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A23 158
�J � The Distr�ct Heal�h Depar�ment CASWELL - CHATHAM - LEE - PERSON COUNTIES Vv/ater Supply ond Sewage Disposol IMPROVEMENTS PERMIT No. _—T_ Date—►r.,� ~ i � ' ner�� �� l`c:� V ti �� i r Location: �-'� ,- ; f, ,�-�= J � /� _ �� •'r,: C..-Ya�.�' c1r" Contractor: • Water Supplp: Private ��` � ' Public Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal. washing machine, /other sutomatic appliances � Size of tank: / �'�'f��''��� � �� NitriBcation line: '��� �'f� � ? ; � 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- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTAI;LATIO� IS COV- ERED AND PUT INTO USE. �;� f'' ,� . `l - ��f � � � ,;, / ,� � Date approved: Signe j � '� `j �`� ,` ��� � � � /� l s . Sanitanan Well: " Sewage Disposal: By: Certiticate of Completion Co gnter- ��� �' 4� ( � � � � 9i ned r - - (Owner or�,h;is iepresentative) v Date Approved: ,El-a_-�'_lCf�G46;s By: G'' t �s�..:.:.�/'z,. ��G_.,_.��,.�sd...,.,' �' , Sanrtarian (OVER) Location of well and sewage disposal facilities sketched on back. ihe Dis�ric� �ea��� Depar�rnen� CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMITI No. � Date Lr� ' �=-�-��— Owner: — Location: _ Contractor: ''" d , � Water Supplp: Private Public Sewage Disposal Facili2ies: No. bedrooms Dishwasher, Disposal, washing machine, th r automa��C appliances _ Size of tank: � Nitrification line: 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- PROVEI} BY A MEMBER OF THE DISTRICT HEALTH UEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTf�LLATION` IS COV- ERED ANB PUT INTO USE. Date approved: — I Signe Well: Sanitarian r . �/ Sewage Disposal: Counter- �� �signed . • BY: (Owner r h' re�iresentative ; � Cerlifica2e of Comple2ion , l '� , }� � r o.._. t a Date Approved: '� � BY� � � 'Sa i arian i (OVEft) 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 supplies, etc. Note special problems eacisting on lot. Write in measurements in order that installations may be located NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. P7ote special problems existing on lot. Write in measurements in order that installations may be located � � _ J Application Date: � ���� � � � TaY Nlap: �o� � Amount Paid: � d. 0 0 Farcel #: �— .Receipt�: g 9 Q �F9 6 �� ��� �"�� � -� ��' �l� �6 � � � . _ - _ �� � � ��� �I''�" ����o� �� 1.�.: aza,a- si s- � axa ,•-,.�, «:_ s�_ �i...-_a IL IE�� .�e.�. w.. � a��� � � �� F� �( ��O 1/ . � � �. 1-�i�3��flC�$flO�fl �or �e�vae�s (Septic Systems and Wells) J`�` � b�Y'� � 0 Servic:s �e ueste�i � 3mprovement ��rmit (Site �vaivation) ❑ Construction Authorization �200.00/$300.00 (if> 600 d) (Fee is de endent on the tyne of system ermitted) �'iobile �ome �2eplacement or Building .�ddition �J Permit Revision �1�O.Q0 if site visit re uired) �75.00 C�eil �'ermit (New/IZepincement/i2epair) ❑ Itepair of Existing Septic System �300.00/$200.00/$75.00 No Charae Servic�s 12�quested by: 1 ihA sv►ow �9?-597a Nam�: iT r1Ck �nc�� `�rv►.•� `'�.x�puJ Phone # (home): .33�0 ��1 r1�5��7'O �n'`L Address: ��� � Wrr�r�s-�-o; ��n�� (�vork/cell): 3�- �" f—1 D�9 �►^oc.