A40 80The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
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Water Supply and Sewage Disposal
IMPROVEMENTS PEFiNIIT •�To� -
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Locatio • �-�`�"'
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Contractor: ��' �
Water Supplp: Private �` � : Public
Sew`ag¢�ispvssl-Fac�lities: No. bedrooms �� Dishwasher, Disposal,
,�
ashirlg �a�hine,�ther automatic appliances _ .
of tank: j� r��� `} • Nitrification line: � r-� == �' �.
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 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-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:���.
Well:� l
Sewage Disposal: �
By:.
.
Signed �;''"ys,t,.-.,�...�,,,,.lrr i� -
�anitarian �� �f
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.
Counter-
signed
(Owner or his representative)
Cerlificate of Comple2ion
Date Approved: By:
a itarian
(OVE
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketeh of installation showing lot' size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing ori lot; Write in measurements in order that installations may be located
at later date.�Note location of water supplies on adjacent lots.
(1) �- � � (2)
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Builciing Additioas/ lO�Iobile �ome l�eplacements
Tax Map #: A'-l.�
Approval Requested for:
Parcel#: �O
Mobile Home Replacement
�_ Building Addition �
Applicant Name: cZ a`` c� , �.
Address: " t3� `�► �ne�cz�n"��- c1
�t�(JX���Y�: rJC c�-1�`7� �
� Phone #'s: 3�-�'-t - �43
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� Pernut Located: ✓ Yes No
Installation Date: 3 3O -��i Design flow: 3�N (gpd)
Cuirent Contract with Certified Operator on file (if required): N A
Water Supply: ✓ Well � Public or Community
Wastewatex system shows no visual evidence of failure on: (date)
(Applicant's signature if site visit is not required) � . � a,,,� �GL � c�i �� �' � �- � �
Additioa�eplacem�nt Approved
�� �-111� � s. ��
Environmental Health Specialist
11/15/OS
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�la�li�
Date
Application Date: �'� i- �� � Tax Map:
Amount Paid: Parcel #:
Receipt#:
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Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d (Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition � Permit Revision
$150.00 (if site visit re uired $75.00
� Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Services R,equested by
Name: �z�r V- d S� v� v��. �� v� s
Address: ( �-F-,;L � vUc,t•tit /1���
l , c.� � /l!C% v(757�
Phone # (home): � �'� " 5 `l�i ' C�'�3
(work/cell):
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size:
Address and/or directions to Property: �
Subdivision: Lot #:
4) Proposed Use and Type of Structure: u✓�t�i��
Residential Business/Type: Other G`X /� 'c� c�
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No
5) Water Supply:
Private Well (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A comvleted apnlication must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid. �
�
Signature (Owner/Legal Representative): �Gv�.C�1rc.�1 GL�iY� Date : �Z ` ��— /�
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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R EF -" C.B. Davis, Jr. �� by Philllp
J. Holl , Jonuary 197$
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