A23 74The District Health Departrr�ent
Orange, Persoi•., �as"well, Chatham, Lee Counlies
. �
Water Supply ond $ewage D�i�posal
' IMPROVEMENTS PERAflIT � .
+ Date ;`�5"`' ��P �
Owner: � '�" u �� �� �
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Location: f•� ;t +;;�''"_." � �
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Contractor: � h � � ` ... N• �
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Water $upplp: Private ,,^� lic
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Sewage Disposal Faciliiies: No. �b �cr�h�,.�i# er isposal,
c..� �. • t
washing machine, o er. auto tic appliances • �
Size of tank: t� �` t'' �� 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PUT INTO USE.
Date; approved: —
Well:
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Signe �`�f."'7.rvs,.",, �, ��'^.,��..:,,
Sanitarian��
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Sewage DisposaL• Counteryf,o�',�/ � �
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By
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(Owner or his repr senta e) �-
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Certificaie of Com�s'I'eti n %���
, �✓ � C / t�t v
Date Approved. � y.
anitarian
(OVEft)
Location of well and sewage disposal facilities sketched on back.
\ NOTE: Make sketch of installat�on showing lot siz and shape, location of house, septic tanks, privies, water
supplies, etc. Note special proble s sti �g on lot. rite i asurements in o der that ' st llations may be located
at later date. Note location of wate sup�lies on ad' ent lots. , rl
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Application Date:
Amount Paid: 15b•OC7
Receipt #:
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APPLICATION FOR SERVICES
Tax Man #: 1'1' V ✓
Parcel �: � �"1
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
CHANGED. OR THE SITE IS ALTERED, THEN THE IMPROVE�/IEI�I' PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. - �
1) Pertnit requested by: (Owner/agent/prospective owner): �–�/� V�'� _7"� ��
Home Phone:, � a ,a � �-��r %2-L:�u Address;i 3� �'i:--' -� ' "
Business Phone: ..� , . ' , � ' c� ��
2) Name and address of current owner: —J �` i�v�'���i�
-�a J � �.°?,�i�� ii�
� � ,�J, �Z' � ' �;�I� j. �
3) Property Descrlption: Lot size: �A=-�y"f' Township:�v�����- y;�ubdivisio : Lot#
Directions to the property (Inciuding ro names and numbers): r� �'',•• r' �,�A'' 'Jrz�- �
� �i.F! i'� ��Y"-- r � � � �.
4) F�roposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing ,�ype of Structure: Width: 2�i' Depth:�
b) Number of Bedrooms: -_� Number of occupants or people to be served: _�
c) Basement: Yes . No �, VNill there be plumbing in the basement? �.J%"
d) �arbage Disposal: Yes , No �
5) Water Supply Type: Private ✓(new _ or existing�, Public� Community� Spring _
Are any welis on adjoining property? Yes_ No �L/If yes, please indicate approximate location on the
'site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No t--
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 PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED.
➢ THE SITE MUS'� BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application.to the Person County Health 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 tnae and represent the maximum
facilities to be placed on th�-property. I ynderstand if the site is altered or the intended use changes, the permit shall
be�ei?�valid. _ // %
or L.�gal Representative
3- l��j�
Date
PCHD, rev. O6I27l02
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Tax Map #: (� 23
Approval Requested for:
Applicant Name:
Address:
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o-�
o� } L'i.�+�n
Parcel#: iy ^ �"'
s-k�,� �r�o d�;•to,�C, 1�b�
�� Mobile Home Replacement �� 38z st'�• -a Ut o�- �
Buildi.ng Addition ��.,�.� �� �. d•+ Q a
1� 1�+c�v�s o•. S2.
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Phone #'s:33to � �3�.� _ 7�3
Permit Located: x Yes No
Installation I�ate: 5-/�/� �l� Design flow: Z.�{O (gpd)
Current Contract with Certified Operator on file (if required): n�
Water Supply: �_ Well Public or Community
Wastewater system shows no visual evidence of failure on: 3-���a (date)
(Applicant's signature if site visit is not required)
Comments:� l��,Re c1 �,¢a�,�. ( c'� F�'� �i�+ c.l /�D� �
�dd'atno�eplacea�aeni App��ve�
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Environmen Health pecialist Date
11/15/OS
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SITE SI�']CC�I
Name J��s�rd Ta.g Map # A 23 .Pa:tcel #�
Su division Section/Lot#
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Autho ' ed S e Agent . � Date
System cvmponents represent a�bproximate�contours only: The contractor must, flag the systemprior to
beginning the installation to insure that pro�iergrade is maintained
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PGHD, rev. 09/12/Ol