A24A 32� The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
.�
'�� 'Water Supply and Sewage Disposal
IMPROVEMENTS PEAMIT No.
,
_ i; 4'Q1D a;;:r 3 Y'ear. Dat - -
� Owner• ,�� ',T �,� 1e �' �' �� Y�t'„�;
pq Location:
�' � .
.,
Q, Contractor: �
�a -."
� Wate: Supplp: Private� Public
� Q t� � � �
��;.L ^ V S ` ; !" ' � A .
3ewage Disposal Facilitfes: No. bedrooms�� Dishwas}�er, D sal�
;�washing inachine, other automatic appliances' �p u''r �F d Ya' �, i e c✓1" °�
� Size o1: tank: Nitriflcation 1Y�i .
,. ,: � � t
Other disposal facility: �� `�rL�
�,•f� N�ny
Water supply and sewage disposal facilities location, installati�`�it� �
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be mairi-
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 DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
r-
;
Date approved: Signe
Sani i
Well:
Sewage Disposal: I Counter-
signed
BY� (Owner or his representative)
�
Certificate of Completion � j `' ;' � .i
t ' /��� j ,,,_,.....
Date Approved: .1.� T-� By' ,
Sanitarian
(OVER)
Location of well and sewage disposal facilities slcetched on back.
A�Qitcahon Date: I �� 7'43
:4mount �eid:
Rec�i�
Tax Man #• � Z�
Parrxl��: 1 Z Z
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APPLlCATiOM Ft3R 5�RVlC�B •
1j Penr�it reque�ted by: (Ownee}agertt/pms�va owner'): '%!� 'rri (�� ���5'-�
Horne Phone: �• - S'"�'7? Addreas:, 3.�"� C� s ����
Busineas Phone: 9- d , to x.�{ �) ; N� ,� ?��"
2� Name and alddtess af catrr�ent aenreeer; �`n�► r� i �Uw �� S
3j Pr+��serty Des�c:iption: Lat size: Townshlp: Subdivision: Lot # �
D(re.dians to the property (lnduding�r�t names•and numbers): :) �- � i'n� ��a n,. t��'� `
4) i�ro{�os�d U�n ansi Stru�turs D�sc�l�n: answer eact� af the f�ilowing questbons:
n
a) Proposed _, Exlsting Typ� �f Stru�ue: ' Width:_,� Depth:�
b) Numl�er af �edroams: � Number �f occupants ar peopte ta be served: �� v -
c) Basement Yes . No ✓WW there he plumbing in ths•basemeni7 �.9� � t�
d) 6art�age �ispasal: Ys� . No s� 5 G'rc ,gt ���%x :y
�j 1Nater ��P�� Tj�p�: Prlvate �_ ac e+xlsiing_ j� PubUc_, Canmwilty�. SP�9 �
Are any wells on adjalning property? Yes No _ If yes, please indtcate appt�nxlmate locatiari on th�
sii�e pi�n. •
' 6� �oes yaur propsrty contaln_previously id�ntifled jwrissdic�n�i wetlands? Yes,_, No �
�j ���iCl[-�li�,� �QiTIC:L�
➢ A PLi�T OF THE PROP�T( t�R 31TE P�AN MU9T 8E SUBMRTE� WI'ii�i THIs APf�l.1C�►i10N.
➢ PlZOPERTY UNES AND CORldER� IIAUST BE CLEARLY MARt�fl. •,
A THE PROP08ED LOC�4TION aF ALL STRUCTURES adlJST BE STAkED OR FiAGGEi'�.
9 THE SITE MUST BE READILY ACCESSIBL.E FOR AN EVA1.UJiT10N BY THE NEl�LTH DEPARTiItftENT
STAFF. � � �
I hereby make applir.ation to the Person Caunty Health Department for a sfte evaluatlon fior the on-site sswage �isposai.
system for the abave-descri6ed property. I agree that the cor�tents of this applicattan are true and represent the maxirciux�.
faciii�es to be placed an the praperty. l understand if the siie is aitered or the intended use change9, the perm� shalY
b � invaild. •
� �� � � ��
--_,� r
Cwner or Legal Representa�ve
=a �-�3
Date
Pc•�. ��. ost271o2
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cac�P ,�. ,��
�pitr.atfon Date: i��'�� �Z
Amount �aid• � c�.�� �
R���c �: �,�—�� �
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r �Tax flAa #•
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APPLICATt�N F-0R SE3i1/IC�S �
IF THE INFaRMAT10N IN THE APP�CATtOi�l F�R AN IMPR�VE�AENT PERAAIT 1S INCORRECT. Fe4LSl�iE�J.
