A40 5_.. �; ,� � The District Health Department
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CASWELL - CHATHAM - LEE - PERSON COUNTIES
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Water Supply�and Sewage Disposal
IMPROVEMENTS PERMIT No.�-
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Owner:
t�t�.l�r,�.,�t '���
Location: _ _
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Contractor: '� _ ,--- � ��� � �
Water Supply: Private Public
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Sewage Disposal Facilifies: No. bedrooms Dishwasher, Disposal,
washing machine,�her automatic appliances
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Size oi tank: �" � � `, "� �"� Nitr �tion �line: r �
1��_/�C'.,1 it`� ���11.� �Z�?.:�,�`�. . ,
ther disposal f cility„���C �� � 6�`, ", `�'� `r��"�^'�.
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ater supply and sewage disposal fac lities `location, installati)on and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 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-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE II�STALLATION IS COV-
ERED AND PUT INTO USE. �
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Date approved: Signe� �
'�' Sanitazian
Well:
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Sewage Disposal: Counter- �'-"
�igned � � �����
BY� ( er or re esentative)
Ce:t'�ficate of Completion '� �
Date Approved: _ � BY: 1��� r�•
Sani arian
(OVER)
Location of well and sewage disposal facilities sketched on back.
�NOTE: M� sketch of installation showing lot size a��ape, location of house, septic tanks, pr— water
'.upplies, �lote special problems existing on lot. Wr.ite in measurements in order that installations may be located
�at later date. Note location of water supplies on adjacent lots.
�(1) �� �'1`� �--- (2)
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The Districf Health Deperrfinent
Orange, Person, Caswell, Chatham, Lee Counties
SEP1'IC TANK PERAAIT
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Date..�"6� (C7 � �
Name of owner: Q' ���t ��`% � f�i�J���
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Name of contractor: �L� j
Address and Directions _11T� "� ��� ' Q ��� ° , ��r�l
�— �"► �-�-�J-1�-r�� 1 � �� I� y� (�71"i : �i ?'�'"}"9r�
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Person or firm doing installation:
Address
No. of persons to be served Bedrooms 1, 2, 3�4.
Additional appliances to be used: Disposal, dishwasher, washing
machine �l1 a��
Recommended: Septic tlnk—"7! ��1��
Nitrification line: � ' � � � �
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecfed and
approved by a member of the District Fiealth Department siaff before
any portion of the installation is covered.
Date Approved: ,� ��?-
By:.
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
'NOT�: Make ske f t llation showing location of house, septic tanks, privies, water supplies on
: adjacent � r�, t. Write in measurements in order that installations may be located at later
� date. + �
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SUGGESTED INSTAL I� (� t ) FINAL INSTALLATION (Date ' )
(I�o d r S�r et) � J (Koad or Street) .
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Amount paid ��G G6
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Receipt U _ a��
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Pers�n Courtiy Health DEp:
325 S. t�organ Streef
Roxboro, N.C. c75?�
Cqurier �J2-�3-'i5
.P-S-99
Date
Improvements Permit.(F.stabIished/Recorded I.ot) �._ Reinspection of Existing System (Loan Closing)
Improvemen[s Permit (Unrecorded Lot)
Improvements Permit (Mobile Home R�
Improvemen[s Permit (Addition)
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Bacteria _ Chemical
1. Permit requested by: .
owner/prospective owner/agent: ���e�
Add ss: .S'7 93 u c�� !s cQ-
o N. �- a 7s 73
Home Phone r: -� 3 G–��`-f—� � 4�0
Business Phone ;:: � -
Repair/Replace existing Septic System
) _ Pecmit for New Well
Replace Existing Well
_ Petroleum � _ Pesticide � _ Lead
7. Dimensions or Proposed Structure:
Width: '�� ' �� "
Depth: a o' G "
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposai system is intended to serve?
2. Name and address of current owner: 9. Water supply type:
�S�m� ' private � : public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes C�' No �..�.
