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The District Health Department
Orange, Person, Casweli, Ch `ham, Lee Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PERMI�' I�]o..
�„ DatA =-1 ! `: �
�wner. � �i-�����z�•�
Location: �
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Contractor:
Water Supplp: Private ..� �- Public
• ii — --• _�
Sewage. Disposal Facilities: No. bedrooms .�_� Dishwasher, Disposal,
_ ,
washing machine, :other automatic appliances
� �
Size of tank: ' �;� � � �,.' � � �'� �� � 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 INSPECTEB AND AP-
PROVED BY A MEMBEft OF THE DISTRICT HEA�:T�i DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV :
ERED AI�TI3 PUT INTO USE. , :�- , _ /
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Date approved: Signe� `
Sanitarian
Well:
Sewage Disposal: I Counter-
signed
By� (Owner or his representative)
Certificale of Com t' n
Date Approved: By
� nitarian
(OVEft)
Location of well and sewage disposal facilities sketched on back.
NflTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Amount paid � bp,60 /- (�- � g
Receipt .�E ' � G $ (�
, J � �0�3(� Date
C�-i�� � an�T.T('ATInN FnR SERVI�E�
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Improvements Permit.(EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) ._ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Im
Bacteria
ts P.ermit.(Addition�. •
_ Chemical
_ Replace Existing Well
_ Petroleum � _ Pesticide � _ Lead
. Permit requested by: .�'I��x � O`V��s'''� A� . Dimensions or Proposed Structure:
owner/prospective owner/agent: C'ouTfdA�foJ3L_ Width: �.� �' _
De th: �-� �
Address: �� I/_���!�/T -�- �/- _ P
ome Phone #: �i� Ci � 3�3 't� l�i �'1
usiness Phone #:1-g/ �i - .`f,�- J $7?
ame and addre&s of current owner:
�t���� �F. v'�At�'T
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►.��.�A r� r� �'. ,�77�5
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?
9. Water supply t}pe:
private� . public � community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
3. Property Description: Lot size: 1�1 � _
�. Tax Map#: . 02 - . Type of stcucture/facility: Proposed: �Existing:�
Parcel#: LO T S- SFG- �- WH �T STON c. Type of dweliing:
Townshin: �' ��N�v i�,►�.Na rv� House: �] Mobile Home: C� Business: ❑
S. Directions to property: State Road #& Road
Names,�tc. ,
Number of occupants or people to be served: G-
Type of business:
Number of Employees:
Number of bedrooms: � ``'fadd i `�-� ��'
Garbage Disposal? Yes ❑ No�
Basement? Yes ❑ No� If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'Soi1 COunty Health Depat'tment 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 true
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 shalt become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the propercy to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signc, Owner or Authorized Agent
Permit Issued ❑ Signature Date
Permit Denied ❑
Plat Observed ❑
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9. SCfECLASSIFICAT70N(SEEBELOW)
SOIL SER(ES
S-SUITAOLE PSPROVLSIONALLY SUITAIILE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAIv1(Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� etC.� C:V�MIPR0IDOCSIAPPSEC.5�1 FlNANCE.PC
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The District Health Department
Orange, Person, Casweli, Ch `ham, Lee ��ounties �
Water Supply and Sewage. Disposal
IMPROVEMENTS PERMIT No.
Datc� —� � ` T�
! d
�wner. � �' � . r'�,�--, �� z�
Location:
� � .�,1 >
IContractor: .
Wa2er Supplp: Private �— Public
Sewage Disposal Facililies: No. bedrooms �� Dishwasher, Disposal,
� washing machin.e, other automatic appliances
• Size of tank: � ;�,> ; � �: Nitriflcation 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 ]ine MUST BE INSP�CTED AND AP-
PROVED SY A MEMBER OF THE DISTRICT HEAi:T�I DEPARTMENT
STAFF BEFORE ANY POFiTION OF THE INSTALIiATION IS COV-
ERED AND PUT INTO USE. • � ____ .!__.
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Date approved: Signed ' '�
Sanitarian
Well:
Sewage Disposal:
By:
Counter-
9igned
(Owner or his representative)
Ceztiiica2e of Com !' n �
Date Approved: � � BY
� nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
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Person Coun�y Health Department
Existing Sewage System Report For: Mobile Home Replacement
�dition
Requestee : I►�QGk �• � V e f►MQ,+'�
S� 1� ��.Po n-�- C,�-�I 'b'
�u� �a►M, NL. �-`7�D�
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Home Phone#�� -3�3—�/99
Business# � � 9�'yZz-J�7"7
'rax Map# �4-ay-7�
Location/Directions: �G l�Y1e.f_ s I r i�� � rl�-- i i'1�0 I�JY�.P�TS'�e
C�X �•
Original Permit Located L�
Septic System Uesigned For: -
Kesidential V Business Other (speciiy)
# �3edrooms � # Employees Other `_�
Uate Installed �`r� — 7`7 Water supply f,�iQ�--�
'P y p e o t 5 y s t e m �=U (1 v 2i�1 '%,� or li U� f�7��_c�i�".� �
Nitrification Line �"t � ��k3 �
Tank Size
Certified Operator Required � \
On site wasL-ewater disposal system showes no visually apparent
malEunction on b /`'� I � �
Yermission is granted to: c,{CK- ��P� 1i')Qy1 �Y
�
� 0 be-�(�F- � �Y2C�-
According to the attached site plan..
Comments: �� � (�fit ����L�Yi �
Environmenta:l Health �'�'y.
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Person County Health Department
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Existing Sewage System Report For: Mobile Home Keplacement
Addition
Requestee: �! , C s�J �IJV Q�(l��c-✓�
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�ln,. � r << �n�
Location/Uirections:
Original Permit Located
Septic System Uesigned For:
Home Phone#�'/`� �g,�6iQ9
Business# `�`� `�o����%%
'Pax Map� �l ~��
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e
Kesidential _J,� (3usiness Other (specify)
# Bedrooms � # E�mployees Other _
Uate '1'nstalled -� �� Water supply ��, JQ�P
'rype ot System l� �) � V�1 rt-in (��ei
Nitrification Line �t LX.�,���
Tank Size
Certified Operator Requ red �/!�
On site wasLewater disposal system showes no visually apparent
malfunction on ���/ Q�
Yermission is granted to: �����T� �iY��-�"1—
According to the attached site plan.
Environmental Health
DATE