CHANGED OR i'�iE S1TE IS AL'TERED THEAI i'HE 1MPROVEAAENT PEi2MR AND AUTHORIZ�4'f90PJ TO •
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CONSTRUCT SHALL BECOdAE INVALID. � .�tY �
1) Permii requested by: (OvmerJager�t/prospeciive ne • h''GS�� r� (�� .
Hame Phone: �i— jl�f � Address: � -e
Business Phone• 3 —/�i 1� �� rnar� �3 �
2) idame and �ddress of ca�rrent ov+mer: 1r��t i�S ��2.n(� �e hk ( nT.S
' -� a rn _ a- � Q_ a�J'-t—
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3) �roperty �escription: L�t size: � Towr�hlp: �unniw� Subdivision: Lot#
Di�ctions to the property (Induding road names�and numbers): �• c'�-o. � e. ,
�' -
_ ` b 1 � pr� �1'15��,�
��.5 dr��c ar t-� �.�- a� �hb�w i. g�., . v
4) Pmposed Use and Structure Desariptlon: answe�eact� af the foll 'ng questions:
a) Proposed � Existing �Type of Structure: ��-� �r b�i� 1 h��s e Width: � Depth:
b) Number of Bedrooms: � Number of occupanis or people to be served: -
c) Basement Yes . No,�,ciNill there be plumbing in the•basement?
d) CSarbage Dispasal: Yes , Ido ,�-
5) 1Nate� Supply Type: Privafie �new �r existing�� Puhiic . Camm�sniiy' , Spring � .
� Are any wells on adjoining property? Yes No _ tf yes, please indtcate appraximate loc�tion on the
'siie plan. .
6) Does your property c�ntain_previously ider�tified �wisdlctionai w�lands? Yes_ Ido I�
PLEASE NOTE Ti-lE FOLL0INING:
➢ A Pl.I�T OF TaiE PROPERTY OR SI'T� PLAi�i flAUST BE SUBMITTE� WITH 'T6�i1S APP�lCATION.
➢ PROP�TY UNES AND CORNERS MUST BE CLF�►RLY MARl�D. �,
9 THE PROPOSm Li7CAT10N OF ALl. STRUCTURES MUST BE STA6�D OR FLAGGEi3.
9 THE SiTE MUST BE RE�DILY A�CESSIBL� F�R AN EVALUATfON �Y THE HEAL.Ti-i DEPARTMEiNT
STAFF.
I herel�y make application to the Person CouMy Health Department far a site e�aluatian for the on-site sewage disposal
system for the above-described property. 1 agree that the cantents af this application are true and re�reseirt the maximum
faciiiiies to be placed on the proQerty. I understand i� the site is altered or the intended use ct�anges, the permii shail
become irnalid.
� O�-�0. �� � ` �' -��a�'
Cwner or Lega! Representative Date
Pcan, r��. aslz.7ia2
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�'3..E�SE SEE A'i'�A�i) ��11V FOIt WE� SY"�E L�YOiJ'I'
T�� #: a r� �az�# 3a �m�p
�PPlican� ��'�`� ItS P�r K r'n S
Subdavision: Se�ion: Lo�
Locatioa:
'I'�pe of Wa�r San��lv: �Iradividual Commu�itp Public.
��uireffie�ts-
Site Approved by �� � � �3 �'
Gmut�ng Appmved. bp -S �- �i-4-o4
Well Log ✓ � � `� � -04
WeJI T�.
Air Vent
Hose Bib
Coacrete Slab
Well I)r�ler.
Well.Approved. �g�: D�te•
�°See Attachesi Site Sketcla'�
WeDs must be 14 feet from pmperty liaes.
