A25 111The District Heoith Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
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-Water uF�a y and Sewage �isposal
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� Water Supplp: Private
Sewag� e Di�s�l i,
washing machine,
Size of tank: —;
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No. bedrooms ��— Dishwasher, Disposal,
automatic appliances —
� � � i Nitrification line:
Other disposal facility: � � �`� �•� 1 � � % � � � Y 'f�� -
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� Water supply and sewage disposal f cilities ocation, installatidn and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 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. �-j
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Date approved: Signed `�� �-�`''' �= �' I , �,,` f , t �
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- Sanitarian
Well:
Sewage Disposal:
By:
Counter-
signed
(Owner or his representative)
Certificaie of Co�letion
Date Approved: � By:
S itarian
(OVER)
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. Note location of water supplies on adjacent lots.
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Bacteria
1. Permit requested by: .
�wner/prospective owner
Address: - _�1�1 /�/�
ome Phone #:�,
usiness Phone #:
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Chemical
r �
_ Petroleum I _ Pesticide I ._ Lead
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. Dimensions or Proposed Structure:
v�acn: z � —
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
and address of current ner: 9. Water s ly t};pe:
;(a, � � private public ❑ community ❑ sprin�g ,❑� q
` ecs ,{N�,� Are any wells on adjoining property?Yes l�" l�io
�,n,rQ t C_ � 3�3 If so, identify location:
Property Descri
Tax Map#:�
Parcel#:
Township:�
. Lot size•
.—_ . _..
� �n h c�..--. -- .
. Directions to property:�State Road #& Road
... _ _
_ ....._ . ...__ . _
fames,�tc. / �e_
5� -fa Ci�;c�i�.� (ifem�a�►%Q�d..� ►� a�-
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10. Type of structure/facility: Pro osed: UExisting:l�t '
Type of dwelling: �
House: ❑ Mobile Home: Business: ❑
Type of business: �
Number of Employees:
Number of bedrooms: �—�..�/ " �
Garbage Disposal? Yes ❑� o�J --
Basement? Yes❑ No,�'If so, # of basement fixtures:
6' Number of occupants orpeople to be served•��,�� -�
. CLEARLY STAKE ALL CORNERS OF.THE PROPERTY AND THE CORNERS OF ALL
�__ _ _._.. _... � � PROPOSED_STRUCTiJRES.
I hereby make application to the PerSOn COunty Health Department for a site evaluation for the on-site
�_...._.. _._ �
sewage disposa l s y s t e m f o r t h e a b o v e d e s c r i b e d p r o p e r c y. I a g r e e a t the contents of this a p plication are�true _..
and represent the maximum facilities to be placed on t he prope . I un derstand if the site is altered or the
intended use changes, the permit shall- become inva d I und tand that before an Improvements Permit can be
issued; I must present a survey plat of the property to he He h Dept. I understand that in the event I have not
delivered a survey plat of the property to the He ept. ' hin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this applica ' s 1 com oid an all jf`es paid forfeited.
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Author�,�ied Agent
9
Permit Issued ❑ � �ignature
Permit Denied ❑
Plat Observed ❑
Date
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9. STTEMS$fF7CAT70N(SFEBEL01h
SOILSERIES:'• • ' , . � ' •
• SSUITABLE PSPROVISIONALLYSUiiABLE U•UNSUTfAHLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, f 11
areas, wells, water bodies, slope patterns, e�C.� C:MMtPRO�DOCS�APPSEC.SA1 FINANCE.PC
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� �i� �-ei%it q001026
PERSON CO TY HEALTH DEPARTIVI�NT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # � �� � Parcel # / //
Zoning Township ,�' �i h ��i rl� �r�i �,
Owner/Contractor
Location/Address
Subdivision Name
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�' r� Dat� / p-- 9- C� (�
S.R.
Lot# '
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SEWAGE SYSTEM SPECIFICATIONS
Lot Area l, C v e
Mobile Home �
# of Bedrooms?�
Size of Tank
Size of Pump Tank_
Nitrification Line
Max Depth Trenches
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Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is a tered intende��an �.
Well and Septic Layout by �
Comments:
. . - � � - . . , • . , . - , � /I«�f!lf!�_G,�
Date Installed by ,�---�� Smi� "� `'") Approved by
This repoR is based in pazt on infonnation provided the homeowner or tyi�/her representative in the application submitted for this pennit The
environmental health specialist is not responsible for false or misleading infonnation contained in the application. The enviconmental health specialist
is also not responsible for concealed conditions on the prope►ty or for statements in tivs report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the envuonmental health specialist wamants that the septic tank system will
continue to func[ion satisfactorily in the future or that the water supply will remain potable.� c:�amipro�permitsam O 1/95 rev.1.0
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