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A24A 35 & 36� The Distr+ct Health Department � � � ... CASWELL - CHATHAM - LEE - PERSON COUNTIES n � X �" � s Water Owner: Supply�and Sewage Disposa IMPROVEMEN'TS PERM T No. r , �e � - � ,12 a I Contractor: �" � ` � � Waie: Supplp: Private � �blic ---- gewage Disposal Facililie�: No. washing machine, othe� auton Size of tank: —���sl� line: Other disposal facility: •��ation, installaY�on and __ Water �»^must Tneet state and local regulations. ncgteStlOnn �.�ou1d 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 INSPECTED AND AP- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT ; STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. /' . 1 j Date approved: — Signe Sanitarian Well: , Sewage Disposal: Counte ~ signe '� BY� wner or is repre ntative Cestificafe of Completion � ( �, I�ate Approved: � � By: � Sanitarian (OVEft) Location of well and sewage disposal facilities sketched on back. _ Apqiieatlon Dabe: � '� -D � Amount Patd� � I Recsl d `1 ��'� . �II� � Tax fUlaa #: Wares! �• ����?. � ���� �� _ _ � �C � ��T��' ��.�.a-.m— ,--� ��.��. �r.sa.s.�. a�QucanoN FOR s�nncEs . . �,�,,,��� �,- u�oeNs Perrtttt-$150.�0 Home R�n�tlA�1 r-�,,;��� W� �9SO.00fS'm0.�0 � �� U vv�av � ���v � � ��� � - - _ 1�armlt requested b:(Oumeda8e�ttJPros�ve awne�% T�- 8 z�t Hame Phone: 2 '?� 2 � Addre�s;/ �� � BusG�ess Phone: h�t� - 1 l� J�� • ' • 2) Name atsi add�+ess oi` i�irr+e� awner: �'`� • l o �� 3 � � . I�v�� iT,�� N(' � 7 3�- 3 . � - . . 3) -Property Descnlption: Lot size: Dit�ttoas t,o the Property, (lndud 4) � d. -z # r- vsf �O 0 ►'` 1 C �'f' ` � . „ - Proposed Use an Structun �sscription: answ� eac�l� of the foilowing questions: / � cr 'a).proposed � ' . �Tjjpeof�Shucture: � �Id�J.s�_� Width: � DePth:� b) Num�r df BedrooEx� Number of �pant� or people to be served: • � �) gasemeri� yes_,, No _ Will th�be plumbing In #h� basement? . d) 6a�rba9e �tsPosal; lfes _, No ✓ . ��. Wadar SuPMY �'ylPe� P��—V (new _ or e�dstin ; Public_, Commun�y . Spring � p►re any wells on adjaining property? Yes�No _, tP yes, please indicate appmximate locatiori on the .siba plan. • . 6� Daes your property «�nt�tn pr+�wiousfy identifled juriscltc8o ,'nai wetlands? Yea_, No � PLEASE NOTE THE FOLLOINING: ' ' ➢ A PLAT OF THE PROPEitTY OR SiTE PLAN MUST BE SUBMCrfED WRH THIS AP�L.ICATION. 9 PROPEiZTY 4NES AND CORNERS MUST BE CLEARLY MAR�. •, D THE.PROPOSED LOCATION OF ALL 9TRUCTURES MUST BE STA� OR Fl.AGGED. � 9 THE SITE AAUS'� l�E READiLY ACCESSI6L.E FOR AN EVALUAT]ON BY TH� HEJ4LTH DEPARTMEAIT STAFF. ' .' I hereby maice appllc�tlon..to �#he Person Cour�ty Health �epartrnent for a site evaluation for ths on-siie sQwage dtsPosa! system for the above-desciibed property. 1 agree�that the cor�er�s of this applica�on are true and represent the m�irnum facii'�iies to be piac�d o� the property. 1 understand ifi the siis is aitered or the irrtended use ci�anges, the permit shaU 1 Y �,6 � � �O� . L-���.