WeI]s must be 100 feet from septic systems. �
Wells must be at least 25 feet from anp bu�lciing foundation•
Other conditions:
s�s
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3��P s' '
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'? � 7 C R-EE K
'� Q.S i'�'��aS�rc.d
q-3-o3 �
Wc[l Q-i�
On loc.a,-�ia^
PC��, rev. 09/07/01
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3
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ir-..S��Il7i'�mm iemm �Ba1��tL.1L ���.��Y3
�r�Gs Per'K�nS
isiAn P�`ncs loorou� �,
Authorized State Agent
SITE SKETCH
, Tag Ma.p #�� Parcel # Q3�
ES-E�-t-�s Section/Lot#
l l'S—�
� Date
System components represent approximate �contours only. The contractar must, flag the system prior to
heginning the installation to insure that propergrade is maintained � � `
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� ��PP�Y �'n` �as bccn exPos�d
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Scale: � �iG�S`
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PGHD, rev. 09/12/Ol
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WELL I'ERMIT
PLEASE SEE A'�'TAC�IED PLAN FOR WELL SITE LAYOUT
Tax Map #: 02 � Pazcel #�� Township
Applican� �i' ��l cs pt r K� n. S
Subdivision:
rJ (��,� Z i on Lcu �
�,d. (� P.�i,irboca_R.�
Section: Lo�
Cl, �.c rc�+ fZ o�+. c� ����n c,s bo�o�.�-5 �,
T�pe of Water Sunnlv: ,� Individual Community' Public
Requirements:
Site Approved bp ��`� �����
Gmuting Approved by �/S �k �1'.�`1"�3
Well Log
Well Tag;
Air Vent
Hose B�
Concxete Sla.b
Well Driller.
Well Approved By: Date•
'�°5ee Attached Site Sketch'�
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be ax least 25 feet from any biulding foundation.
Other conditions: �/15�, (< 1..1 c. �� GLS S�. 0�.�✓1 —
PCE�, rev. 09/07J01
il--�.��- ,��.� �U.�..�� ��:�,. .. ..:J .� �a_..,�y .
�, C� �U ��.J .l. �1 �l. t 1>>-- �"l:. -�J ��i�(nnX:) ��l �1 r�_'-��c 1 �r � ; �, n.5
- --, ._�' �'� DU�UOC�1 1
.U.�.1L7L�Y']LJL •� 3LT.7i7�:A.�t3 JL'A.ii�..:��. �l. �.1. J.�•C.:.h.�� tl:J�:P. 7� " ��03
. ��� �Ob
/ � ' �1�.L1 1���:1() �� ��:U'CC� ir �3 1—
� WI1CC: n I� �.cs /�1�,�. r� n c 4
Location: �'n � 1�.� ,-.�.�, Ec -��, ��. �! ��, „ bn l , � �_
Subdivision: _ Lot IF �
b��cil Coxiscx•uctiozi
Distancc From �lcarest 1'ro��cx•ty Li�ic (IvTi�iiinum t(; f�e:t) �"_.._�____.......
Distancc fron� Scpcic System (Ivlini�num GO icct) �
Total Deptl�: �6 z—R Yicld: %_ GI'M S�a�ie W;►c�r L�:vc:l: ��_____ ll
Wacer nc:arinb Zoncs: Dcp[li 10 D tt it _.�� _��
Casiub:
Depth: From (� to c� Y (l. D11111CCCi': _�;. in
Type: Galvanized Stcel '� �� �
Wci�ht: �� ':�hickness: � I•I�i�;ht abovc Ground: ___/ � ill
Drivc Slioc: ./" Ycs No 1111y �7fUVIC1'11J C11CUUl1�Cl'CCi W11lIC sc:lti�i�; c:isii�;;'? __ Ycs �No
��`�CS" �,'1VC I'C�SOIl: _. �__.__
Grout:
N�at: Sand/Cemc;i�t �i Concrcic Gxavel/Cement
,�1.ru�;uiar Space: Wid[�i �_ inches Walcr ii� �..tziiular S�ace Yes `— No
Nlethod o�Grout: Pumpcd z'ressure ' 1'oured `� Dcpth {� to �t.
