A24A 6The Distr��ct Health Department
Orange, Person, Ca�'well, Chalham, Lee Couniies
r _t
Water Supply and Sewage Disposal
ate "�
Owner:
Location: �
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a, Contractor:
m
� Wa3er Supply: riv te — blic
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Sewage Disposal Faciliiies: No. bedrooms -�— Dishwasher,
washi a ma�hine� ryother automatic appliances
5ize of tank: �,J�� �'�'� Nitrification
Other disposai facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use.
Date approved:�!�
Well:
Sewage Disp /
By:
�Locat'on of
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� Sign � '
' Larian
�11e District Health Cepartm9n�
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well and sewage disposal facilities sket hed on back.
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�� NOTE: 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
�,r� at later date.
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Apoiication Date: (a�<<`�(o
Amount Paid: 15�. o0
Receipt #: 171 �f 3
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Tax Man #• l 1 � � �
ParcEl #• �
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APPLlCAT10N FOR SERViC�S �
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT�Fa4LSiFiE�
CHANGED OR THE SITE IS ALTERED. THEAI THE IMPROVEiVIENT PERIVIR AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Pertnii requested by: (Owner/agent/prospective owne�: �� g<<{'�e�e.�'
Home Phone: �(�- 5a� - aG3'1 Address: 1'Z5 (�L��i(o
Busir�ss Phone:`�t19-5�.9-ob3-� FR.c�n Klin�n; NC �-�5a5
c�.n �e: a �g - a.o �- ue�,
2) Name and address of carrent owner. �w �� R� .(�Je r'
3) Property Description: Lot size: � A� . Township: Subdivision: Lot #�
Directions to the property (including road names and numbers):
�-t ���- 2.� s� zo�.,1e,��1 c�, le�k o.• -te� P,;,�<bce
4) P'roposed Use and Struciure Description: answer each flf the following questions: -
a) Proposed , Existing �' , Type of Structure: Width: �� Depth: ��
b) Number of Bedrooms: ��gre.�eeNumber of occs�pants or people to be served: 4
c) Basemen� Yes�C , No _ dVill there be piumbing in the basement?
d) �arbage Disposal: Yes , No ,�C
5) Water Supply Type: Private �(new _ or existing�, Pubiic , Community . Spring _
Are any welts on adjoining property? Yes�„ No _ If yes, please indicate approximate locatiori on the
'site pfan.
6) Does your property carrtain previously identfied jurisdictionai wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPE32TY OR SiTE P�AN MUST BE SUBMITTED WITH THIS APP�1CATiON.
➢ PROPERTY UNES AND CORNEitS MUST BE CLEARLY MARKED. •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA1�D OR Fi.AGGE�.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAI7'
STAFF. �
I hereby make application to the Person Caunty Health Department for a site evaluation for the on-site sewage disposai
system for the above-described property. I agres that the cnntents of this application are true and represent the maximum
faciiities to be piaced on the property. I understand ifi the site is altered or the intended use ct�anges, the permii shall
became inv�lid.
or Legal Representative
�D-ti-��
Date
PCND, rev. 06/27/02