A35 31The Disfricf I�ealth Deparfinent
Orange, Person, CaswelL Chatham, Lee Counties
SEPTIC TANK PERMIT
Date �` ! �' — ��
Name of owner: � h7 � �'� J Q' �a �`a h
Name of contractor: ��'
Address and Directions
� i �s ,. . /
Person or firm doing installation: ,
Address
No. of persons to be serve� Bedrooms 1,�3; 4.
Additional appliances to be used: Disposal, dishwasher, washing
�------.
machine
r '`�' ��.,�.' /
Recommended• Septic tank—��s�' � c�-/ I
�
/ /
Nitrification line: f �� � � �� ,x �� (�
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus! be inspected and
approved by a member of the District Health Department stafE before
any portion of the installation is covered.
Date Approved: 8� � �--' �0�
By:
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Iiealth Officer
Countersigned
(Over)
G�
'� D�
NOTE: ' Make sketch: of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
'' date.
. ; ...
SUGGESTED INSTALLATION (Date ) � FINAL �NSTALLATION (Date )
, (Road or Street)- (Road or Street) ,•
- tl ./_. ,� ��•y"f . �
.�
A iication Date: o'�-6 d
A.mount Paid: _��
Receipt #: , I 7 4�'�
Person Countv Health Deaartment
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #: 1`�'3 �
Parcel #• 3 I
IF THE INFORMATiON IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Permit requesbed by: (Owner/agenUprospective owner): 1�►��i•�Ax� f3. SMJTN
Home Phone�3�'o),S�i-(�3� 5� Address: a'�O IY��GH��s �'>11L� ,�t�
Business Phone:f33rQ)s�-�9.��- )Zo x3a�a i�fc a7S 73
2) Name and address of current owner. _ -� . A m►Q N i� f� Sm � T�-1
��170 J VYIcGt�f'ss �►r i R �>
,�,Y�o�o,��.tc a �s�3
3) Propertyr Descriptiom �ot size: q/� Township: '_�G1�bSDf�tt
Directions to the property (Induding road names and numbers): F�o►�
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed 0, Existing e�
b) Stick Built L�Moduiar �, Single wde ❑, Double Wide ❑
c) Number of Bedrooms: � d) Number of occupants or people to be served: �
e) Basement: Yes [�; fVo D lf yes, # of basement fixtures:
� Garbage Disposal: Yes �, No �
g) Dimensions of Proposed Strudure: Width: � a Depth: /D � _
5) Water Supply Type: Private �new 0 or existing 0 j Public �, Community 0, Spring ❑
Are any wells on adjoining property? Yes Pf No ❑ If yes, location,�/ � Doo�Z ����`��
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
_Conventional _Modified Conventional _ Altemative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURYEY PLAT OR SITE PLAN TO THIS APPLlCAT10N
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 faciiities to be
placed on the property. I understand if the site is aftered or the irrtended use changes, the permit shail become invalid. I understand
that as applicant, I am responsible for identifying and maricing property lines, comers and making the site accessible for the
personnel of the Person Couniy Health Department to condud their evaluations. I understand that I am responsible for notifying the
Health Department if property ains any wetlands as designated by the Army Corps of Engineers.
�2,� �/-��
Owner or al Representative Date
PCHD, ►��. �a�tiss
�
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. CONTROL
� CORNER
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� � � � � MONUMENT � , /� � - 6. � . � 5 4 � �
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E'erson County Health Oepartment
E;xistinq Sewaqe System Report For: Hobile Home Keplacement
�Addition
Requestee: ������ �J• S��T�
Z�OI�ICG�.��1�,(,t -
� s�[� or� ► l�,�C �,��7�
. _ . ,�
Home Phone#� � ��'�,�Q�
Businessx ' Z �
Tax Hap� r���
-.- - �
• • - • �IIII������LI���/1�I�V�I/1IIR�l-�IIA��I�rr��
1�/ . . � �, � ,
Original Permit Located '
Septic System Uesigned �'or: _
Etesidential � Business Other (specify?
� Bedrooms �_ # Employees Other
Uate rnstalled �Q� Water supply
Type ot 5ystem
Nitrification L
Tank 5ize
� �Certified Operator Required ,_f�� �
. On site wastewater disposal system showes no visual.Zy apparent
malfunction on ���`i l/�
Permission is granted to: ,��(� VA�TVI��QV �' `
Accordinq to the at�ached site plan.
Comments:
Env.ironmental Health g�`G.•
5�� �(�G(�U � Vl
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�i�GC s�,.��
OATE