A24B 8The District I�-lealth Deparfinenf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date ���,�1 � �%�
Name of owner: ��/g�'f �7
Name of contractor:
Address and Directions I � ►"�. ��l�-C�'s[�2�',l�ll %f
ne % ) .� � _ 1 . � , . . _ .!
Person or firm doing installation ���/'�e��E Y
Address ..L��X �b2. �-t nrti/ �favr� � s. �_
i/
No. of persons to be served ��/ (� �' Bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Recommended: Septic ta �` �'
Nitrification line: +d�J� �/Y A �
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecied and
approved by a member of ihe District Healih Department staff before
any portion of the installation is covered.
Date ; 8;z(��`12
Signed
� � Sanitarian
sy � 1�.��C�• -��
O. David Gazvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
, adjacent property, etc. Write in measurements in order that installations may be located at later
• date.
� SUGGESTED INSTALLATION (Date )
(Road or Street)
FINAL INSTALZATION (Date )
(Road or 6treet)
c.�ea s rY1�/%,(�•
/.�36
�: alicaticn Date• -=�'��'—��
Amount Paid• �- 8�.��j�
ecei t #� ^ � �
����
Tax Mao #•
�arcel #•
Person Countv Health Department
Envi�onmental Healtfi Sectlon
. APPUCATION FOR SERVICEB .
�,F THE INFORMATiON IN THE APPLICATION FOR �AN IMPROVEMENT PERMiT IS FALSIFIED. CtiANGEO.OR THE SfTE IS
ALTERED, THEN'THE IMPROVEMENT PERMIT AND AUTHOR2ATION TO CONSTRUCT SHALL BECOME INVALID.
1) Pertnit requested by: (OwneNagent/prospectiva owner): �'�:.r. n. r
Home Phone: r_ �� � � - �'7 � -�i L� 3 � � Address: �— ,
8usiness Phone: ��
2 Name and address of current owner. � �� �� W` K�- ��2�1/
� � , �� . �� - ,� �-
� r. a� � ��� �• ��
��� _� � �
3) Propetty Desc�iptlon: Lot size: _� �ownshtp: �,� ,,,,� ha`.,,� � ���
Directians to the property (induding roa names and n ers)� M,, -,.� � • 1 �� - �� r'\ � GlL
(l� �.`..in�., �f'n � or, ��i - �i r�� -`J � r>�. i� !» «1� a .. �M�-° Q-�- •
4) Proposed Use and Structure De'scriptton: answer each of the foqowing ques�ons:
a) Propose�:� Existing EY'
b) Stick Suiit �. Modulac �, Single Wide �, Double Wide� �
c) Number of Bedroams: � � Number of occupants or people to be secved: �
e) Basement Yes 0, No�] if yes, ,# of basemer�t fuctures:
�� Garbage DisposaL Yes 0� t�� �� �
g) Otmensions of Proposed Struc�ure: Width:��'�� Depth: ��
6� Water Supply Type: Private q(new � o� exlsUng �), Pubiic Q Ccmmunity 0. Spring 0
Are arry welis on adJoining propert�t Yes� No � If yes. IocaUon
6) Please indicate Desired System Type: (systems can be ranked In order of your prefe�ence)
Ccnventlonai Modified Conventlonal _ Attemative �nnovative
Othar (spociiyj:
-% CLEARLY STAKE ALL CORNERS ANO LINES OF THE PROPERTY.
3TAKE THE CORNEEtS OF ALL PROPOSED STRUCTURES.
PL.EASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make applicaBott to the Person Ccunty Heatth Depa�tment tor a site e�on ior the on-site sewage disposal system foc
the above-described property. I agree that the conte�ts of this appUc�tion are lrue and represent the maximum facx7ittes to be
piaced an the propecty. ( understand if tha sita is altered or the ir�eertded use changes,lhe pem�it shaU became invalid. I understand
that as applicant, 1 am respo�sibte fo� identifying and markin9 properly Gnes, comets and maki�g the site accessibte for the
pecsonnel of the Person County Fleafth Oepartrnent to condud their evaluatlons. I understand that I am responsible for noCdying 1he
Heal Oepartrnent if my pro etiy an wetlands as designated by the Am�y Corps of Engineers.
.�.s c ! �_ �'�/— l.1fJ
er o R entative , Oate
� t �
Person County Heaitri Department
�:xisting Sewage System Report For: Hobile Home Keplacement
�Addition "
Requestee: Ivl���%C��' Q�-��� Home Phone# ��G /(�?C
���tUCI �J ���^�'�' �• B u s i ne s s x
�/IV��VYI��.VV' 1/VV l// Yf-'�� 'Pax Hapx
Location/Uirections: 1�/�`(,`�� IvwVl ��`�� � �►�� ��' -r�� ���y�
-����2.-�+.�' Y� - �D � #� � � fJ1/I ,Q,�'/) � � � �
Original. Permit Located
✓ .
Septic System nesigned �'or: _
Kesidential _�� 13usiness Other (specify?
� Bedrooms � # Employees Other
Uate '1'nstall.ed - / � Water supply
Type ot 5ystem � f
Hitrification Line 1�%Q� S�� �
Tank 5ize
—� � /% .
Certified Operator Required //� —
On site wasL-ewa�er disposal. system stiowes no visually apparent
malfunction on �'—���
Yermission is granted to: U1�1� .i� �e �����' -
According to the attached site plan.
. „ , - :(/�I I � / � // � .i � �%�%/�����1
� . r�� 1 �I_' � � 1�� �ri� ' , �� / �, "/ J
,..
\ \ 'J
�`9cY \ 3�' •
�•,� ..--`
� • ��
.�.
.�
�
i
. v�.�ti��
C.
i�
i�il��il���'���I��'Ti�Ti i�l�,
5 6
�
-:- \
- � 6 !_ G8." � 'E /9�O.fjS � ._
I