A33 45.
�he District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERM�T No.
�te Ll — / (. - �,
Owner: ,• Y t � I.� P Y' •� 7 t r�
Location: �„T�j ,
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Contractor: ��"`�
Waler Supply: Private —t�— Public
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Se age Disposal Faciliiies: No. bedrooms ,-� Dishwasher, Disposal,
w� ri� machin other sufomatic appliances /
iz��f tank: �_ t't f�' Nitrification line: J...�,C,��� �
Other disposal facility:
Water supply and sewage disposal facilities location,
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an� 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 POR�'ION OF THE I�i3 AL TION IS COV-
EftED AND PUT INTO USE. ,/ r
— / � / �� �
Date approved: ,Signed � �
: Sanitarian
Well:
Sewage Disposal:
By:,
Counter-
9igned
(Owner or his representative)
Ceriificate of Completion
Date Approved: � �`� BY� ` �' ` —
nitaria
(OVER)
Location of well and sewage.disposal facilities sketched on back.
Aq�o`uri t pa•id � ��� �
, Receipt l� ' I IQ 4s'.r
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Improvements Permit. (Fstablished/Recorded Lot)
ts Permit (Unrecorded Lot)
mprovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
�-o� � —� �
Date
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
Permit for New Well
_ Replace Exis[ing Well
1. Permit requested by: . 7. Dimension/s/ or Proposed Structure: I
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-�• 8. What type (if any, additions, expansions, or
C �� replacement is anticipated to the structure or facility
_ that this sewage dispos�l systemA is int�ended to se�rve?
ome Phone #:,�„� � � '� `I'7'`�/�
usiness Phone #:
ame and address of current owner: _
�q
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� P /af-3Il �-�.� i�n 71%%
roperty Description: Lot size: •
Tax Map#: /-t h h �-
Parcel#:� �
Township: � _
Direction to pro percy: State Road #
ames,�tc��G2.. Ir1��hP�s m���
Number of occupants or geople to be served:
9. Water su,pply ty pe:
private ��public ❑ community ❑ spring ❑
Are any wells on adjoining property?1'es ❑ No �.
If so, identify location:
10. Type of structure/facility: Proposed: C7Existing: L�"
Type of dwelling: ,�,�/
House: ❑ Mobile Home: L14 Business: ❑
Type of business:
Number of Employees:_.
Number of bedrooms: .�.--,�/
Garbage Disposal? Yes ❑ No �1d
Basement? Yes ❑ No�f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'sOn COunty Health Departmellt for a site es alualic tion ahe �e ite
sewage disposal system for the above described propercy. I agree that the contents of th pp
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 presen[ a survey plat of the 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 after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
SiQnc� Owner or Authorized Agenl
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. p�operty o1`
GARY l�I��I YNE Z/lI
� DARLEIVE MAT/S L
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� Cunnmghom Twp., Person �
�"�� Sept�nber /980, Phi//ip % Ho%
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,
Yerson County Health Department
Existing Sewage System Report For: � Mobile Home Replacement
Addition
Requestee: l.. �� ���ome Phone# 5��33
Business#
'Pax Map# �133 `��
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Location/Uirections: ���
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Original Permit Located
Septic System Uesigned r'or:
ttesidential __ 1/ Business `
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Other (specify)
# I3edrooms �_ # Employees Other _
Uate lnstalled � u'. �� Water supply
'Pype ot System �1�"i�, ilTl�llO-1
Nitrification Line ��01 X �.�
Tank 5ize `��� �C�
Certified Operator Required , � �
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On site wasL•ewater disposal system showes no visually apparent
m a 1 f u n c t i o n o n �I a�� 9� '— (��%��lLu� ���,���� ������ +
Yermission is granted to: �� ���Q171 Ill.d�� r��'
�, � � •
Accordinq to the attached site plan.
Comments:
['• : .. i �
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Environmental Health $'�G.. L��.� ��� "�1��'��
DATE