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A23 121The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply ond Sewage Disposal IMPROVEMENTS PERMIT No. _ Date Owner: �=' • 1 Location: _ � r � Contractor: Sewage Disposal Facilities: No. , Disposal, washing machine, other sutomatic appliances Size of tank: � Nitrification line: _ ...w_ `J , _ .� , -� � i t _ ! _ . � , Ll ^J,-, ,� �i- ther dispo3�l�azility: "` r' � � , , . -� ` �� ,-� , �ater supply and sewage disp c s location, installat' n and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years an� 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 I�N�jTALLATI S COV- ERED AND PUT INTO USE. � Si n � Date approved: g Sanitari Well: Sewage Disposal: By: Counter aigne (Owne or his representative) _ Certificate of,.Complelion � Date Approved: �� B : �i//��' " " _ - - anitarian (OVER) ' Location of weil and sewage disposal facilities sketched on back. Aaolicatlon Date• � �� Ama�unt Paid• � 1�0� Recei #�: �� 3303 Person Countv Heaith Department Environmental Heaith Section APPLICATION FOR SERVICES ?ax Maa #• �� 3 ,� , Parcel #: - IF THE INFORMATION IN THE APPLlCATION FOR AN IMPROVEMENT PERMIT IS FALSIFlEDs CNANGED. OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INYALID /f ) Permit requeabed by: (OwneNagerrtlprospective owner): C L�, pE Home Phone: �3 �—�'7�f� o,Q, $c7'� �a-�}�6G y0 Address: � D,e �� Business Phone: SC=Y}?�9� �,C, 7 5�3 2) Name and address of currer�t owner C{{E�Y1� f� • yvld0 �� g C� � � D�P, 3) Property Descriptlon: �otsize: •D Rr�ownshtp: CGJNitJ/N6yS'�41� Direc�lons to the property (Induding road names and numbe�s): �, Qa: �,� ��ri,V�alrcr.a-wr t�n _ 5,�,, ! � � 4) Proposed Use and Structure Descrlption: answer each of the following questions: a) Proposed� Existing � b) Sttdc Built� Modular �, Singls Wde �, Double Wide � c) Number of Bedrooms: - d) Number of occupants or people to be served: e) Basement Yes �, No If yes, # of basement fixhues: � Garbage Disposal: Yes 0, No� �r � g) Dimensions of Proposed Strudure: IMdth: � Depth: � lra 1r� o� �. . �' � 5�y-� Water Supply Type: Private �(new � or exis�ng �, Public ❑, Communityr �, Spring ❑ � Are any weils on adjoining property? Yes � No o If yes, locatlon 6) Please Indicate Deaired System Type: (systems can be ranked in order of yaur preference) Conventional lModifled Conventional _ Altemative _Innovative _other (sPecifY): � � CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURE$. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATION I hereby make applica�on to the Person County Health Department for a site evaluation for the on-site sewage disposai system for the above-desc�ibed property. I agree that the corrtenb of this application are true and represent the maximum faalides to be placed on the properiy. I understand if the site is altered o� the intended use cfianges. the permit shail become invalid. t understand that as appiicant, I am responsible for identifying and marking property lines, comers and making the site accessibie for the personnel of the Person Courrty Heafth Department to condud their evaluations. I understand that I am responsible for notifying the Health Departrnern if my property contains any wetlands as designated by the Army Corps of Engineers. 8 a 9 00 wner or Legal Representative . Date PCHD, tev.10/12/99 Ye.rson County Health Oepartment Existinq Sewage System Report Eor: Requestee: � Mobile Home Repl�cemen� � Addition �� J Home Phone# �g l�b l�a Location/Directions:. � � C ��' ��'�%�O Tax Hap� � , � nd � ��!1��i1.7�1[� �!�'ii[li1',.'T.] i7i� ... 6 !