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The D�istrict; Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PER IT N
Date � �
Owner:
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Location: �_
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P ; � .s�
C T s' � , .. `' �
Contractor: � � �� j f �
Water Supplp: Private � Public
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other automatic appliances
, . . i � , i' ..----�--.' �_
Size of tank: ���J - _ '� � � 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 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 DEPAR.TMENT
STAFF BEFORE� ANY PORTION OF THE IN$T�ALLATION IS COV-
ERED AND PUT INTO USE. ,
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Date approved: Signe � �a�` '� '
Sanitarian
Well:
Sewage Disposal:
By
Counter-
signed
(Owner or his representative)
Certificate of Com leiion � _
;
Date Approved: � By:
anitarian ,
(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
s lies, etc. Note special prob ems existing on lot. Wrste in measurements in order that installations may be located
at la r date. �Tote 9�cation �f�water supplies, on adjacent lots.
(1)
'' ..
5
(2)
Application Date: � u�'
Amount Paid:
RecEipt#:
Tax Man #: � 3
Parcai #• 3�
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ZF aa��.a—msa-a�—�--� .D��mll. ��o.eo.11.-�7la.
APPLlCATiON FOR SERVICES �
IF THE INFORMATIOfd Ild TFIE APPIICATiOPI FOR AN LMIPROVEMEiVT PERMIT IS INCORRECT, FALS1FiED,
CHANGED, OR THE SITE IS ALTERED, THE�1 THE IiNPROVEiViE9AITT PERMIT AND AUTHORIZ�4T7ON TO
CONSTfBUCT SHALL BECOAAE INVALID. •
1) PeRnii requ ed by: Owner/ ent/pros�ective owner): �G� / ��
Home Phone� .�%� • d, /� Address: l�� S,-�� .�
�usiness �h�ne: �. v y
2) Nam� and address of cumerrt owner. � -� � �
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5 !� Z
3) Property Description: Lot size: Township: Subdivision: Lot #
Directions to the property (lncluding road names and numbers):
4) P'roposed Use and S,truc€ure Description: answer e ctt of the following questions:
a) Proposed . Exis�ng Type of Structure� � r�% Width: �� Depth: �, �,
b) Number of Bedrooms: � �. Number of occupants or people to be served: � _
c) Basemen� Ye� . N�Wiil th�e be plumbing in the basement? -
d) �arbage Disposal: Yes _, No � �
5) Water Supply Type; Private �new _ or existing,�Public� Community� . Spring _
Are any welis on adjoining property? Yes_ No _ If yes, piease indicate approxima#e location on the
'site pian. � . ' �
6) Does your property cantain previousty identified jurisdiciional wetiands? Yes_ No�
PLEASE NOTIE THE FaLLOWING:
➢�4 PLAT OF THE PROPEiZTI( OR SITE PLAN 11flUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTf UNES AND CORNERS MUST BE CLEARLY MARfCED. �,.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf�D OR FLAGGED.
➢'PHE S17E NiUST BE READILY ACCESSIBL� FOR AN EVALUA710P1 BY THE HEALTH DEP�a►RTME3VT
� STAFF: �
( hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the cantents of this applicatio� are true and represent the maximum
facilities to be placed on the property. I understand if the siie is aitered or the intended use changes, the permit shall
become invalid. „ , .,
or Legai Representative
L/ �� �
Dat
PCND, rev 06f27102
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