� � 1�� . �.l��y�. � � �•'���1 1`V �LT .1! � 1�����\ -�w�� � _ 11 ��Y� r�1Y �_ ::�"a� '.�� 0 .lti - • � ��l .e� � � � � .tR«- r a sc � �r sis '� � i -- �w� � ■ • �' _ • -y� �; //. .��'♦ ♦ • / /II �� � . - - v : ura s�■ r�• rrr !� :.0 �, r- ,-. ., i, s; r. ,., . � - _ �� ,,,,_,. � _ .-��,�� , �•> �t� •r : , ,, r, r� - - .�. !i i_ .i ii �� z• N�.: •_- tV�w w��� s=-rE. 5�nnr�-�t5�o r'�`7 ? '�Lv� ��S CT�� e�uv p�c.E w ��y _,.� �� c� -rwo �ES=C�tJ FtT��'J �}4�.� , �� S 82"07'41'E 301.19 �- —_.-----�-- . . Si� L.��`i+ �',.`L'X TO ������T G�} � M�t�� ��-� a ���E ��-f L�T� � ��0�� ��I�`SO S`�O ��� sj� �ri � �J 'D�i�E � , � F v�5z.��C-, wc� 5='T� CD � �/� N� W e�� �nt,x-r ��- � c,�zu.-� Q� �1 �xAc�' LoC��T$�� "T�-.AT S.-5 � f�Kl�2YiE'L] � S�TP.�CXiS � `1,d'L� /�T T�+� .. M i�JZM�::tvl .�-� �ra���.� , KE� ��' �r�cN� ���T ��� ,a�r� \ Z' `C'(Zt�N\ �}�;�4`� t� �L f�5 W�LL. !�5 C�O� �-�,� �st� �Ex To ORA� t� 3.�Ls.�. � �szNc� wE.� s=-�. �% : �NE�.J W��— (�\�7S'T '@�� la` �'��;IV\ S`-r..3_:� � l. ANY� �'S' �YLc."�. ,� �-�k: �TLG�tv�� i�t~+`1 : �^ :::.�''c--� • � r n//��/, OIY� WE� ' (� SSTro 'PO'S5z 1a1� � � / . p� S'� �NE�J WEI.l..STT� / K,J D=99-53=31 R=50,00 • ARC=87,17 CH=N 70'40'24'W 76.54 �p�2ZLt_.. NE4-� i,J�v-- �e�.o�J txe ,-SC.�. �ceF�'Z'Z� 1 oWAYLY� 1�r4'�� H`2Cc7 129,60 S 88'51'45'W 17'28'18`E S 17'36'2 — 42.D8 S 17'36' 8.D0 � �:�.+..r . .. �. ,:� . �.•: �••;. <; :'. . . ``'`.��:_ ...y� • .�� �7�'JA':�.� , ,• t.. . . � ..�.. .t:• . �F��� .4�,�.�v'r• • hti.• + r: .... , ..... , . :•'• r<:a.;i:• ; t;;.�:�:'��✓�.��:�� .,... s.,..yi..ti:�•..;..v.; :::�..r,�...:.:...;.. y . : ,.. . . .: � � � , ... 7�� �'�rix:i..• �.. ' �` .�u�'v�p..1L�': .... . • .. �... . ..r.. . ... . . . . . .... . '? . r.. � . .. ... . . , � ,,: .. . . . - �. • ..••:,:••.7�9:.'�•at]Lyqti;?��� 9,L�3i:�a� ::=: VT :�,�n •LL.� g"'1'+JL�L17.D.IlJL . �JL9�1-'917� ��� �.11 JL tL�l.� �J4tb1� Y' �LL6 �� �H Y J[:! '1�19.,;L �.y aJ 1 Tax Map Pr�A Parcel # 3S .. Tovvnship: Appli�at�t: Q�� � . 4�n.-�t.x�, �u'llb(�1V191011. �t�5�'?;c�2�c^Ct�+�F �— 5Tr`�--tE='S �,Ot # _ �-�j • i.ocation:_Sc rv� ��t � � ,r� � .� L� � i— � C' .�- � ,,, � � � c�� �� � � r .c� �t � �X-,�.+ ,-�-rf�"t '_' 6��n � � n.� ATt �v�r'`��� (2 � �':�'iF '20 � I� rJ1t-r�� �t� L�z- � 2A=t�'�rc � 2-r4�c�,�= �ype mf ���r �e��nply: � Individual Community Public �q�eanen#�: Site. Approved By: Grouting Appraved By: • Well Log: � ' Pump Tag: • Well'Tag: . ' Air Vent: � ' Hose Bib: � � Caging I3eight: � Concrete Slab: � � � Well Driller: � Well Approve� by: ;r��'*Jee.��claed �i� S�tc�*a�* Liner: � 'Installed by: Depth set: _ Grouted; Dafe: — Water Sample: Wells must be 10 fest from propesty lines. V�lells must be 100 feet from s�ptic systems. �1'ells must b� at least 2S feet from any building foundation. Date:. ; Other conditions: 5�� 5=-,� 5v, �� c s�-< < Sz-��s ,4�►�� �.,-�T�r �����5 �CHD re� 01!27/0� a���.-' 'T-' .�?: . .. ``�.`..�:: ..L�••�;�'�.;::�.,.«i.•`. �s.. . `�,+�.. l:: • ���� ��`''�;�^`rs:��: '1nt;....M1s M1�::. ,�<" •a� ��ttytiii'i.::.',^,..¢.�?.}.`..4:T..