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The Distr��ct Health Department
Orange, �'erson, Caswell, Chaiham, Lee Gounties
Water Supply and Sewage Disposal
ate ����
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Owner:
Location:
Contractor:
Water Supply: Private Public
Sewage Disposal Faciliiies: No. bedrooms ---� Dishwasher, Disposal,
washing machin , t auto tic appliances r`
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Size of tank: • Nitrification line: �
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on- information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use.
Date approved: — � "" .�
Well: '
Sewa��sp 's�aL � " �
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By.
Countersigned
� ERTIF TE ,f�' , MPL 10
`"'' ' � ������
� Sign _ .
(OVER)
The Dist�ict Health Department
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
su�plies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date.
` (1J _ � .� , � __I�1 `-i— �_
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The Disfrict f-lealfh Departmenf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date -
h y� - �3
Name of owner: !-� �� ✓�'� � �
Name of contractor: �'a h�J n� Dj � i? [' (�
Address and Directions ��� TJ��TIYi G �
o F F-���" p F��P�r�l i�� 1�2 R.
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Person or firm doing installation:
Address
No. of persons to be servec� Bedrooms 1,43, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine �,� +� � �
Recommended• Septic ta �
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecled and
approved by a memi�er of !he Disfric! Health Department staff before
any portion of the installation is covered.
Date Approved: � �'�'
By
Couatersigned
Signe�
Sanitarian
O. David Gazvin, M.D,, M.P.H.
District Health Officer
(Over)
�TE: ke sketch of installation showing location of house, septic .tanks, privies, water supplies on
t p'��acent property, etc. Write in measurements in order that installations may be located at later
� � �p� date. ��
SUGGESTED INSTALLATION (Date ) FINAL INSTALLATION (Date � )
(Road or Street) . { (Road or Street) '
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� I I � I� I 'I I� I I I+'"F t� • I I I I I... I I I ( I I I
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Application Date: � -) �2 -d �
Amount Paid: I �'0 , 00
Receipt#: � 8�� a3
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7E� 3rn.wn v: .ra v�n.:�ra-n. ¢.�+.n-n.d..en..11. IF'�C .�.�.�ll. s:.ika.
Application for Services
(Seotic Svstems and Wells)
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
� Mobile Home Replacement or Building Addition
$ I50.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: �--2�"
Parcel #: 10 �
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
" No Char�e
Important: If tlie information in t/ie application jor an Improvement Permit is incorrect, falsified, or the site is altered, tl:en the
Imnrovement Permit and the Aut/:orization to Construct shall become invalid. _
1) Services Requested by
Name:�Joc� -Powell��De.s���+ leci� %3�ldeRs
Address: flo (3oX I a.5
RoxhoRo } r� G 2-,"157-3
Phone #(home): 33 �� 59 R- g8 g 5
(work/cell): 331� — S 0 � - 0 �.I .�i �
2)Name and address of current owner (if different than applicant):
Name: �R��IciS 9- (3R�r�da (3c��
Address: --
rn,d�.lo h,AN VA
3) Property Description: Lot Size: � A C-
Address and/or directions to Property: _
�-I-o 2� d cn-N�- Q�z o N R► h}.
' ui' Roo�_ �,.i}�r�e. %ous�. Co? e�� o-I
Ye.RA �.o
Ro
� ca�� �o
� a�'� �� - 1-e
N` . � ��b
Subdivision: �o� �'�ave2 SN.bd �u Lot #:
TR��I - frlcGi�ces (Yl�ll o Si�oat U2�v�
'ii oa 'f'o .� Rci �-4-�}' n Ni'o .51) VtRAdo T2Q�� •
4) Proposed Use and Type of Structure:
Residential � Business/Type: Other � e Yb o�
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Ye3'� No _(with plumbing: Yes`v No � Garbage disposal: Yes _ No �
Approzimate size of building foundation: Length �(a r Width I(o �
� �dd ��-��.
5) Water Supply:
Private Well� (Proposed Existing � �
Community Well: Public Water System: ;a
Are there wells on the adjoining properties? No Yes �i (please show location on site plan)
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Note: A completed application must also include:
➢ A platlsite plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of tJte `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Si nature Owner/Le al Re res a i W � Date: ��1 ��
� � � r
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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F,u: k ;;f� r.ib r�a�c r,•— �rL - 3s: 1 '�t ���' e-- i�.. t� ���E
�a�a�� ����-d���! ��b�� �o�e ��������t�
. Ta� ibia.g �:���_ Paac�i#• �1J -� . . .
A�pmv�t R�queste3 for. � l�obile Home I�glae�meut
. � � Buildiug �ddition � ' �
A�plican� t�me: �r�,T�,i s�. grp� �o �e � I .
� �s: � • .
��h�n�#��: _ 3 - _ — 2� e! �ic•�ell1
. . . . . Ge)� J
Pezmit Located: v �'Yes No .
Installa�aon Date: u'Z.S-ly D�gri $o�v:. 3� �(gPd)
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Cu�nt Contraet �vith C�r�ifi.esi erator on fiie {if res�aures�: . .
�l'ater Supply: i�Ie�I � Pui�lic or C�mmu�.ity '
. � . � , .
�i7ast�water system shows no vi9uai evidens� of faiiui� on: Z- Z 1 o f� (�)
��. {A�plicant's si�e if site vasit is not �ed) .
" � �da�a� ����� �p��e�s�
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' Enviro entai H�aith �pe�ialist � Date
� 11/13/�5
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IE�.�u-��,r,.,, ��.�.H. IE-3C��.fl�
� SITE S�'I`CH � .
Name �ranc'•iS � gr�nd.a QQ,�� Ta.zMap #�,� �Pa:tcel # �6 - D
Subdivi ' n _ � Section/Lot#
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Autho�ized State Agent . � Date .
System cnmponen�s s�present ap�iroximate�contours mnly: The conf�ricior must, flag the systesn�Drior to ,
beginning the install'ation to ires�re thatpropergrade is maintaisied
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