A25 101Size of tank:
The District Heal�h Department
Orange, Person, Caswell, Chaiham, Lee Counties
Water Supply and Sewage Disposal
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Owner: �
Locat�i'o']n: /�
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Contractor: 1w � �
Water Supply: Private � Public
other
Other disposal facility:
No. bedrooms �— Dishwasher, Disposal,
� appliances —
Nitrification line:
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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.
(OVEft)
Location of well and sewage disposal facilities sketched on back.
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
at later date. �
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Application Date: a 3�`�d �3
Amount Paid:
Receipt #:
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ication for Services
Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Build�
��50.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
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Taz Map: ��
Parcel#: /D /
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In orm ion: f�
Name: I � � t�
Address: i
2) Name and address of cur ent owner (if different than applicant):
Name:
Address:
an�'t�z �i s� n� nw{'�s� n h�rh�
�.A�t�►�-in�. ne.� S
Phone (home): ����n 1��t.t_,i ( `�-+ {-�4,,�—
(work/cell): ���
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Phone: f � � �-4-fl /h Ct�
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3) Property Description: Lot Size: Subdivision:(,�.rr+ Q>� f'e Lot #: �
Address and/or directions to Property:
❑ yes ❑ no ' Does the site contain any jurisdictional wetlands?
� yes ❑ no Does the site contain any existing wastewater,systems?_
_.
O yes " � no' Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes '❑ no Is the site subject to approval by any other public agency?
� yes l7 no Are there any,easements or right of ways on this prope;ty?
(if `yes' is checked, please provide sup�orting'documentation)
4) Proposed Use and Type of Structure:
❑Residential
� New Single Family Residence Maximum number of bedrooms:
❑ Bxpansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Ma�cimum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: � New well (�1 Existing Well �❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? �I yes ❑ no
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6) If apptying for �Authorization to Construct', please indicate preferred system type(s):
0_,Convent�onal _ C] Accepted , O_Innovatxve ,�, , O Alternatave_w,_C] Other ' ,O Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurat,�, or i�the siteiis�ubseQuently alt�red, or the ir{�enq{ed use changes, all permits and approvals shall be invalid.
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* Supporting documentation required.
9^�0�- o��
Date
Permits are valid for either 60 months or are non-eapiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(]0/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #: �S Parcel#: 10�_ Address: �l ���3 � r����,
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--- _ _ -- - - -- - --- - ----- - _ _
Approval Requested for: Mobile Hame Replacement
_� Building Addition
Applicant Name:
Address:
Phone #'s:
/Ulae .��I� �lo �S�
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Permit Located: Yes No
Installation Date: —� ��'?'s Design flow: 3 6�(gpd)
Current Contract with Certified Operator on file (if required): �_
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �d' �' � 3 (date)
(Applicant's signature if site visit is not required)
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Addition/Replacement Approved
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' vironmental Health Specialist
1� ��Z�t �
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net
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Name � / "��'� � � Taz.Ma. # as � Parcel # �� �
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Subdivi ' . � Sectiofl/Lot# �
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Autiho�ized State .Agent . � Date .
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