�:Sn.�Y�.••�;;:��•�•� v,� �:wv w„•:. i. • . : :A � . • , ���'�.��'�1��� ,��i�_��1�+�~:'�����- +�'p� ` � ��� � . , Y � �a:I� 51�13� �� �V� I � •-•+�W IJ+i•IL/ .. . �Si L V i Tax Map ,4�1! Pazcsl # 3S Tb�wnship; Applicain� c�-� � . ��,. ��.x�. Subdivision. �-r�.,e5,r-=., sz�:�^�a..� �-ra�--cr=--s Lot# �S" . I.DC3t10II:_ S�. n�� n.y7 ;� -rY' ,r�, --� -r �^�� t C- � 1'_' i i� ,� � r ��� C'�rJ _ `� Tt�.+.= a � �..til �" �i �'{'�_i. �-�e�-.,`.. ; �'�' .�Vl '�S �.) C�t f-�-T �:2C�`c al '_ � _ n p � � `�`Cr"�� '217 __ � �5+ 1�T\� �N ' ���'�T �Q I�-rl"Z�.�'; l7 ( 1 yi/r.,l �8 0���$�$' ►�9'B��D�D�y: �` TII(�1Yldlla� �'0�1� P11bI1C . —�� �IIl$'�ffieYl�: site. Appro�ea By: Grouting Approved By: W ell Log. . . � Pump Tag. � . Well Tag � � - ' Air Vent: ' . �3ose Bi'b: . � . Casing Heig� ' Concrete Slab: � � ' Well Ddller: . j]U'ell A�rprovec� �by: ' �=**9e�.�i�elted �rte S�e#ch��*� Lin.er. � 7natalled by: � . Depth set; ' Gmuted: Date: . . Water S�nple: � Wells must be 10 feet from pmperty linea. Vlells muet be 100 feet from se�tic systems. �Tells must b� at least 25 feet from aay buiiding faundation. Date:. _ ��lET CAIIdI"t1011B: �F� cT� � =F � C 1`�; i �-T -r+=� =1i�� 1 t��'S�ro r �{�T'-:-a �.�� PCH� ra� 01127/0� .L��� �� ���� �� ' . . � � ..... . � � `�J 1'�l �� IEvava�c-.maa.ua-bnoa.�m.11 �C�mll�a. SITE Sii�TCH � . Name Taz Map #,���Parcel � � 3 , Subdivision �fa-�e. : � Section/Lot#,,,�,� , � /—/l,� - ��� � Authorized State Agent . � Date . System cnmponen�ts �repi•esent u�iproximate�contours only: The contractor must, flag the system prior to . beginning the installation ta i�sure thatpmpergmde r;s �naintained ' ,�, o . , �� W w �� N !� � z r� � G:7 �;� ��'� :'� � _ � �:,,�U�1.1 - .__ - - CO('� U7o �u�-......�:.: (11� `1J�i 'foY� .:. _ _ :..�.t,�Q� �.. � C•� 0 I � I e .. .,�"`•,�� . Vi "y ` . � �u9t�,6t�o20 S_��y..,,j'" � --._I O' � L �� I ir o � ,. e� � , . � �- �7ti 11 c � 0 G � ya��, � 1 0 �D � (Y7 ./_ � J �� �� M � . S, �. (`"1 ��1��, ��_u-� o �� �� � �, � o �. o� in � u u Q ° ca n� H !� ' , � � � �..� �\ � y Q � �L �(�� � � pp° . �o-�� c� � a� � � j ���� o° ti� Q / �S� °°o Sp �'1� , °�a . s`> '� �L/ \� ���� � � � �Z��� �� �� �,��. ��� , � . _ �; _; � { C..r, �i�E '� C�x'.:C.+,J �; �-i�..� ��:;R`.::- `t_' t? Ll�1t�-�lL:.cJ1 ' �"' '� �,'. �i�C�C�:, -1� �,tat;o� ,� �}- �,r� i n� e ldt s -� i ; �cQx � � � �-`� � ��� t� b�, l c�-� .� �' 6--��1 c._� l 1�s; -t e ,� � ����' ' - ' �� ` ��,� lc:�.��-��s:� �„a-v�n :�e�� S lo�in't�a--x c�..v�c_�1 _ , P ��.�..-�e�S � :��.s�.� ��:::1c-:� L�c�1t -�-:;�}�;, �..�s r. -- � -ti � �:�V;i.,.:;t�.�4 :.�t"�'E: 1r, �,...�;,;.r c ,�;;Y' Z:::'t" �'M1q:;. � k-{--t �, �1'�.i.:i � ���n�FS'�Or��.�C� G�'�...'�ES ��%� /�,��+�ti;;;,a� �c_��c.:� t'�;:s`.c�� c_� , ~ �'-�E�� . �, 4 � r��:r��4� c.�. `%,� C�11 �;�� r��n. ����.s x 2���- �.� ,�. �`t.'�C..J �.-ci• C.4� 1,��`�,� ?-�`1LGu r�.�z. �'��,��� C�(QY15 �"d�d. �am�oc�ner �� �OU�C� �it?T �L'T- i"Iq � f��o(7GSP� y /-� � • Me�' �o:�� ��li5o� �r� �c� �fld r�.-5r�� u e�i J , ` - T<