� Cc_(� Z)l��m� and address oi ��rr��t ar�vaaer (ii alif%r��t #�an appiica�a#): Name: `�rU �� S � Address: b �n � X. nc . E�IC. � ?.S-� `f" �) �roq�es-� �escr'sp�non: Lot Size: �� �2 �Subdivision: Address and/or directions to Property: 5�-}5 l 2rt-t� ( SC T_,ot #: 4) �roposed Use a�td 'Type oi Siructure: Residential ✓ Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees):� Basement: Yes No (wi�plumbing: Yes No _) Garbage disposal: Yes No �) �Vater Supply: Private Well �(Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? T10 Yes (please show location on site plan} 1'��te: �4 �orrt,vleterd �rpvlication �rau�� r�lso include: ���lat/site plun of tlze,�r�pe�ty that sAiow�,��a�e� �li�raen�ian� rand t%e �iz�e ffi�$d ,�ocutioaa o�'radd proposed structures. . s�1 sigr�eri capy �f tlie `.��� ���p�ratio�a' for�a� veri�ya�a; thai �lae,ps��periy as �aardy io be evcaluuterl. � am submi##in� #has �pnlication to re�aae�t s�rvic�s �ro� the �prson Couniy �ealt� �e�a�-#�►esnt. I understand t�a� af the infoa-��tion �rovide�i is 9ncori �st or i�' Yhe 3n#e is su�s��g�ae:nt�y altere�, or i� tt�e inte�ade�i u5e �ha�ges, ��� per�its amd approvals si�all �ecame invalid. - �ig���u�� (Owner/Legal Representative): ��a- �-�� ���� : �"`6�d '�/ , � 10iO3 Person County Environmental Health, �?5 S. �iior�an �t.; Suite C; RoYboro, NC 27�7� (336-�Q%-1 �°0} � � �� i � �,�" {� �� }� � � '� �i � -' � , . �: .. .;' ; ` ' � .��'������1����� S.r.4.TZ'11. �iIL' �C� �'.:.;i..T�""ia. i�{� 1%b tl..G''L.11 �� �':c.`+i. �1 lC..� �u���a�am� �s��a��a��/ I',�������e �i��n� ����������n�5 Tax Map #:��� Approval Req�ested for: Parcel#: ✓ ° Ylobile Home Replacement Building Addition � S Applicant Name: % ih� �/rdv n aw Address: � �0 � �Qwm2n-�2r,�n I�d• RQ�C�er . Al G 2�57� Phone#'s:��1�3�(�-597-5q10 ��� 33�-SD�F- /019 Permit Located: Yes No Instailation Date: �-1�- ZS �� �esi� flow: z�o (gpd) Current Contract with �ertified Operator on file (if required): Water Supply: �/ Well i'ublic or CQmmunity Wastewater system shows na visual evidence of failure on: ��l3' D� (date) (Applicant's signature if sit� visit is not required) Aa�a�n������a������� ����°���r� � y—/3'oq Environme al Health Specialist Date 11/15/OS .�r���J� / " ��• .���1J� � l ti�� 'Y a-l` ��/ � � � � � 7��m-�ay-�D�����.�.ffi.]L ]HI��.11� � � Nar�e _��c�_ �' l ro v sn oc., Subdivisio � A tho�ized State Agent ���'�' ���' ���� Ta.g Map #� 2.3 Pa��el t` 1 SS Sec.-rio�/Lot# __ _ y- �3-��- _ Date Syssesr� cvrr�ponents s�epresent uppr,nxim�rte contorsrs o�ly: 1"he conamcior »a�est� fiag the systerre��ior $e� bmg�ra�ais�� tlae installrxtzon io znsx�re that jirb�iergr�d� as rriuis�tairred � �l�S��'+�� � ��� � �^ �� C��?l i•'cC� ;�� -5��-1�`Ic� ��a�'r��q �'�. �o ��raw� ���h � S�� S�� �� an� ZS' �om wel� � _ _ _. y , y.ad . � � � .. . `+�"" k . � A. r y3 '� x;� ua., p ��... �i � , � � � 3� �� '� a 9 �S � > >' � � .' � � � �. � ��� �� � .��� � � ��• �,�� �., � �� � � ,.;;,� � � �� � <,�� ..� . � � � . � .� � � . .� �� � '� —�'1--�' � � � ' � �- °', ��^.-a.-�---�� � � . �, _ � _ ;� , � � ? � c� ��¢�� pr ����" � ��;z J � � � 6 � �� ����� � � �� " � � ���� � � . � : � f�, ;� � i'"" �a„n, w . i -, , ..._ . .. . � _ . � � � .` , ' a, ; � � � ; � � � �.�� ^� E .� ,j � �� .. . � � . �'� ;«i 'y.v � � _ .. . . � � "� � , .... �, � . � . . p � , . � � _ . . .. � �. . � s 07 ..ss, . - . _ � . , . � ��... � ' . �. � . ... � .. . � .. � . . a � , " - X'� S T � ; . ��. . . . . .. � � . r ,. � � � •��. . �. �� . � � Ni � &-' a . g?� �� - - - . .. � >�' . �, . � � � �� , . . �a � � �� � � �� 1 .� _. 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