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The District Health Departm�nt
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PERM T N
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Owner: w
Location: � '
Contractor: ` � '
Water Supply: PFiVate' Public
Sewa Disposal Facilities: No. bedrooms Dishwasher, Disposal,
wash' machine, other automatic appliances
Size of tank: f D�G Nitrification line: 0�
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 INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY POR,TION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
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Date approved: � r � � � Signe L '` +'' �
Sanita ian �
Well:
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Sewage�lisposal: Counter-
$Y. � `� signecL
„ (Owner or his representative)
CertificaYe of Compleiion � �-•"''f�'
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Date Approved: �1��By:�S,. `"
San�tarian{
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(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of in
supplies, etc. Note special p
at later date. Note location
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�,'�howing lot size and shape, location of house, septic tanks, privies, water
r ting on lot. Write in measurements in order that installations may be located
supplies on adjacent lots.
(2)
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Person_ County_ , H�aiti� D�partm.ent.` _
, S:��ncage �ystem Improve�ents Permit.
Y�ate: ^ ^9� . is Permit.Void. After 5 Years
Owncr. ��.�..�— � SR# ...� �;��A
L�cation/Direct�,pns' . . - - - _ ` .
�� � ....e.. rs �' .. .� n /I �
5ubdivisi�n Na
Lot; Size: �
Water Supply:.
Bedrooms: _
Basement __
uvr�r
. $ilII]t8I
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` LOt #
1�Type:uf Dwelling:
Public• Community:
_ Gazbage Disposal ,� � �
_ Basement Fixtures_ i _ . , � - - �' 1 .
` owner or
R�PAIR: ' ` REEVALUA'TION '� �
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Size of Se�dC Tank: _ - gallons Size of Pum Tank: �� � - �
Nitrification L:me: '" � /• ���'—ly�-
Depth of 5tone: 12 uiches �
1Vlax Depth of Trenc}:es:
Altemative System: Conv. Pomp _ I.PP Pu�mp .
Remazks: •
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Dat Well� Approved:� Well should be 100 ft. from any sewer system
Re.,..:.,........
u� � e'� em p�roved: -• J- o
BY SBIlli2il$Ii
TIFT OF COMPLETIC�N
Cnntractor. �
___ �� �_•,� ��.�____��___�_ �
Sewage System location,� instaIladon,- and protection must meet state and lo�al �
•reguladons. Sepflc tank shoul� pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not 7fo creaze a.public he�l,th hazazd. Septic tank and�d
nitrif'ication line must be inspected �and approved Uy a member. of the Person Counry �
Hcalth Depaztment;before any,portion of�the installation is covared and put into use. If
th�•� site plazis ox.antended use change this petmit is-sub,ject to revocation.
(C.S. 130 A -335F) ;
L.ocation of sewage disposal sewage system sketched un bac;k.
••• (OVERj
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Building Additionsl Mo6ile Home Replacemeats
Tax Map #: Qu � Parcel#:�,,,�_ Address:
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Approval Requested for: ��Home Replacement
Building Addition .
Applicant Name:
Address:
Phone #'s:
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Permit Located: � Yes
Installation Date: y- I 3-� 7
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Design flow: 31�0 (gpd)
Current Contract wi±h Certified Operator on file (if required):
Water Supply: �Well Public or Community
Wastewater system shows no visual evidence of failure on: L�- Z`1-I(o (date)
(Applicant's signature if site visit is not required)
Comments:^�pracd +a r�(a�P �e x►s�►',� s,���fu�e w� � n���.h„�._<Q
�ddition/Replacemen� Approv�d
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Env ronmental Health Specialist
(�- Z8-I e
Date �
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
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I�aa.vriso�assmcs«�m.::�o.II' lE-1La.�.11��a
SITE PLAN '
Name��n� ������nQv_i.�. Tax Map#��_._Parcel#� _
Subdivisio 3action/l,oi#
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Authorized State Agent Cate
System components represent approximate contours only. The contractor mustJlag the system prior to beginning [he
installation to insure that propergrade is muintained. .
Note: An Accepted system may be used in place of a convenlional system without perrnit aulhorization or modifccalio.n.
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