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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
,� � Date C„—_� �=Sa'-�T-----
Owner: �_� -
L'ocation: ' -
� Q � �1'3 �!�
; j , ..
Contractor:
Water Supplp: Erivate � Public
Sawage Dispocal Facilitie:s No. bedrooms � Dishwasher, Disposal,
washing machine, other sutomatic appliances '
Size of tank: �N)T ���r;�— Nitriflcation line: -�� �.�—
Other disposal facility: `
9✓
Water supply and sewage disposal facilitles location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and sha1T be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and .nitriRcation line MUST BE INSPECTED AND AP-
PROVED Bir A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE �NY PORTION OF THE IN�TALLATION IS COV-
ERED AND PUT NTO USE. /f n „ �
Date approved:
Well: .
Sewage DIsposal:
; .
Rv. ,. -' -- � -L
1 '�
:ouriter-L�, -'��� � ,
aigne
(Owner r his representative)
f�
j,
Certificate of Comple3ion � _
✓
Date Agproved: By: �
Sa tarian
(OVER)
Location of well and sec�age disposal facilities sketched on back.
'r ' A � ication Date• `
� ' Amount Paid: �` 0
' Receipt #: � I 7,�
��
36� �
. �•
Person Countv Health Department
Environmental Heaith Section
APPLICATION FOR SERVICES
Tax Mao #: � 3 -1
Parcel #• $ �
1) Permit requested b (Owner �
Home Phone:
Business Phone:
owner): ' .
Address: ,�,� f. i` � K. a .,t . yl� ,
.i�rra7?on,� �/�. d:l�%�
2) Name and address of current owner. � 1,diYl�P. /J� /�,[5��ti�, �
3) Property Descripticn: �ot stze: /f� �'. Township: l���L
Directions to the property (Indudir�� road names and numbers): +
;��'�.��r�' �����y r�; z1
� �n.Jtrr� /� ,,
4) Proposed Use and Structure Description: answe�ach of the following questions: ��� >��k `�'� l�
a) Proposed� Existing ❑
b) Sticic Built �, Modular � ngle Wde ❑, Double �d� �
c) Number of Bedrooms: `� d) Number of occupants or people to be served: �
e) Basement: Yes I�lo�.'if ye�, _# of basement fixtures:
� Garbage Disposal: Ye§1�1, N�
g) Dimensions of Proposed Structure: Width: �' Depth: iS %
5) Water Supply Type: Private�(new ❑ or existing , Public 0, Community �, Spring ❑
Are any welis on adjoinin�operty? Ye� No O lf yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
Conventional _Modified Conventional _ Aitemative _Innovative
Other (specify): � r�r �i, ; �%i��; �7r� �i ,
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLlCATION
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 a ree that the contents of this application are true and represent the maximum faalities to be
placed on the property. I unders d if the site is aftered or the irrtended use changes, the permit shall become irnalid. I understand
that as applicant, I am r�spon ble for identifying and marking property lines, comers and making the site accessible for the
personnel of the P rso ou Health Department to conduct their evaluations. I understand that I am responsible for notiiying the
Health Dep� nt ' y p erty tains any wetlands as designated by the Army Corps of Enginee .
/
Owner o al Representative ate
PCHD, rev. 10/12/99
A, FERSON COUNTY
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Yerson County Health Oepartment
�:xistinq Sewage S.ystein Report For: � Hobile Hame RepLacement
Addition �p �'
. ✓ ! % �.
Requestee: Home Phone#
'� � Businessx t�
�Q�I/ /�v �, � Vt� � 6 J-�; � T ax H ap w (�ii -{-F- D�
Location/Directions:. � ,(,f�� �� �� �'�� � �_. ���1J/'1��� ���""` �(-� .
-� I � �a� �n ��o vr - � � � ���� y�; �,r,� ��,��j � . �'l L �c�k �v�r� v� �
-�2?�� � l�i� �
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oriqinal Permit Located
Septic System Designed t'or:. _ .
itesidentiai ,�_ Business Other {specifyl
� Eiedrooms �� # Employees Other
llaze Installed '�2� Water supply l�r� �a �
1- n n r
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. �
n�l�u�;!�.��
Certified Ogerator Required /�11�� �
On site waste�rater disposal. system sliowes nc visually apparent
� malfunction on �2���
�, �ermission is granted to:
- _ . . . , .
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Env ronment !
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