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The istri'ct Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Sup��� arcd Sewage Disposal
IMPROVEMENTS PERMIT o.
Date -
Owner:
Location:
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Contractor:
Water Supplp: Private Public
Sewage Disposal Faeilities: No. bedrodms Dishwasher, Disposal,
washing machine, o r sutomatic appliances � �
Size of tank: _,Z� Nitriflcation line: _ .3
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 and 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 TH EPARTMENT
STAFF BEFORE ANY PORTION OF THE ION IS COV-
ERED ANB PUT INTO USE.
Date approved: Sig e
ian
Well: '
Sewage Disposal:
By:
Certi�cale of Compleiion
Date Approved: � } � v'3
J Counter-
aigneci
(Owner or his representative)
Y�
nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make et
supplies, etc. Not
at later date. Note
(1) �i��li
.
of installation showing lot size and shape, location of house, septic tanks, privies, water
:ial problems existing on lot. Wrste in measurements in order that installations may be located
�n of water supplies on adjacent lots.
(2)
5�.� I3..� �
�3s
Application Date: ?�-�3-0� � Tax iVlap:
Amount Paid: Parcel #: �_
Receipt#:
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r��plic�tion for Se�ic�s (Septic Systems and Wells)
Sep-e�icEs Re uested
❑ Ymprovement Permit (Site Evaluation) ❑ Construction Authorization
�200.00/$300.00 (if> 600 d) (Fee is de endent on the tyDe of system ermitted)
i obile I-iome I2eplacement or Building Addition �J Permit Revision
$150.00 (if site visit re uired) $75.00
C bVeil �ermit (�tetiv/Replacement/�epair) f7 Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charee
1) Services Requested b: c��,�e
Name: �� r�� ���, Phone # ome): 3��O S��t -���'�'
Address: < < , (wor ce 1•�3 Cd 3' S�3 � 00,3
j -��-�--� ����3 fJ v i�� i� ,b u ��, �� c� a w�
�� �2)N�me and address of curr nt ownea- (iff iffer�nt tH�an applicant): ,q '
Name: � a.v� f 0 k�2e� -�`ov� �a`�� U� i5 � a`f" G"�a, c� �,�
r �
Address: � Al��(� �� C/ f �
�� ct'�(� � T' ! U-, 4 I � Q��av ^'' S
addPJ.
3) �roperty �escription: Lot Size: Subdivision:
Address and/or directions to Property:
4) I'roposed Use and Type of Structure:
Residential Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No �
5) Water Supply: /
Private Well l� (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
T ot #:
(please show location on site plan}
1°Tote: �4 completerl a�nlication mu�� aLso include:
�,4 plat/site plan of tJze propes�ty that show� pa�operiy dimensions and the size and docution o�`s�ll
proposed structures.
r A signeci eapy of taie `.�nt Preparatiofa' form verifying t/iat tlae�roperty is rsacly ,�o �ie evaluute�l
� am submitting this application to request �ervices #'rom the P�rson County �ealth �epartme�at. I unc�erstand tha�
'af the information provided is inco�r�et or if the site is subs�' eq�tly altere� or if the �ntencied use changes, a�l
permits and approvals shall become invalid. f� �j = ,
�ag����� (Owner/Legal Representative):
D��e : �-,
10/03 Person County �,nvironmental Health, �?5 S. bior`an St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�a���m1�m� ��a���a�a��/ I�`������ �i��n� ����������n�5
Tax Map #: 35 Parcel#: 33
A_pproval ReqLested for: �/ ��ome �eplacement
Building Ad�lition
Applicant �iame: � arol,� 6aK ��P u'_
aaa��ss: �� �cY�,�es� M;�I
Phone #'s:
V �
Pemut Located: �es No
Instailation Date: �- 3-B 3 �esign �ow: (�_ (�pd)
Current Contract with Certifie erator on file (if required):
Water Supply: Well Public or Community
Wastewater system shows no visual evidence o€faiiure on: 2-/9-a9 (date)
(Applicant's signature if sit� visit is not required)
Comments:
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Enviro ental Health S�ecialist i7ate
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