If so, identify location:
. Property Descri
Tax Ma�:
Parcelr: _
Townshiv:_
: Lot size: � _
S
� 5. Directions to property: State Road r& Road
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6. Number of occupants or people to be servea:
10. Type of structure/raciliry: Proposed: DExisting: Q
Type of dwell}ng:
House: C�Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: .�.�_
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ NoQ If so, � of basement fixtures:
CLEARLY STAKE ALL CORI�IERS O�' THE PROPERTY Ai�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOn Coun�y Health Department for z site evaluation for the on-site
se�vage disposal System for the above described property. I agree that the contents of this application are true
and represent the ma�cimum 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
deIivered a survey plat of the propeRy to the Health Dept. within 60 DAYS aftec the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signcc� Owner or Authorized Agent
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A 1511
PERSON COUNTY HEAL�TH D�PA.RTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # Parcel #
Zonin� '�ownship �Q �`vC/'
Owner/Contractor
Location/Address
Subdivision Name
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Lot# �
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /. � C' Size of Tank �U�
SFD ✓ Mobile Home Size of Pump Tank _
Business__�_A # of Bedrooms__,�_ Nitrification Line �'X�J i�v
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zorung regulations.
Permits may be voided if site is alter d or intended use changed.
Well and Septic Layout by �. �r�---
Comments:
Date Installed by Approved by
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public __ Replacement Air Vent
Site Approved Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
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 Uus permit The
environmental health specialist is not responsible for false or misleading infocmation 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 Peison County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemut.sam O1/95 rev.1.0
ORIGINAL
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L'erson CounLy Health Oepartment
�xisting Sewaqe System Report For: Mobile Home Replacement
✓ Addi�ion ^/e� dvw.�.s��,�l
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Requestee: �.e/�Jc�c ��vCs'�e� Ho�e PhoneK .3G�1-2/�iG
5793 i�iu�c��c ����5 ��. Business�
�ox�o�� fJC - . 2�573 Tax Hapn
Location/Ui=ections: /s�-S
Original Per�it Located �es '
Septic Syste� Uesiqned �or: _ ,
ttesidential '� Business Othe� (speciiy)
� 8edrooms 3 # Employees Qther
l�e�,��� 1/a/ve -,.�:� /,:�c.
Uate rnstalled S-/9G y,3-/9�� Water supply
Type ot Syste�a �o•�ue��•�..,a� -�b�su�•4icc
Hitrification Line ----
Tank Size 7� C���lo:� —
Certified Operator Required ��
On site FrasL-ewater disposal. system stiowes no visuaily apparent
malfunction on �' $- 9�
Yermission is granted to: /7�� New ���'�T'`°`'' td �C�r o`�
Px;s��9 �o �sc.
Accordinq to the attached site plan.
Comments: /�eear�r�e�� �ur�� .S�At/� to.�.� euC��/ S t/�rt�,S
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Environmental Health �' �a^"•9 � 8�S �
�� �- DATE
. .. _. . _.. _. . ._ - -�- . - - .-------: -.. . . - .. . . -.• : _. ; - - ...."�--
Application Date: .�1��1�_
Amount Paid: ��G
Receipt #:
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❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 �pd)
Home Replacement or Buitding Addition
.�@:66rtiP�tfe visit required)
0 Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
��� ) (' ������ Tax Map: ��1C�
.r. ,,. � • - f Parcel#: � _
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II�:�cao a.a•a��anaxa�and.s.Il �L�I�e,.�..II�Ilr.
ication for Services
Services Re uested
� Construction Authorization
(Fee is de endent on the e of
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: (�,,� a���ro.�-�e r Phone (home): ,3?� o�.`�1 n� '"c� I�4 �
Address: '� \ \s�CJ (work/cell):
`�c�cbz"�YD � ►�' n7�7�i
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phane:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Resid�ntial
Type of business: 1`�.'�k- ��c I�-/ � Total Square footage of Building:
Maximum number of employees: Maximum number of seats: _
5) Water Supply: ❑ New well � Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccu�te, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature`(Owner/ Legal Representative*)
�` Supporting documentation required.
�3�t,i�1�
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:�_ Parcel#: � Address:
Approval Requested for: Mobile Home Replacement
_ c� �uilding Addition
Applicant Name: �Y�9an�9��c��.r -
Address: 6'�3 i-I��re11e N�►115 -
��xlo�� t�C �'�5'7�-
Phone #'s: �� ��',�� � o� l4 c�
Permit Located: ✓ Yes No
Installation Date: �- �3-�,_ Design flow: l aa (gpd)
Current Contract with Certified Operator on fle (if required): �_
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: ! / 2— date)
(Applicant's signature if site visit is not required) .
Addition/Replacement Approved
`�ru�E �:�. ��-iS
Environmental Health Specialist
.����1»
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net