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The District HP�Ith Department
CASWELL - CHATN:�'M - LEE - PERSON COUNTIES
Water Supply and Sewage Disposol
IMPROVEMENTS PER �/t' No.
f Date �
Owner: '
Location: � L! � L�r� ����,�%
Contractor: � �� �-S
Wate upplp: Pri ate � blic
rs �—
Sewage Disposal Facilities: No. bedrooms �_ Dishwasher, Disposal,
washing machine, ot r automatic appliances —
Size of :tank: NitriBcation, line:
Other disposal facility: r `
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Water supply and sewage disposal, facilities location, in ta lation 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 DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
Signe
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Sanitar'
Counter- %? � s ��✓/'�^��
signed
( wner or his repres tative)
Certif'icate of Comple2ion
Date Approved: �IS-�3 By:
Sanitarian
(OVER)
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
y 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. ��
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PERSON COUNTY HEALTH DEPARTMENT
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WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �-� Parcel # S �-
Zoning Township i�-��" �—�
Owner/Contractor :Y�L.�'� � ` ` Date %-� f�-9'S
Location/Address 1 � �--ti -� ��y -�_�l,
,/��-L.,.. I S- 7 s.R.# 11 � o
bdivision N
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Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area � 2 6 S ize of Tank I B��
Mobile Home Size of Pump Tank N��I
# of Bedrooms� Nitriiication Line�
Max Depth Trenches_
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed. `
Well and Septic Layout by J��� � w-��-� ��^�'�-� �
Comments:
Date -- �-`I Installed by ` Approved by CrJ.�%2� ��-c��c-„�.
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. 7'he
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental healih
specialist is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or
misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants tha[ the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0