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A35 77The District `Health Departmen� � Orange, Person, Caswell, Chatham, Lee Couniies � .. r � Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. � � % � 1 Date � Owner: "� � ' •. Location: � �"��� _ •�l ._��+ - . • �� I�3� - � Contractor: ____��.�,4...+�� Wafer Supply: Private �-,� Public Sewage_Disposa� Faciliiies: No. bedrooms `� Dishwasher, Disposal, t�,washing. ma_chin�,-.,other; auto�iatic appliances - -� i .. , ` Size of tank: { ��L j�-/� ��� Nitrification 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 line MUST BE � SPECTED AND AP- PROVED BY A MEMBEA OF THE DISTRIC�T'H ALT �DE�ARTMENT STAFF BEFORE ANY PORTION OF THFi IN TAL TIDN COV- ERED AND PUT INTO USE. �J � f� jr�� � 1 �i ��� i � ' ! � ''� : r�. ^r�'� ,(, Date approved: — Signe�l 1` �! �, ``' ��,j..=—:� ;, Well: Sewage Disposal: I Counter- BY. signed (Owner or his representative) � Certificate of Co letion '�� ; �i � Date Approved: �� BY: '� i � i mtarian (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. Note special problems existing on lot. Write in measurements in order that installations may be located at later date. Note �ocation of water supplies on adjacent lots. (1J � ���-��3� (Z) _. . __ E_�'�: 1�1 59,�?95 F'L�h,Jf �'�_� �IdL? �C!hJIflu/ ��,� F���E � � ��� � �Mu���• r.. f�� �� ,�2� �zs s:'Mor�an st�ecc e ti`�� �_� --�oov • `,`�."". ��/� �iox�oro, hl.C. �?,5?� � R �= � � ;t �--�1_V.�_ I � ---- _. COUtier .'-��-��� � 3 c e �-}��a'�A�,�:.fi�,T10t���R.�, v� �e��'� q-�i-0� I . 'a . "; ,L "... �r...� ,� �x � i i .. Y�'{����1�,�,�! i ti.�"Q•�"'M.�� �,f� {~� ~ � t ik 9 „tt �",.F; �{ w !�` .�:%: "'"'y�A�;� c�� y ( ��wrri}• .�� .. �� ... .. .__. 1 t.�� :,`.. i;:.rv���it�F,.Y:y.Y.l:i.1'MFS,'�'t�,���rl�[('Y�:�h�l'`'�C�. . . . �Mk�.'s^,�Sc.`.d��e,(L.. • S�+�i.'�� i . � �Improvem�nts Per.nit.(EstablisPted/Ftccordcd Lot) I..._._ �teinspection of Existing System (Loan Closingj Im�ovcments Permit (Unrecordcd �.ot) ��.._ Re�airlReplace existirtg Septic System Irnprovemcnts Permit (Mobile Home Replace) �},�ret;nit for New liWell ���; �� � �...._. ��pl�c� Exis[ing W�it �� � Improverner.+s Pecmit ;Addition) - ___..._. _._._�.._r.�..�— - — — — � • -„��..�... ! �. s-> '�V� ,�e��,�;�+:: i �� -� d�GL� '�IiJAN1.�'�v-�.� ��...�..�M��.. - ,:p>-i .:r�.vcvr..s....n�.�.. :i.'..:` r � ...�_:: �.v�Y..JIj; '.�^�:� �,�� '��`�1.:... •l,. 1�: ��• �,�„ :;k ;..... . � Bac«ri� _. Chemical � �etroleum .�._ Pesticide Lead ~ CL•Ee�,�T Y STAK�+ E1,LX. CC?1? �'t� ;�4:.' THE PP.UPER'�`X Ai�ID Ti�. CO�ti�tER.S C7F+ ALL �:,. .. �S��7 ���'��G';'CJ}''.��. I hereby make �ppEication ta thc 1'erSOn C�uT�ty �I�.�Ith 3����rtMe�►t tor a site evaluation for the on-sit� sewage disposal system for the �bovc d�s^ribed prt�percy. I agrec �hat the conttnts of this applicatioti ar4 c;uc ::nd �epcesent thG maximum facilities to be pl.,c�d on the property. I ur�dcr�t�nd ir tn. site is rzlterGct �,r cnL intended usc changes, the permit sh�li �ecoma inva'iu. I understand that `�_�fore ar� Im�ravemen�s P����i� ��tt �� issued, � must present a survey plat of the prap�rcy to the kicalth ��ept. I undecatand thac in ct�e ever�� I havU ,,:,: dciivcred a s��rv�y plac af th� property to tho k�calth 17ept. within o0 DAi'S after the da�t� af t�e �valuctiari o; th� siEe by thc� H�..aleh Dept., this apalicatian shall b�come void and ali fees pai:� forfcited. 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