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_The`._�'rst�t Heolth Deportment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
�� Date
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Owner:
I.00at10ri: � � � ,
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v ::E�f^r � ,�
Water Supplp: Private ��'�/ Public
Sp�r ispo acilities: No. bedrooms Dishwasher, Disposal,
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washing machine, ther automatic appliances
Size o! tan . Nitriflcation line: �--y� `�-
n . � � V� X �
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tanls 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 INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE 'ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. ,
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Date approved:, ��{
Well: .�. �
Sewace D'1SDosa1: ��
/•Sy�
Signed � "�^-•,'" � . �r+.x�e� I
1Sanitarian --T
tf
Counter- •
9igned • —
(Owner or his representative)
Certifica2e of Compleiion
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Date Approved: _ "� BY� �
a itaria
(OVER) .
Location of well and sewage disposal facilities sketched on back.
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t1��=1�� ��IZ �'1 � % ( � ;�U
PERSON COUNTY HEALTH DEPARTMENT
WELi, AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT
q001133
Tax Map # Parcel #
Zoning Township
Owner/Contractor.�_(� D�v � S Date
I,ocation/Address So , s ;�� �,,� �� a N n A �� s z D i/� ��
�AY��'� iAvc7ZP� f�' NLJtSJ� �cJ iZi �-N 7' S.R.# Jltf Z
Su�division Name Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area _� ,�,9 A c Size of Tank � X i 5 j�,� CT 1 z� ��'r A L
SFD l/ Mobile Home Size of Pump Tank
Business # of Bedroom� Nitrification Line t,� i s; r�v�� so�' y3 � �
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is tered or intended use changed.
Well and Septic Layout by � /
Co1ri2Tlents: ,Q D 1� _SG[> ' h 3� ,�E i..� LJ L� � i��T �
Q. � l�i-+K �tF-=D t- u� C--i � 1? �.4L�cv�
Date 6 Installed by � �r�i� Y�ri..rt,S Approved by � L
�D S�'X
3 ��w
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2AAt
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�' Date Installed by.
Approved by
• This report is based in part on information provided the homeowner or his/her representative in the application submi tted for this pemut The
environmental health specialist is not responsible for false or misleading infocmation coirtained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in Uvs repoR that may have res�lted from false or misleading
statements provided to him in the application. Neither Petson Courrty nor the environmental health specialist wazrants that the septic tank system will
continue to func�Gon satisfactorily in the future or that the water supply will reman potable. c:lamiprolpermitsam Ol/95 rev.1.0
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