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Yerson County Health Department
Existing Sewage System Report For: i/ Mobile Home Replacement
Addition
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Requestee: �Q,,l�l�� S C�( �I , �I'�
�. c� , (�a�, � 53
N � �l l� �; � Js , �7�y/
1 ` �
Home �'hone# ✓� 7 "7�7 7�
Business#
'Pax Map# �3G ^��
Location/Directions: ���'�""�1/� . �'{i����l����
i J�5 n L� C��1 ��%r 1�.1 /<O�c •��-r.�r�,� � c2�- ��`'he
(`� ,�.�.. �� .
Original Permit Located
5eptic System Uesigned For: -
Kesidential v Business Other (speciry)
# I3edrooms ./ # Employees Other T_
Uate '1'nstalled �'�"�-7,� Water supply . �
'Pype oi System _
Nitrification Line O�"7�ri���� _
Tank Size
' U /}� �
Certified Operator Required � ��
On site wasL-ewater disposal system showes no visually apparent
malfunction on �'���- G �
n . .1,/ _
Yermission is granted to:
�, n .
Ac�rding to the attached site plan.-
Comments:
Environmental Health Su .
llATE
7
Amount paid � l .00 "
Receip� �� � �o �`� � Date
� t � - • -----,...,....� ...-...Yrrnr[� _
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p rnnit requested by: .
ner/prosp��ive owner/agent:
dress: J a�� �"`�I
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U Home Phone #:=
� usiness Phone �:
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Name and address of currenc ow
3c� . P� '
2
. Property Descripcion: Loc size:
7. Dimensions or Proposed SCructure:
Width: �� u Gd-
�Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
Ithat this sewage disposal system is�-intended to serve?
,
�'
9. Water sup ly cype:
S�-r' private public❑ community❑ spring❑
Are any wells on adjoining property?Yes ❑ No (�
If so, identify location:
I �- �
Tax Map#: � 3 2 —
Parce]#: r% �
Township: _= . - � `A S �,� Fa �'k
. Direc[ions.to property: State Road #& Road
lames,�tc
.r. _ 1 ., _ . . 1 12 � .•. �,_._
2
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, Type of stnicturelfacility: Proposed: �Existing: Q j
�
Type of dwelling: �
House: ❑ Mobile Home: ❑ Business: ❑ ��
Type of bus'iness: _ '
Number of Employees:.
Number of bedrooms: __�_____
Garbage Disposal? Yes � N� �ement fixtures: ..
Basement? Yes❑ No1<] Ifso, # of b
ON " � � c, ..
6. I�Iumber of occupants or people co be served: �_ �`
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS 4� ALL
PROPOSED STRUCZ'URFS• �
I hereby make application to the PerS0I1 COUnty Health Department for a site�� aualicatf on ahe �ci-uel�t
sewage disposal system for the above described property. I agree tha[ the concents of t pp
� and represent the maximum facilities to be placed on the property. I underscand if the site is alcered or the
intended use changes, the permit shall become invalid. I understand that before an Improvemencs Permi[ can l-•
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have nc,
delivered a survey plat of lhe property to-the Health Dept. within 60 AAXS after the daece� of the evaluacion of
the site by the Health Dept., this appl'�cation shall become void and all fees paid forfeit
,_
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Signcd Uwner or Au[non�� n��«<
,ernnit Issued ❑ Signature
�errnit Denied C�
�lat Observed❑
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_ Dale �
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���mn��NllATIONS/COMMENTS: y
SITE CLASSIFTCATION DIAGRAM.(Include: Soil areas property lines, roads, streams, gullies, wet areas, �ill
areas, wells, wa[er bodies, slope patterns� C�C.) ' C.N1MfPRUDOCS�APPSEC.Sr1 FWAN�E�
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Application Date: 5- �(� - � Z ���+� (� ���� �� Tax Map: �l 3�
Amount Paid: � Parcel#: � 2
Receipt #: � � � � ����
IG�ma-aa��anmca�and.ai.11. �]C�I�o�.Ildl�,i.
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Additior.
$150.00 (if site visit required)
� Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
� Construction Authorization
(Fee is dependent on the type of
❑ �ermit P.evisicn
� $75.00
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �� C-U Y f �.
Address: IJ �
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Lescrip�ion: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 33 (� - 3(� �1- ZO ZS
(work/celi): 33� - 2c�� - �f 332-
Phone:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands7
� yes 0 no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage7
� yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property7
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
� New Single FamiIy Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfi:ncticr.ing Syst�m `h'ill there �e a basement? ❑ yes ❑ no VJitk: �lurnbing fixhares? ❑ yes 0 r.o
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New we(I ❑ Existing Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is comnlete and correct. I also understand that if the information provided is
inaccurate, or i, j the site zs subsequent[y a[terea, or tne intended use cnanges, ai[ permics and ar�provais snaii oe invuiicl.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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