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The Dis�r�ct Heaith Depa.rtment �
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•' Orange, Pe"sSon;'�.Caswell; Chalham, Lee Counties
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� Water Supply and Sewage Disposal
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� Owner: �
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Contractor: ^' ' ' �' r '
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� Waier Supply: Private �j E.� Public
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� Y �"*n'�� • Dishwasher Dis osal
Sewage Disposal Facilities: `i�Fe� bed�^ ..�— � P �
washing machin hei automa ic appliances � .
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, Size of tank: `' J'"-'' Nitriflcation line:
bther dispos8l facility: .
; Water supply and sewage disposal facilities location, installation and
protection must meet state and local 'regulations.. : �
j Above recommenc�ations based on .inforination received and observed
; soil condition. Septic tank : and nitriflcation 1me MUST BE INSPEGTED
AND APPROVED BY A MEMBER OF THE DISTftICT HEALTH DE-
� PARTMENT STAFF before any portion of the installation . is covered
. ; and put into use:
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' � Date approved:
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�.-Sanitariari ` V " ." �"�.�
iha Distrlct Health Department
Countersigned
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(OVER) � - .
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�. Location of well and sew�ge dispos�l facilities: sketch�d on back.
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te Evaluation Application
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Date:
APPLICATIOId FOR IMPROVEMENTS PIItHIT
3 1. Permit requested by: owner/�ruspective owner:
k-.: " agent :
Address: �
Home Phone ��:
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2. Name and address of current owner:
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Business Phone �ir:
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3. Property Description: Lot size: �� .> /r�- -
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4. Tax map ��: �}�_ Township: -I- L/� ( ��U��
Subdivision Name: Lot ��:
�L L /3G.' i�
5. Directions to property: State Road �� & Road Names, etc. �
l.S -� fi o �-f ��2 .1.� /� ��2 i//s �� 6 0�-� T/� S i v� ���C S
C'I Pt ��'J !!N s �,��� � e ���� / v���'_L2--G� c�i/� r � � � __ �
a.� � ,� �> �P � �-,� �'� s �" r�� „ .( � ,� , v� _ c� < . �
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6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system: !/
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width: y Lj Depth: ���
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
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10. Water supply private? public?
Other source? (Specify):
Are there any wells on adjoining property?
11,
12.
community? spring?
If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes ro
Basement? Yes No If so, number of basement fi?ctures:
Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the.Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
. � � � .
� Sign d wner or Aut ize Agent
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Permit Issued
Permii Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (X)
2 . SGli. TEXTURE (12-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTIJiLE (12-36 i.n.
(Clayey soils)
4 • SOIL DEPT73 (in. )
5. RESTRICTIVE HORIZONS (in.)
(Im{�ervious Strata� rock)
6. SOIL DRAIIZAGE/GROUNDWATER
A
(bcternal & Internal)
7. SOIL PERMEASILITY
(Percolation Rate)
$. OTHER (specify)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R FCO2�4fEI�IDATIONS /CO2�III�ITS :
S:�_TE CLASSIFICATION �LAGRAH (Include: Soil areas, property lines, roads, streams, gull.ies.
Wet areas, fill �reas. crells, �aater bodies, sZope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION INIPROVEMENT PERNIIT
Tax Map # 1� �f-D Parcel #� 3
Zoning Township ��� � _' �
A 0�24
Owner/Contractor ` Gv � DateS =/9 9'.S'—
Location/Address / S ' -�'� %�
P�-Yf..��. ` � �1 1�-��',��, r�-�lt �l S.R.#�J�� � �.5�-���'ti
Subdivision Name /u/� � Lot#
Layout
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SEVVAGE SYSTEM SPECIFICATIONS
Repair Lot Area /� 3�� Size of Tank 18� ��j ` ' )
SFD 1i Mobile Home Size of Pump Tank �/�
Business # of Bedrooms�_ Nitrification Line a'�o ' K3 �
Max Depth Trenches � `
Permit Void after 60 months.
Permits may be voided if site
Well and Septic Layout by�
Comments:
Permit Void if not in compliance with zoning regulations.
s altered or i tended use changed.
Et��� GrJ� ����..-�.
Date S=19'— �i'.S^ Installed by Approved by G�/.��E'�.�9 �—y,-.
�
ividual S
Site Approv d
Well Hea Approved
Groutin Approved_
Installed by
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PECIFIC TIONS
Required lab
Air Ven
Requir d Well Lo�
Well ag
This report is based in part on information provided the homeowner or his/her representative in ihe application submitted for ihis 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 repoR that may have resulted &om false or misleading
statements provided to him in the applicatioa Neither Person County nor the environmental health specialist wazrants that the septic tank system will
continue to fundion satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemut.sam Ol/95 rev.1.0
ORIGINAL