A35 74�-.The District Health Department
Ozange, Person, Caswell, Chatham, Lee Counlies _:
! �
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Dat
Owner: ` ��J
Location: `,�,.�— , _
p, Contractor: �
�n • �
� Water Supply: Private Public
Sew Facilities: No. bedrooms � Dishwasher, .Disposal,
washing machine, other auto tic appliances .
Size.of tank: d�Titrification line:
. , � �/?� ��
' 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 3ine MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT. HEALTH DEPAR,TMENT..
STAFF BEFORE ANY PORTION OF THE I LLATI N IS COV- �
ERED ANB PUT INTO USE. . � •.� �,
Date approved: Si ne
Sanitarian
Well:
Sewage DisposaL• I Counter-
BY. signed
(Owner or his representative)
CertificaYe of Com letion
Date Approved: � BY.
anitarian
(OVEft)
Location of well and sewage disposal facilities sketched on back. ;
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. No�,e special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location o water supplies on adjacent lots.
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or a•-
Relocation Activity shalt be issued until Authorization for waste water system construction
has been issued.
.
Tax Map # i� � �
Owner/Contractor
Location/Address
iY ✓„�✓ �T
Subdiv�sion Name
Lot
Parcel #
Township a c„
�s Date (o — -2� —q(o
� 13 � 7 fi�J�/'c� / 33 � o� �e �=f- c�—"
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SEWAGE SYSTEM SPECIFICATIONS
Size of Tank
SFD Mobile Home Size of Pump Tank � /
Business � # of Bedrooms Nitrification Line� i�� �-,'
/_1 �I �'�,�,,,,, aF l���i.��v,� ��„��.�4e �n Max Depth Trenches
Permits may be voided if site is altered or
Well and Septic Layout by �
Comments: __
Date
Installed by.
- %'lI D /� �VYN ��'�
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Approved by.
Comments: _ _ _
- ,
Date
Installed by
Approved by,
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain pota6le.
c:lamipro\permit.sam O1/95 rev.l.l
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�� Pniuip J. Hall, certify that under my directio
and supervisivn this Map was drawn from an a
field survey erformed by me, and that tt�e error
clostxe is � . Wi;ness my a
this�_day of � ig� _
Sv�(ofn to and subscribed betore me this � T�y
of_J�Ly 1976
Notary Pu lic
My CommissJon expires -� o��g l��
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APPLICATION FOR SERVICES
__ _
_ Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
_ Impxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System `'
� Improvements Permit (Mobile Home Replace) _. Permit for New Well
_. Bacteria
ts Permit (Addition)
_ Chemical
_ Replace Existing Well
_ Petroleum I _ Pesticide � _ Lead
1. Permit requested by: . - 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: �1�-1'�� � Width: (7 iC 3�
Address: 4b`1 aG�� C�Q�IC ���'�C.% cl.. Depth: ,�_
ome Phone #: `i ^
usiness Phone #: Sq
, Name and address of_current owner:
_ ♦ � . � y
Description: Lot size: �� 1 C.C.re.S
. Tax Map#: Y-t - J.�
Parcel#: �.0'4' - `1 �
Township:�n, �: C�.SC�- ti 1.c
. Directions to property: State Road #& Road
iames,gtc.S�� F� •
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Number of occupants or
Zl
to be served: �
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water su ply type:
private public ❑ community ❑ spring 0.
Are any wells on adjoining property?Yes �No �.
If so, identify location: ��
10. Type of structure/facility: Proposed: flExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _
Garbage Disposal? Yes ❑ No C7
Basement? Yes ❑ Noi� If 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 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 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.
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Signec� Owner or Authorized Agent
Permit Issued ❑ � � � Signature Date ' ' •
Permit Denied ❑
Plat Observed ❑
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. . . . ... .. . . . . . ..... . . .. .... . ....... . .. . . . .. . .
FACI'ORS-S1iEEVALVATIOti... Ntt'A:t. AFtEX2 > AREA3..; AAFA4
. . ... _ _
1. SLOPE (%) S S S .. . S
PS PS PS PS
U U U U
2. SOiL TIX�URE (12-361N.) S S S S
(SANDY. LOAMY. CLAYEY. NOTE 2:1 CLAn PS PS PS PS
U U U U
3. SOIL S77tUCIURE (12-361N.) S S S S
(CLAYEY SOR.S) PS PS PS PS
U U U U-
S. S01L DEPTH (IN.) S S S S
PS PS PS PS �
U U U U
?. RESTRIC77VEHORiZONS(IN.) S S S S
(IMPERVIOUS STRATA. ROCK) PS PS PS PS
U U U U
6. SOILDRAINAGFIGR011NDWATER S S S S
(EXTERNAL R INTERNAL) PS PS PS PS
U U U U
T. SOIL PERMEABiLITY S S S S
(PERCOLOATION RATE) PS PS PS PS
U U Q U
8. AVAILABLE SPACE S • S S S
PS PS PS PS
U U U U
9. SifE CLASSfFiCAi70N(SEE BELOW)
SOIL SERIES
S-SUITABLE PS-PROVISIONALLYSUITA6LE U-UNSURABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etC.� C:WMIPRO�DOCSAPPSEC.ST1 FWANCE.PC
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: -,� �, - q� IMPROVEMENT PERMIT #: OD�'2
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�'AX MAP #: PARCEL #: �'� _
OWNER/OWNER'S REPRESENTATIVE: �+� Gh a✓� Pa t/ e� _
� LOCATION/ADDRESS:
�� / 3 3 ��—��� � 3� 7,� S'/� /3 3s�
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.ta �'1 f P�� /.; � l'.�r/h r' ,� 7 �,� b T Gr�l'P v� �l (..F� .
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # (� 8z The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
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Person Requesting: