Loading...
A23 32�'he District� 1-lealth Depar�menf Orange, Persoa. Caswell, Chatham, Lee Counties w• '�' �A/a�er �Supply�and Sewage Disposai IMFROVEMENTS PERMIT:'No `_ i .� ; �_;�"i���� �a:`- ��� ' � , Owner: � _. __.�.. _... � � , � ~' Location: �� pq' , , - t ` ! ' ,� � "' t ' f ' _ ' . „ �, .� Contractor: ' r�` � ' f �i - 1 .. �" � . . �� ; . y�y'� �+, � . � f, ✓ �� Wafer Supply: Px�vate��-.�, Pub�l , � rj . .. . i : � �� . . .'� y . �r. � , �:� � a ,... � t �.-� �ti,Lrti „� •a�, Sewage.-Disposal Facilities: No. ��edrooms � Dishwasher, Disposal� r:..... .... _ wasiiing' machinc, other�autoi}�atic appliances � r � Size of" tank: � �� ����� rt +� � � Nitrification liae• � � r - r ✓ � t.�' ' / ' • ._ .� �Oth�r disposal facility: ' �w • ��`�•.:WateT supply� and sewage disposai facilities location; installation and pibtection must meet state and local regulations. 5ept'ic 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 he�alth hazard. 5eptic tank and nitrification, line MUST BE INSPECTEB ,.AND� AP'- PftOVEI} 8Y A` MEMBER OF TIiE DISTRICT HE�TH DEPAR.TMENT STAF.F B�FORE 1�°NY PORTION OF THE IN6T, LI:ATION IS COV- ERED AND PUT INTO USE. ,�' �' %t . i,�� � +�,� t � ;�� , � Date approyed: Well: Sewage Disposal• By: Certificate o� Complefio �, ^ .. . IDate Approved: L . '� ' . � � f 5anitarian . Counter- signed (Owner or his representative) . Location of well; and sewage disposal facilities sketched on back. -� 11/07/2013 14:52 3362283200 PAGE 01 f 03 Application Date: t�'7' /.3 �� �� ����(�� �a� �g�: �'� 2, Amovnt Paid: / S�d �GO �.*•. `�'.�� Parcel#r � S Receipt #: 1 �G y3�{ � � ���� - .IE���a•�����,��..A �]H[��..�a:�. A,pplication fo�r S�rvices S��rv�ice,s R�a�ested 0 Ti►rapravement Permit {Sete �vatua6pq) $2U0_00/�3dU.Q0 if> 600 �obule Home Repfacement or Building Additep�l $�SOAO i�sxtevzsrtxe u�red) 0 Well Permit (New/Rentacement/Ren�irl $304.00l�20QAOIS75.00 Fee is dependent on the type of Permit Revision � �75.p0 - ❑ Repair af �xisting Septic Syste� ,A,pplication: No Charge/ CA $i50A0 or $300.b0 1) Ap�licant Z�tfor,�aat�o�: � �T�o: ��lths �honc �r : 336�7.Z��4�40 Address: b BCO� 2.Sc�7 . . (worlc/ �: 33 � , $'1 � �b�1 i �, �_U�r � �•�a�'c tti t� C. �'7 "�l � ^ , ,..� 2} NAme and �ddress af cur ent owner (a� dx�fexe�t tha�a. applicant): Name: 5 t�r1 Phone:.-- ��Ge. ►�l � "'7Q � $ ,Addz�ess: 3 I • r 3) Property �?escript�aia.: Lot Size: ,566� Subdivision: I,ot #: '� ,A�ddress az�dlor direc�ions tu Pr�periy: ���ri�t�ljt�. ❑ yes ❑ no' Does the sxte ca�ptai,� a�,y��nisdiction�al wet�an sd ? •� � 4ri �r "�yes ❑ no Does the site contain any existing wastewate� syste�as? ❑ yes j�i�o �s aniy wast�watex going to be generated on the site othcr thaxi @anoestxc sewage? ❑ yes ❑ t�o Is tkte s�te suhject to approval by any oti�er public agency4 � yes C) no Are there any ease�et�ts or �g�t p£ways o� tb,xs �xopezty? � � (if'yes' is checked, please provide suppo�Ezng docwm;e;�eationj 4) �ra�osed LTse aaad '��e of Structiare: ❑ e�'de�t'al New Single Famiiy Residence Maxi�»um nutnber o�'bed;roo�s- „�_ ❑ Expansxoa of Existing System If ex�sansion: Current number of bedrooms: �_ ❑�epai,r to Mal�'unctio�,'t�ag Syste� WiZ� there be a basement? O yes?C] no With plumbing �xtures7 ❑ yes 0 z�o QNon-Residential � �'y�e o�busivaess: Totai Square footage o��uxldimg: __ .. Maximurn number of empIoyees: Ma�,iziauz�n number of seats: �� ��� � 5) Wa�er Su��pl�: � New wel� � Ezr,iistz�g We11 0 Cozzununity Wel� ❑ Public Water ❑ Spring � .Aare tk�ere any existing wells, springs, or existing waterlines on this property? � yes ❑�o 6) If a�plying for `Authorization to Constract', �Ieas� indicate prefe�-xed system type(s): ❑ Conventianal O Accept�d ❑ Innovative 0 A(ternative ❑ Other , �_�� ❑,p,,,�y ,( eert� nc�rt the is�formatiort provided abnve is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsec�uently altered, or the intended use changes, ul! permits and appt^ovals sJu�ll be invalid. {Owr�ex/ I;egal Representatxve*) g dacumentation requixed. i ,U te + Permits are valid for either 60 months or are non-expiring when accQ��ap�ied by an ���rowed pIat. * ,A, eampleted `L�t .Preparatfon' �o�'uu �ut�t acco�pa�y �►�uy app�ze�tion re�uiring a site evalaatio�. ; � � � r- �, �' l� � r i �. i �.�� � ,; �\I �� S� q ..� �� � � � V �y « .i^ � �.�`�'� y �� �1 ���� �� � �,��.z�-�.���=�:�.���.-��::�,�. '�����.�.11�:� �a����1��� �����m��/ l���bn�� ��a�� 3��������a��n�� � Ta� N1ap #: qZ3 Parcel#: 3Z t�ddress: 9 q A��+�Ar%F. DP.�►►v�- Approval Requested ior: _� Mobile Home �'ceplacement Building Addition Applicant Name: �pr►E..S �:o �i� t�S Address: '�o Qa�, �sOh 3uv�►.�c��� , t� C. �� �l5 Phone ,#'s: 33b -.aa8- 04�0 33c�- Sll. - oo�fS Permii Located: i� Yes rlo Installation Bate: ' Is' I�t'1 � Design flow: Z.4o (gpd) Current Centract with Certified Operator on file (if required): ►� A� Water Supply: �_ Well Public or Community Wastewa#er system shows no visual evidence ef failure on: 13 1' (date) (Applicant's signature if site visit is not required) Cor�s�,tw` ���1������/���fl����a��at �.�p����� �..�,—Q. Q. ..�,.�. Environmental �iealth Sneciaiist L Iz ��� t3 Dat Pe:son Counr� Eilv;ronm�ntai ;�eaith; 3�'S �. tiior�an St., Suite C, RoYboro, NC 2 i�73 Fhcne: ��5-�97-??9C1 ra?;: ����-�9"-7508 V� iv-�:��v.�ersoncount �.i,..� � �AT , �.-��.?. � 1L ��� �� `^ � 4� �..T1�°�C�Y ICaao�asoanaaa�aa.�m]I.' lE-7r��.11�Ikn. SITE PLAN � Name .�A�S CAw�aS Tax Map # a3 r��� � 3°�' Subdivision Secrion/Lot 'U� eA.4,�.C�` . Sr► t 11 \ Authorized State Agent Date System campaneats represent appmximaa contours only. The contractarmust 17ag t6e sysrem prlar to begiruiing the insralJation m iasurc rhatpmpergnde is maintained. � � � . �, ; _ �, � _ -� _ , , _; � ��� o� ' ` _ � �i� �� �, � � ��_-,�„i � `'��� � � 'o . ;,� �, �' �: �►' : :� �,�:�, �' �''°�°�,�� � � � �. �t .1 . �,�- . .� . x.��'� l�3'/l� y: � ` �r �sxs � � � : ���"� • �:' : � � 7` ��;;,,�` �,�ar� � -� � 5, " �, ��� p �:,� �� �'� �� :.: `� � � � � �'°� r � '�� � ��E � � � . �� � r� � ¢���� � � �,� �K p.�.4� �x�s��b Z.' (SR.. � .�" , • �„r �,�, f� t��,.� �' �:,. S�Ia�,�.. ��-- f ,� �� �.� _ �, - t��. �,ri��.-�C.�. • , �� .� . � ta�.w S1�,�1Y�E �a-r � ��*`'"' a�3s � � �ov"L A�1`� �cs �o `t�k 1.�:,� �t11�,� : s,n� b ��� S�xrt�f, � ' _ � �� �� � � h? �,,,. ,�� � : _ r�� �. 1fiT7 1 : 5t} Feei