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The District Health Deportment
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT �To.
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Owner: �' �; = •
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Location:�-`-, � --�-• '�� ' ,j
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Contractor: �
Wa2er Supplyr Privat � f'� ' Public
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Sewage Disposal Faciliiies: No. bedrooms Dishwashe Disposal,
tu`asfiing m chine, bther auto atic appliances "
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Size of tank: - Nitrification line: -...
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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 INSPECTEI} AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTIi DEPARTMENT
STAFF BEFORE ANY PORTION OF THE. INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:_ �7L�.L—L�
Well: _�L-
Sewage Disposal: ✓�
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Signed�_L-�vs^._-�y,�c.li � •� 1_,%tt,: ;; �yt,
� Sanitarian �
Counter-
signed
, (Owner or his representative)
Certificale of Completion 1
Date Approved: ��'�%�BY: /
San' 'an
` (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 location of water supplies on adjacent lots.
Appiication Date: � ���o �� Tax Map:#: f'��'i(�
Amount: Paid: - •�b .. � " -'( �
Receipt#: � 3 � � Parcel'#:
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� APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS_INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID.
1) Permit requested b:(OwnedagenUprospective owner): eA% E�4i.��
Home Phone: - Address:
Business Phone: � 3
2j Name and address of current owner: � � S ��1 ���'`�
A� /r.'�! G�
3) Properly Description: Lot size: � � ��fownship: Subdivision: Lot#:
Directions to the pro erty Including road names d numbers): d
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4) Proposed Use and Structure Description: answer each of the following questions: � �
a) Proposed _, Existing _, Type of Structure: Sv �/ �ad iYl Width: � Depth: �z
b) Number of Bedrooms: ,�C_ Number of occupants or people to be served: �_
c) Basement Yes _, No � Will there be piumbing in the basement?
d) Garbage Disposal: Yes _, No 1(,
5) Water Supply Type: Private%� (new _ or existing �, Public_, Community � Spring _
Are any welis on adjoining property? Yes _ No _ If yes, please indicate approximate location on the site plan.
6) Does the property contain previousfy identified jurisdiational wetlands? Yes _ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WfTH THIS APPLICAT70N.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF.
I hereby make application to the Person 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.
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Owner or Legal Representative � Date
PCHD, rev.10/17/01
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L'erson C:ounty Heaith Oepartment
�:xistinq Sewage System Report For: Hobile Home Replacement
V Addition�{�(�p�m
Requestee: �e�nN�. << X�J���S Home Phone#J~-,��
��j�j ���� Business�
_�LQ �� ( v� v` ��� ' Tax Map� U�, �
Location/Qirections: t� l ►�l5 ��
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oriqinal Permit Lccated �
Septic System Desiqned �or: � _ .
Kesidentiai � Business Othe.r (specifyi
� Sedrooms � # Employees Other
Uate rnstall.ed ���J %% Water supply ����
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Certified Operator Required
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On site wastewater disposal system sliowes nc visually apparen�
malfunction on ����J� ` -
Yermission is qranted to: _S• �•I�l�'
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According to the attached site� plan.
Com�ents:
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