A24A 43The District Health Department
� CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposol
I OVEMENTS PERMIT No.
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Owner: �` { "• { -
Location: �_ � �
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Contractor: L' S' � r^' v' `��!
Water�Supplp: Private '••'� Public
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Sewaqe Disposal Facililies: No. bedrooms -"-� Dishwasher, Disposal,
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washing machine, other suto�atic appliances �
Size of tanki T'`�'� f�� �, -� NitriScation line:
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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 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. � f. y �
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Date approved: Signe r/�' 'Lf �` /; t,�' �."`'`�Y:�` 4-:
Sanitari '
wetl:
Sewage Disposal:
By:
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Counter; � f' /,� ��� �f '� %
signeclL,- � K.-r -� "'�" � _ °-� :s-* „
(Owrier oihis representative)
Certificate of Completion
Date Approved: �"7—� By: `'�� ` `�
a itarian
(OVEA)
Location oi well and sewage disposal facilities sketched on bacic.
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WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSUED: - ATE DRILLED:�i�� P�"/ COUNTY: CY _
OWNER: " ROAD/STREET:
ADDRESS: . Y PERMIT VOID AFTER ONE •AR �� �
DRILLING CONTRA'TO : /�',/n..n.c 1�/./I / ,�.
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WELL CONSTRUCTION -e:�,
Distance from Nearest Property Line �� n U..0 Distance from Source �f
Pollution_���c 2b _ S -Y•.
Total Dept t. Yield: GPM Static Water Level:_��j_Ft.
Water Bearing nes: Depth: ' Ft. Ft. Ft. Ft.
Casing: Depth: From_�to Ft. Diameter: �Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner appro Yes No
-- Weight: �� Thickness:l Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountere in S tting the Casing? Yes NoJ/
If "yes" give reason:
Grout: Type: Neat 1� Sand/Cement: Concrete
Annular Space Width �Inches
Water in Annular Space• es No ✓
Method: Pumped Press e Poured • '
Depth: From to � Ft. �
Materials sed: No. Bags Portland Cement�eight of
1 bag �lbs.
If mixture (san�vel, cuttings) - Ratio:_ � to�_
ID Plates: Yes No Chlorination: Yes No • -
4 x 4 slab Yes No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST.�HEALTH DEPT.
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Si a ure f ontr cto��` Date
REASON FOR NO
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itarian's S g a ure Date
Sketch well location on reverse side. Use established reference
points.
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` Applicatlon Date: 7 02-6 3
Amount �aid• D .
Recai t�#'. 3
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Tax Maa �• � 2� f �
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APPUCATiON Ft3R S�iiU1C�S �
IF Tt-IE INFORMATION IN THE A,PPl:1C�►Ti0i�1 F�R AN IMPRfl�/EAAEAIT PERMIT_IS_ INCORRE�'T. FALSI�iE�J:
C�IANGED OR THE SITE IS ALTERED. THE�I THE lABPROVE�IAEM PEi�MR AND Ad1TliORIZA'�IOIN TO .
CONSTRUCT SHALL BECOME (IWAL]D. �
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1j Permit requested by: ( wne � ent/prospective cwnerj: W' 1�� l �t- � �` C:
Home Phone: � - .2 � — S / Address: 'f' .
8usiness Phone: ' �- (� ( � O Z n r.s o�o�� f �
2) Mame and aiddress of carrerit owne� ' � �� �,..��.�
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3) Properly �escription: Lot size: , G:rcTownshlp:
Dire�ians to the praperty (Induding rroad names-an�.
L Lot #
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4) Proposed Use and Structure Desariptlon: answer eacii the fopowin e' � ��;
a) Proposed �,, Existing , Type of Struct�u�e: v��� C=� . to be serv :. �dth:� Qe�th: �� .
b) N u m b e r a f B e d r o o m s: N u m b e r o f o c r a� p a n t s o r p e o p
c) Basement Yes . No ,2( Will there be piumbing in the•baseme�t?
d} 6arbage Dispasal: Yes , No ?� _
5) Water Supply Tj�e: Private �, (new _ or existing�, Puhlic,_, Camm�snity� , Spring � .
Are any wells on adjaining property? Yes No _ tF yes, piease indtcate approximate locatiori on the
.site Pran. . /U_ �t �
6� Does your property c�ntain_p'eviousfy ide�ffied jurisdictional wetlands? Yes_ lde�,_
PI.EASE NO'TE THE FOLLOIMNG:
➢ A Pf.AT OF THE PROPEiZTY OR STf� PLAiN MUST BE SUBMITTE� WITH 'ti��IS APPLdCAT10N.
➢ PROPERTY UNES AiVD CORNERS MUST BE CLE�►RLY MARi�D. -,
9 THE PROPOSED LOCA�TION OF A►LL STRUCTURES iV1UST BE STA�D OR FLAGGEi3,
➢ THE SITE MUST BE �DILY ACCESSIBL.E F�R t>iV EVALUATION �Y THE liEALTi-1 DE�ARTMENT
STAFF.
I hereby make applic�tion ta the Person Courrty Health Department far a site evaluation for the on-siie sewage disposal
system for the abave-described property. I agree that the cantents of this application are hve and re�resertt the maximum
faciiiiies to be piacad orytt�g proQerty. i undetstand ii the site is altered or the ir�tes�ded use changes, the permii shaii
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Qate
PCiiD. rev. U6/27102
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Tax Map #� Parcel # � �
Existing Sewage System Report For. �L- Mobile Home Replacement
V Addition Type: n�- ��d Ga�a�_
Requester. W� � �11c�rv�, (iiACldcn Home Phone# a� 3�}' 195�
�a�� �i'�c.S(�o�oc,«� . s-Er.�.�EC- �o�d Business # ��"l9 ��
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Locati.on: 1� 2 Z��n Lcu�� Urt.� IQOaC� O 1��4.sbor'x-c �S�r,
Qoc�d i� �x � ��c � .
Original Permit Located: _� Water Supply: .Orl �ft. W C� M
Septic System Designed For: V Residentiat Business Other
# Bedrooms�_ # Employees Other
System Type: �D 1'1 U�.fl-�-i ��'i � Tank Size: �� Ga 11 on Nitrification Line: O��X 3�
Date Installed: J` 7-�� Certified Operator Required: N�
On-site wastewater disposal system showa no visual signs of malfi�nction on r ����
Permission is granted to: J>U 11d � a r� �/ G
Comments: �0 �� o tJ `J r�bc. �S Kc tc-t, /� �'T 0 v 1 cic
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Environmental Health Specialist Date: �
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