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PERSON COUNTY HEALTH DEPARTMENT
WELL AND S�WAGE SITE, LOCATION IlV�ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has fneen issued.
Tax Map #_ a Parcel # �
ZaninQ Townshin Cv n n i'n C
Owner/Contractor �/�� v� S t/�i (� ..�e U1 i v��r TSate J/-/S — y 6
Location/Address uwnri �� r�. .- �r Y,�v�,� � ,�
S�c� �'�,�3 � sn#133� .�o 57�� / s.R.# 3v`' .
c�r�'�P o
Subdivision Name Lot# / �,��-
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area�<�� Size of Tank � �� S;� �
SFD Mobile Home Size of Pump Tank ��
Business # of Bedrooms� Nitrification Line ��
Max Depth Trenches
Permits may be voided if site is altered,
Well and Septic Layout by
Comments:
Date ' �' � Installed by.
Well Permit Paid ❑ E]
Individual emi-Pu
Public Replac
� Site Approved
Well Head proved
C� Groutin pprove
Co ents:
ate I alled by,
'�Approved by.
ECIF 'TIONS
equired Sla
Air Ve
Re� 'red Well Log _
�Vell Tag �
_ Approved by
This report is based in part on informat�on provided the homeowner or his/her
representative in the application submitied for this permit. The environmental
health specialist is not responsible for faise or misleading information
contained in the application. The enviraumental health specialist is also not
responsible for concealed conditions on t�he property or for statements in this
report that may have resulted from fals� or misleading statements provided to
him in the application. Neither Person (:ounty nor the environmental health
specialist warrants that the septic tank sys�em will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�
AUTHORIZATjON FOR WASTEWATER SYSTEM CONSTRUCTION
'- (Void sixty (60) months from date of issuance)
DATE: ( I_. � S- 1 lo IlVIPROVEMENT PERMIT #: �,SO
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: G P h�i •S � V�-�/ ��c� �r d�' �Cv
LOCATION/ADDRESS:
s�Z� ���.� � S� .� �3 � � ��� 13 /� -�a
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SUBDIVISION
SECTION OR BLOCK:
LOT #:
AUTHORiZATION FOR CONSTRUC,T��ON ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #_��O The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
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P�ic�, s�l��-P �c,V1, c <.� �—Fe �•.•
Person Requesting:
,, ,
�r -' The District Health Depar�ment ;� , . ;
• � • � ` CASWELL - CHATHAM - LEE - PERSON COUNTIES �
� �� � ' �
. ��' :��iNater Supply and Sewage Disnosol
. ;�• 1��� f, IMPROVEMENTS PERM� iNo. r �
.� p � . Date 'T=l�_� �
. ,
�,a' o Owner: �"� �' ��G4� . `�� #
�� r pq Location: � , � .
�'�+V��lC �� � :� ` � �
,��� � �
. � � _ : �
a, Cont or• � '� • ;. '�� 1 ;
, � _ � ;:, �
� Water Supplp: Private Public �
�'� ��`
Sewage Disposal„Facilities: No. bedrooms � Dishwasher, Disposal, '
_ waslung machine, other. automatic a liances �
.
. ,,:
_ ._ _._._ __�..__�. .._ PP . `
. Size of tank: w` t: , N�rification lin � �
_ ,: .
,
Other disposal facility: �� ����
Water supply and. sewage disposal�acilities,location, installation and �
protection must meet state and` local regulations. -
5eptic tank should be pumped out eve 3 to 5 {
1`Y years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard. i
Septic tank and nitrification line MUST BE IN
PROVED BY A MEMBER OF THE DISTRICT HEA TH DEPARTME.ANPT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
'' ' ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal•
By:
Signe � ,���
' Sanitarian - "
Counter-
aigned
(Owner or his representative)
��
Certificate of Completion � ^ '1
Date Approved: ! �� .' � - � �By. ` ('"�. ( ��
• Sanitarian .LJ
(OVER)
Location of well and sewage disposal facilities sketched on back.
_ ...
F;�-Y �_y�. _r�^_.�����.'N�`.-V.~__`� ---�`�..�..^.�~`�*.a...-� location of house, septic tanks, privies, water
$ �����: Make sketch of installation showing lot size and shape, be located
k ���� �`'p'p'lies, eta Note special problems existing on lot. Write in measurements in order that installations may
? i�� at later date. Note location of water supplies on adjacent lots.
----� l (2)
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