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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ond Sewage Disposal
. IMPAOVEMENTS PERMIT No.
Date f — 13• � 3
Owner: GV►� �
Location: —��
�k 3
Contractor: � j � �� ��''�"� � � � � �, f�
Water Supplp: Priva� T,i� Public f
��, c d,� . �, ;�� �
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other autrimatic appliances
f <GU _3 -�
Size of ta.t►lc� ��'f Nitrification line:
n��,�l��;��,< <.,._!��.� �.,,��r�, h��rl �,,,u�.��F ,..,r�.
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 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 HE�LTH DEPARTMENT
STAFF,BEFORE ANY PORTION OF THE INS'�A . T� N S COV-
ERED AND PUT INTO USE. , f ;
, , 7
Date a roved: Signe '' ���/ r� �`
PP
Sanitarian '
Well: ,
Sewage Disposal:
By
� 4
Ca gned � � � �
(Owner or his representati
Certfi'icate of Completion
Date Approved: _�_� B :
anitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
- �' Rerson County Health Department �
' Well Permit
Date: -a `9 �This Permit Void After 3 Years
Owner: Q SR# 13 �7
Location/Directions: , a r.
Subdivision Name: •
Drilling Contracwr:
Lot #
WELL CONSTRUCi'ION
Distance from Nearest Praperty Line Distance from Source of
Pollution
Tatal Depth: � Yield: �_GPM Static Water Level FG
Water Bearing Zones: D� F� Ft FG
Casing: Depth: From to FG Diameter Inches
TYPE: Steel ' Galvanized Steel �
If Steel, does owner approve. No
Weight Thiclrness: Height Above Groimd: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the C�s ing? Yes No
If "yes" give reason: . /
Gmu� Type: Neat S ement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No
Method: Pumped Press� Poured ��
Depth: From �� to Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, gr�ve�, cuttings) - Ratio: to
ID Plates: Yes � No
4 z 4 slab Yes —�— No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
FURTH BY THE PER ON COUNTY ��FADI�HR�� CAR ��� I�EGUL^TIONS SET
l/
Sanitarians Signature Date Completed
Sketch well locarion on reverse side.
'�� OTE: 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 e locat
�, yat later date. Note location of water supplies on adjacent lots.�'V�"1 � ���
�(1) (2)
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a ��.■■.�
:�
� licatlon Date• � I D U
�inou�__ .
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Tax Maa #:
patcel �f:
Perso� Cauntv Heafth Departtnent
Environmentai Heaith Section
. APPUCA'RON FOR SERVICES .
IF THE INFORMATION IN THE APPIiCAT10N FOR�AN IMPROVEMENT PERMIT IS FALSIFlE�. CHANGED. OR Tl�iE 51TE IS
ALTERED. THEN'THE IMPROVEIVIENT PERMIT AND AUTHORiZATION TO CONSTRUCT SHALL BECOME INVALID.
1j Permit requesfied by: (Ownerlage�Uprospectiva owne�: _
� Home Phone: � Addres�
8usiness Phone• � 5 7- s S 3� ° '75 >
�j Name aad addc+ess of curretrt owner: Q 4,`t��c� �-:�C�1 � �' Fc�-QL W`c*�
3) Pragerly Oescriptfon:
Oaedions ta the prope
�C°1��77 zi17
6 ox
4) Propased Use and Structure Description: answer eact� af the foUowing qu�.sttons:
a) Proposed 4 Ex�n9 j$`
b) S�dc Bw'tt Q Madutac �. S'u�gte W(de Q Daubie Wide�(
c) Number ot 8�ms: � � Num6et of occ�pants or people to be senred: �
e) Basemer� Yes Q No �( lf yes�# of basement fudurex
� fl Garbage Disposak Yes � No (o
gj Dimer�sions� of Proposed Strucbure: Wfdth: �, �epth: �
3? Water SuPPhI TYPe: Private�(new � o� e�dsiing �!(j� Pub�c 4 ��/ 0. Spting 0� .
Are arry weqs on adjoinin9 ProPeri�t Yes J� No � If yes, location��"'t"` v�°`� Q,� gi��
6j Please lndic� Desii�ed Systam Type: (systems can be ranfoed in order of your p�+eference)
�Coave�t[onai Mcdified Conventional _ Ai� Innovative
Other (sp�tyj:
CL�ARLY. STAKE ALL CORNERS AN� UNES OF THE PROP�RTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
P�EASE ATTACH SURVEY PLAT OR S1TE PLAN TO THIS APPUCATiON
I hereby make applicatio� to the Person Co�mty Health Oepartment foc a s�e evaluation for the a�site sewage dia�sai s� fatem fa
the �ed properly. l agree that the cartents of this applicaiion are true and �ep�t the maodmum f�a�tes to b�
placed on the PropertY. i understand ifi the sitee is alteced or the inte�ded use changes. the pe�mit shan become invaad. l understan�
that as aPQiicxnt. I am respons�ble far id� and marfdn9 ProP�Y �. co�ners and mat3ng the site acxess�te foc tiu
pecsonnd of the Person aurrty Hea�h Deparfinent to condud their evalu�ions. I tuulerstand that 1 am responsble fo� not�n9 th�
Health Departrnent pro �rt cor�iains any wetlands as designa0ed by the Army Ccrps of
- � / D�1
Owner or l.egal eprese�attve . 0
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PE��RY
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Cunninghom Twp., P�son Ca, N. Caroknr�
MarcA /9�83, Ho!/-Hom/eti 8 Assoc.
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Nea/ C. Hom/etf RLS :'46S
. NOQTH CA�Q'_iNAr PfR90}I ODUNJ�
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���,� `,�� li,� that under rny wpeyision ard i
directron thi� rr�aa ��as d2vr� lrbAj -
g��� an actuat fiE:id s�r.• �� and that t�
erra of closvre i �
��•2s65 e � Wrfiess my hand arxi sesi �is
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M C�tKt?�.liw'�, f'£RS�ON C� �:4�Y
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Nota . ceRif�
Sunreyot, per.�onaily aPPeared
beforc me this day and acknawled�ed
the due execution o� the foregoinQ .
inst�umer�t iP{tness my hand ar�
notarial seal tli�s.�aY �
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Person County Health Department
Existing Sewage System Report For: ,_]�Hobile Home lteplacement
Addition '
Requestee : ��.Ui1 U�v � ���C��� �����ome Phone#
�'"70 �(�(��',� �- Businessn ,�D—,7i /�J'Jr�
� �� C�7S�J �ax Hapx L� �4
Location/Uirections: � /� �l� �� , �v�� �" � �l! "�
O riginal Permit Located J�_
Septic System Uesigned t'or:
Kesidential r/ E3usiness _
�
Other (speci�y?
# F3edrooms � # Employees - Other
llate lnstalled Water supply % ��
,' , . .
Type ot System
Hitrification Line
Tank Size
C
- � lJ
Certified Operator Required ���
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On site was�ewater disposal. system showes no visually apparent
malEunction on ,`7�Z2`��
Yermission is granted to: �� � �/t�Qf.�l� �,�l?/�.��
According to the at�ached site plan.
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