iYXatcXials Uscd:
No. B1�S POIIla11Ci CCI11CI1� WC1�Ill' Q��' 1 13:�;; ��._ l'��uud�
I� I111:C1U.1C (sZnd, �ravcl, ctittin�;s) — Ratio _� to �
IU plates: �cs N� �� x�b s1aU �-�.'cs �__ No
Urillizib �.ab Loc:�tiou JJrawiiz�;
't hereby eertify that tllc aUovc ii��onlla�iot� is cot�:ec:t azld tl�at t1�is wcll �vas constructcd in accordancc with regulations
sct forth Uy tlic Pcrso�i County I-Icslth Dc:p.lrtmc��t
Si�,tahirc of Cozztractoz• � il) t� ��,�-- I�:ltc: _�— �%� d3
PCI�D rcv OII16102
Person County Health Department
Existing Sewage System Report For: Mobile Home keplacement
� Addition
Requestee: �� � Home Phone# 3j6— aj�—i`f4'-l�
fv� 1��_�� �J�/�_`c._e� Business#336� s9j— 9lz (o
� 'Pax Map# �- a �f-�
Location/�irections:� ��3 �- �,c.%�Q ���� '
2. �r�,,, ��� �. C S, �� I 3/�+)
� �
Original Permit Located ►�
Septic System Uesigned �'or:
ltesidential 1/
# Bedrooms ?
Business
# �mployees
Other (specify)
Other
Uate lnstalled �f� ���� Water supply
'Pype of 5ystem �--
Nitrification Line v C��0�4 3�/
Tank Size /�-6-
Certified Operator Required �D
On site wasL-ewater disposal system showes no visually apparent
malfunction on �� — 3 /—Gl'�%
Yermission is granted to:
ccording to the attached site plan.
Comments:
!� ., „� �( .������r
Environmental Health $'�C.. �it/�� � _% 2— 3�—�/
DATE
...���. �,� 1�-J I ��'. �.�.� ��J ��
`_' ` --� c� c0 tU��( `�C` � r
.U..�3th1Y7L7L .m ��n„7�:n..�:,�T.��.��,. ii. 7.C�t.�.�.�1 ��:��:n.
Owner: �
Location:
Subdivision:
�:: ., . ;lu :� : � c� � J
��.. ;',��Cln 1J �G�(iu`�i C:) �� �1 �� _c '�.�c 1 i %�c �r �: n.5
U'c� DU�D(lv�l , �_ � - a 3
W��l �ob
�1 :L� ���:ll) ��:ll'CCI if
�_ Lot If �
^��,.
, 1�'�cil Cozistruc:tzozi
Distancc rroui ncarc�t 1'ropcc-ty Linc (Nl�ininlum I(; •fee:t) r`� .__�__.�_.......
Distaucc froni Scptic System (Iviinniium GO icct) �_
Total Deptlz: �_ Ct Yicld: �Q_ GI'M S�atic Wacet• I��ve;l: /t�----- l�
Water }3c�uinb Zoncs: Dc:p[h 7d tc �� i�c _=�< <<'
�— a
C1S),m�':
Dcpth: From _() lo �� tl: Diamctcr: _(� % in
�., `�
Type: Galvanized Stc;e;l '�
Wei�ht: �j�_ ":�hickness: ___ f�y � II�i�;I�C abovc Ground: __/ >� iil
Drivc Shoc:: ./ Ycs No �1.ny problc:m� cnc:ountcrccl wliilc: Sc:tlit��; casici�;'? __ Yc:� �No
(f `j�es" bive reason: .__. --•--
Grout:
�
Y� �
I�I�at: Sand/Cemci�t � Concrctc GX�IV�IICC111C11t
�.nnular Spacc Width �_ inche;s Walcr in �A.t�nular S�ace Yes `—" No
Method o� Grout: Pum��cd I'rc:ssure ' 1'otu'cd `� Dcp�h {�:to rt.
iYXatczisls Uscd:
No. Ba�s Portlaud ccnicnt Wci�;l�l ufi� l D:ti;; _�____._ �'�11ilcls
lt mixtw•e (sand, �rzvcl, cuttin�;s) — ilatio _� �o �
Ill platcs: �I''c� No �� x�E �lab ,�--�.'c:s ` No
.JJrilliu� Z.c�b J.,c�c:ilioi� ur:iwiu�;
( b,ereby eerii�y t�lat thc abovc ii�torn�atiot�, is con:e:ct az�d tliac tl�is wcl� was constructcd in accordancc with re�ulations
sct fo�th by thc PcrSoc� County 1•Ic::.it,cli Dcparcmetic.
. . ,:
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A �1) !E —�y�--�-� ��:�lc _� � �—� '>
Si�u;atuz'c o�' Cox�tractox• _ _ �r�an r�u nill�l��