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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 �� �� � " �'� ',� Location: f•� ;t +;;�''"_." � � /��r en �,,4-k� Contractor: � h � � ` ... N• � �- Water $upplp: Private ,,^� lic � ��:'.. .,,G-tf;.�.�,;aF �L.� .� ,� , f f7 .,,,a- - '�.� K .,-c:�.�.,.. .�.�s�e, �� . 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: .` ��,,. Signe �`�f."'7.rvs,.",, �, ��'^.,��..:,, Sanitarian�� � Sewage DisposaL• Counteryf,o�',�/ � � t � �c �c� By _ ` signed ' .� � t ,� , _0 �. (Owner or his repr senta e) �- �' 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 ( � (1J',, (2) -- -- - � �. � -- � � � - - .. � ���Ie�����.r�Y ������������� o�r����������s� �oii��i���� '��..� ��������,������� ■si.:�=::��c���� ���o��������■ ■���■��������:� ■�������i����� .......�.�.�. .�- 0 Application Date: Amount Paid: 15b•OC7 Receipt #: �����.. � 1t' ��� �� ' -� �C � ��1�T'1L� �� �aav�aa-amaa�^^• <oaa�mIl �a�.m���a 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 �, ''. � �� � � �. , � �� � ~ �� ^� li_.' �J �..J .b. � � J�. �s�rn�~n�a��rn.n�n.�zrn�.m.�. ��.�,���. �ualcfling A�dfl�on5/ l�obile �oane �e��ac�a�ae�ts _—�7 N -� 11g � � � Tax Map #: (� 23 Approval Requested for: Applicant Name: Address: � �� Ra -'� 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. ►:.r, : 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� � 3 - aa-o(o Environmen Health pecialist Date 11/15/OS :�� ?� )� ���� `LJ'�.. �'1 � `� �.1� ��� IE�-�y-�,r,,,,,,-„ ���.ffi.11 ]H[��.]L�]]� SITE SI�']CC�I Name J��s�rd Ta.g Map # A 23 .Pa:tcel #� Su division Section/Lot# - 3- �a-zY� 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 �l� � � � r� ` �u, �cale• w2.1 I v4 • ' � � ' K�p I-,o�Q �s.. ls��- l C� �'� �., �.p'h� o�•z — a5 �. � � . ____- 2�' �r��' . �� ,�}-�---� � ex��: &,J � �f'a"� V � Pf � �y� �h a. �— , , �. �T �'` I � _ -- -- -- _ � ' � �1 �nv , �'°S� ��' c.�a.�. �^�- r^� \ C�l�q.��.t�n �. �..5�'? -1"7g�. w• � PGHD, rev. 09/12/Ol