/t Q $'�(;( ' � ' ' Original� Permit Located _� Sept�ic System Designed �'or:. Kesidentiai � Business � Other (specify} � Bedrooms # �mpioyees Other llate Installed a� Water supply I,L�N f f / Type or 5ystem ��d X3 huA,n�ol�di.f — Nitrification Line `�'OD � X.� r " Tank Size %Od � `ia� _ Certified Ogerator Required �a � On site malfunction �ermission . r�l Accordinq Comu�ents : wastewater disposal. system sliowes nc visually apparent o n i(� �(� C1 b _ r . / is granted to: �lds�r R . . � 1i - � the attached site plan. Env.ironmental Health g�C.• � '" A. 4..st . ..� . �.•'.,:•. _ +'�'��'" : . .. .'_`Yt'„.X'�a��. DATE 0 _ .. . .. _... ... _ _.. .. .._ _ .. ._. _ . :�-- , , , �. . � ARPlication #: . Tax Map �: . ParcE! �: . � • Person Caur�ty Health Department � � � � Ernironmental Health Seciion � SITE SKETCH , �o� - . � � p ' s Name Subd'nrisionlS 'cNLot# ja ro ov Authorized te Agerit �� System compoae�s represent approximute cnntours only. The contractor must flag the �c .�rior to be�inning the installation to i»sure that ArvPei' grade is mai�rtained � �� QG 0 � , � Scale: �� '�" ��' ,� �� ,�� • ��. f � PCHD, rev. 9f?112l99 A�plication Date: � �� 7 Amount Paid: D .0 Receipt #: I 73 � C Tax Ma �023 Parcel �: � vZ. � �_��s� 1�I�I1��T � - -� � � �� .:�-�� .m.n ��.a�� APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � 1) 2) 3) Permit requested by: Owner gent/prospective owner):�LL� S � L. t,�} )11%�� Home Phone: 3- —S 7� � Address: 7Sf� ��• Business Phone: - �..� '� . Name and address of current owner. 1�� -�d L�l�cl/ rIJCJ D�. i . �t� E'_� , N G ,�.? �.� 3 � Townshi uf`'v"v��'�� 0� Property Descriptlon: Lot size: � C. p: Sub ivision:/��/1'N E E lul ��ot #� � Directions to the property (Including road names and numbers): ��Y� 4) P'roposed Use an Structure Description: answer eacKof the followi g qu tions: a) Proposed �,, Existing _, Type of Structure:� . G 1 Width;�� Depth: v2 � b) Number of Bedrooms: Number of occupants or people o be served: c) Basement: Yes , No Wili there be plumbing in the basement7 d) C�arbage Disposal: Yes � No 5) Water Supply Type: Private ✓(new _ or existing�, Public� Community;_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the 'site plan. � 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No,� � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROP.OSED LOCATION OF ALL STRUCTURES MUST BE STAI(ED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF: � I hereby make application to the Person County Heaith Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the prg.�erty. I understand if the site is altered or the intended use changes, the permit shall I�esme invalid. /1 // r Owner or �- -D Date PCHD, rev. 06127/02 �� , i � � � �� '�.! d. � � � �7m,�.g"�CD7m.11�Ca.�:7m.�.�.� ��.�..�L'1��. �uilding Additions/ 1dIobile �ome 12eplacements Tax Map #: 2.`� Approval Requested for: Pazcel#: � 2, � Mobile Home Replacement � Building Addition ' ApplicantName: �c�� q� C�,� r�t��r�PJ Address: � ' l�� S o � G.��13 Phone#'s: ��lo- z3u- "i1�R G,�e) 43y-2�d-212y �b�s. ) Permit Located: � Yes � No In.sta.11ation Date: Design �flow: (gpd) Current Contract with Certified Operator on file (if required): Water Supply: '✓ Well Public or Community Wastewater system shows no visual evidence of fail�e on: r--Z�'o� (date) (Applicant's signature if site visit is not required) " � Addition/lteplacem�nt Approved � �-_. Enviro ntal Health Specialist 11/15/OS /- Z��d 7 Date ��, )� �� . "'— �: � �� , IE��.m��.,�.7L IE��.e�Il�Il9. STTE PLAN Name�n��n5 �% i�1erV� ��.�,in�� TasMap#�Pazcel# j2 S n � Secrion/Lot# '� /^ ZK^D9 Authorized Statc Ageat Date Syarrm compaaenc4:rpneseat appia�au wotoras aaly. The cuauacaormuseilsg r�e spsrem pdar m begmnwg r6eias�oa m ma,•� thatpropergxgdeismsmtvned , '� ��'i . �a � �� La (��, rc�m. �,,. n�i�zioi