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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
� IMPROVEMENTS PERMIT o.
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Owner. -
Contractor:
Water Supplp: Private ! Public
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Sewage Disposal Facililies: No. bedrooms � Dishwasher, Disposal,
washing machine, other autom tic appliances
Size of tank: j Nitrification line: r
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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-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INS LATION IS COV-
ERED AND PUT INTO USE. ^ „ _
Date approved:
Well:
Sewage Disposal:
By
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L� Sanitarian / �
C1„/ii\�, Y�S ,S�l ({ �rYi\u�
Counte�a��iO7 °�Pd O✓1 r%-3'�
9igned
(Owner or his representative)
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CertificaYe of Comple�ion �
Date Approved: _� By
nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
IV`OTE: 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 m rements in order that installations may be located
: at�ater ciate. No �e loc ion of er supplies on adjace ots.
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Renair/Re�lace exisUng 5epuc �ystem
Permit for New Well
Renlace Existing Well
1, permit requested by: . 7. Dimensions or Proposed Structure:
,,,,�,�PrMrosoectiv.e owner/agent: Width: 3o'X�0' �
ress:
ome Phone #:�i
usiness Phone #:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
,
d addre&s of cunen[ owner: ��e 9. Water su y ty pe:
� ' pcivate public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ No p.
If so, identify location:
3. Property Descrip[ion: Lot size:
. Tax Map#:
Parcel#: _
Township:
a 5. Directions to property: State Road #& Road
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10. Type of structurelfacility: Proposed: C�Existing:
Type of dwelling:
House: ❑ Mobile Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: y_
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�7 If so, # of basement fixtL
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Healfh Depal'tmettt for a site evaluation for the or
sewage disposal system for the above described property. I agree that the contents of this application are tn
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit c
issued, I must present a survey plat of the property to the Health Dept. IYS afte thetdate of the evaluah on
delivered a survey plat of the property to the Health Dept. w�thin 60 DA
� the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Signcc� Owner or Autho
Agent
Person County Health Department
Existing Sewage System Report For: Mobile Home Replacement ;��'
�Addition �
Requestee: �
3� 87 NG �� ZzN
F�c�ar� I�� ; I J�, nl G� 7a � 8
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Location/Directions:
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Home Phone#3c3(o- �Z -�19�
Business# �1�%- gS�-�p[}�
`Pax Map# 17�7 ' S �
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Original Permit Located
Septic System Uesigned For: -
kesidential V Business Other (speci�y)
# I3edrooms ^� # Employees Other �_
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Uate Tnstalled �-5`-% q Water supply " C`� � Wc�
`rype ot 5ystem `-l'�nv�,�iY�l7�'1Q,� r Q�l.l.(ll� CJ�c.�Q -�
Nitrification Line
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Tank Size � �� "�O.�t
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Certified Operator Required �V
On site wasL-ewater disposal system sliowes no visually apparen�
malfunction on IDID� ��
Yermission is granted to: �Q�� ��� � � (��,��
According to the attached site plan..
Comments:
Environmen�al Health S�i.
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