A41 55r� � /1 '..�
Address �� � %C 1� � Ir0 , ���� �
C,
No. of persons to be served Bedrooms 1, 2, 3,�4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Recommended: Septic ta ' �
r'C�� ��//J/ X �, 57C�'Y?� �l �'T�I,�G(' � /?ia��flcl��nl�7`i Y�'�����,
� �' x J � ' �-'_ .�)� �i� � �%������,
Nitrification line: < <
�`',��1
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line musi be inspected and
approved by a member of the Disfrict Health Departmeni staff before
any portion of the installation is covered.
Date Approved: �'' — � g —
I Signed
Sanitarian
gy. ������GL� � � � �
Countersigned
O. David Garvin, M.D., M.P.Ii.
District Fiealth Officer
(Over)
NOTE: Make sketch of installation showing locatio,n of house, septic tanks, privies, water supplies �on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ) ; FINAL INSTALLATION (Date )
/ � O �, � (Road or Street) (�oad or street) ;,
�O
,.
-� , ' ; ,•� �a �. 1 _ � ..
. � ` � , :.. � � � _ i ii' �_� �,r
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PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISPOSAL
IMPROVEHENTS PERMIT NO.
Zssue Date: � Z- I- gg
Owner: CX1�,,.,�fp� ,C�li VLLC��
r.ocation: (S7 �
Septic Tank Contractor:
Building Contractor:
Water Supply: Private (/� Public
All wells should be 100 ft. from sewer system.
Lot Size:
Sevage Disposal Facilities: No. bedrooms
Size of tank: /D Dd Nitrification line:
Othe� disposal f�cility
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line MUST'BE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS.
Date Well Approved: Signed (�(/,[��(.' �i(�,.`
By: Sanitarian •
Date Sewaqe Disposal Ap ed:
�' 12 , 1� c1 Counter-
By: signed
(Owner or his r presentative)
Certificate of Completion
Date Approved: � � y: �
Sanitarian
(Over) ,
Location of well and sewage disposal facilities sketched on back.
•
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� �.. . � ; , � � . _ � . . _ ... ., _ �� �C.J �+^— , ` �
� � • .. . - � � . ,. ' .. , I _ ,� ' - � �� .
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�T� �o� . c��t s
WELL PERMZT
Caswell-Zhatham-Le}e=P? zCso� untios �
DATE 255 D•��,�..� DATE D� �s 1 4� COUNTY:
OWNER: �-/C��1�Iins�A:� e.�il�'f/ i.�iien�rnTec�rra Y F�Y . _
itELL CONSTRUCTION �
Diatance from NearesL ProPerty L�ne_-�--D��a from Source of
Pollution
Total Depths . Yield: GPM Statie ilater Level: FL•
water Bearin9 2oness th: �` Fc. Ft. Ft.
Casings DePth: Fsae�_to 1�Ft. D�ters laebes
TYPEs Steal Galvmuad Steel ���
Zf Steel, doas ornes' aPP Yef�— �----
YeighL: �� ?���:� beigIIi Above Gzouads Inehes
Orive Sboa: Yes: �_
Nere Problems Eacountarea in Setting � Casln4i Yes�, No
� �Tes• give raason: ' �A�ete
GrouL= �j�pe= �t S CemaAts ��� �.�
1►aaular Space Widtb �It�ebas
iiater i.a l►a�ular Space: Yes . N�,_
l�etAods Pum�ed sure _ Pourad�
. Depth: Froo to � PL.
Matesials Useda No. Bags PorLl+�d �t tieight of
1 bag �,��- •
Zf mixture (sand.�qravel, eatiis�4s) - Ratio: to��
ID Plntes: Yns�N �� Chlorioatioae Yas��,No��
� s { slab Yes�Tl h1o��
Dt�1
PSORf t0 OZIDIItlOt1 DESC1Dt10I1
2 HERE87 C£RTZFY Tii1►T TlIE 1►SOVE ZHFORtUt1�t ZS CO AliD Sf3AS 2HZ5
1iEI.L iQAS GONSTRUCTED IN I�CCORDANCE Tli REGiJIJITjIONS FOASH SY
�I,-Cf3A?til►!!-LEE-PERSON D25T. �-
Sigaature of ConLra r Date
FOR HEALTH DEPARTTSEAiS' USE OHLY
REJISON F08 NO Z1iSPECTION:
Saaitariaa�s Sigflatuze Date
Sketch v�el.l locatiaa on.reverse aide. Use establishad referenca
poiats. � .
r. _The District H�alth Department
� :�
CASWELL - CHATHQM - LEE - PERSON COUNTIES
§
� Water Supply� �nd Sewage Disposal
IMPROVE1�iENTS_ PERMIT No.
� Date � - ,�.� � � S
' Owner: i.1 -�'�
Z.o�ation:
�-- ,�� r�.� � -
Contractor•
Water Supplp: Private �L, -'� Public
' l
f ,p � ,
� t��,�-, '�� ;? ,�7; v
Sewage Disposal Facililies: No. bedrooms -�-- Dishwashec, Disposal,
washing machine, ot er sutomati� appliances —
Size of tank: � -'�Nitriflcation line:
Other disposal facility:
c�
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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. r.�'!?
r� � f-' ��J�l��
Date approved: Sigiie
Sanitarian
Weli:
Sewage Disposal:.
By:
Certificate of Completion
Date Approved: �" ���
.::1 i '
Counter- i � j ,• : ,,�.p;` ,, �; : !t•-
aigned ' � � '
(Owner or his representative)
/ / // '
i , � !/,
- - :. .
rovEx�
Location of well and sewage disposal facilities sketched on back.
- ' G�� 1 3
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �� Parcel # �S
Zoning Township i�9�� �
Owner/Contractor'�Yl�ir�1- '�� Date'7- � � — 9 S
Location/Address ��- ��� � �' ���� —
C$ �v 1�`'7 S.R.# s7H�s�e,1/33
Subdivision Name �/ l� Lot#
�
► , i/,
i %• �
� - i �'�
�
' � .
` ��� � �
As Installed
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 3��$�"' - Size of Tank ��- `' J
SFD i/ Mobile Home Size of Pump Tank �/f9 _�
Business # of Bedroom �� Nitrification Line -3oa �jC3 '-��r,�c�.��
3��- ' , ____
� 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 chan ed. . -
Well and Septic Layout by J�—� �����=-c � �-�=e—Q °�
Comments:
Date%� ��`�'.S Installed by ' T Approved by G.J.Q 2—P .�
Well Permit P,aid C� WELL
Indivic
Public
Site A
Well F
TIONS
;QLfired Slab _
L_ Replace ?(ent�„_ Ai Vent
ved quired Well Log
Approved ell Tag _�
Date Ins�alled by
by
1'his report is based in part on information provided the homeowner or his/her representative in the application submitted for this pertnit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. Neither Person Counry nor the environmen[al health specialist warrants that the septic
tank system will continue to function satisfacrorily in the future or tha[ the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
1