A25 139The District Heolth Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
�Nater Supply a d Sewage Disposal
IMPR NTS PERMIT No.
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Owner. v " ry �l �� 7 �'` � _.—,_,.��
Location:
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(`nntrartnr• { � "�� S
Water Supplp: Privatq' L� Public
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Sewage Disposal Faciliiies: No. bedrooms �— Dishwasher, Dis
washing machine, other �utomatic appliances
Size of tank: �� -� _� -v� a�� 'f � Nitrification line: _
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 and 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-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY PORTION OF THE INS�ALLATION IS COV-
ERED AND PUT INTO USE. �, �i
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Date approved: SignecL' �"� S 1'�' �''' ''' �
Sanitarian
Well:
Sewage Disposal• Counter-���r
aigne� - �� ���.�,,�
B3'� (Owner or his representa"tive)
Certificate of Compleiion � ,
Da�e Approved: � � � " B :
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
sup�li�s, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
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Amoun t paid ���• �
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RVTCFS
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Date
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Improvements Pesr,iit•(F.,stablishe�/Recocded Lot) I_ Reins�ectior, of Lxisting System (Loan Closing)
IrnQrovements Pcrmit (Unrccordc3 Lot)
Imo vcmcrtts Pccmit (yfobilc Homc Rcpiacc)
mprovcmcnts Pc.;nit (r.ddition)
2eoair/Replsce ezisting Septic System
_ Permit foc New Wc'.I
Re�lace E.:is:ing WeII
I. P�.:r.ic re�ueste� by:
c�.v::�:: aces�ec:;ve �wae:'=���t: (..li ( I � �. �'1� VS
Address: l.l � w �►a d
4 D 3 7 m o•.r -l- o� (��,i, I I:�. r� �d
om� Pno;�e = 59'7 ,Sa�S�
usiness Phone n: S�9- gDB�
?. Dimensions cr �:c�osed Struccure:
w��:::• a-y �� C��.�or�
Deoc;�: �-5� �' -1, _
8. W:ac ryoe (it �ny, zc�itions, expansions, oc
ceoiace:nent u �r.:ic:�:..�� to the structure oc :ac;li[y
thaC c::is se•,•ra� �:s_ ��� syste:n is in:ende� :o serve?
. Name and address oi c::::ent owne:: 9. Water suocly ;:•pe:
�� vn� pcivzce t� . pub?ic r co::u;iunity ❑ sprin; C �
Are 2ny wells c� aciei:tin; orope:ty?Yes ❑�to L�,
If so, identify iccatior.: i
. Prooecty Dcsc:iption: Lot size: � _ '
. Tax Mat�: h1- .;( �
P.:: ���r: I 3 q
Townshio: C,u.� � ► �
. Direccions to property: S�ace
tames,stc.
. 5 I r�-1- e, 1� v�,.d.
Road n & Road
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10. Type of st;.:c:ur���acility: Proposed: DExisting: C�'.s
T; pc o[ dwe!1i,_: ;
HouSe: ❑ �1obile F-iome:C� Business: ❑ �
Tyge of business:
Number of Emoloyees: C
Number of bedrooms: �
Garba�e DisposaI? Yes ❑ No 0 �j
Basement? Y�s ❑ I�Io Q If so, � oE baseme;it fixtures: ;
�6. N4mber of occupan�s or people to be servcd: �
CLEARLY STAI� ALL CORNERS OF THE PROPERTY A1�ID THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hcrcby makc application to the PerSOII COunty Health Department for a sitc cvaluation foc the on-sice
sewage disposaI system farthe above described propecty. I agrce that the contencs of this application arc true
and represent tf�►e maximum facilitics to be placcd on the pcopecty. I understand if the site is altered or che
intended use changes, the permit shall become invalid. I understand that before an Improvements Permic can be
issued, I must prescnt a sucvey plat of the property co the Health Dept. I understand that in the event I have not
deIivered a survey plac of the property to the Hcalth Dcpt. wi[hin 60 D�YS af[er thc datc oE thc cvaluation of
the'site by the Hcalth Dep�, this appiication shall become void and all fecs paid forfeitcd.
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�- Signcci Owncr or AuthociZcd Agcnt
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Person County Health Department
Existing Sewage System Report For: Mobile Home Replacement
i✓Addition —('j,�,�po�+-
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Requestee: �''�1 1�`� � '�-�I �'1��-PI�Oc - Home Phone# �%-S�(o
� ��J� �I���f1 �l• l � � • � KU1 Business# �g �i �R�
�� p-Rl NI�Z��J 7� 'Pax Map# ��� �
Location��irections: 57� �Il� i�Or�a — �w��iam � ��%b3i
n e� e-D �(1 CbYY.� - C L°�O C,�' •
Original Permit Located V
Septic 5ystem Uesigned r'or: ^
Kesidential � Business Other (specifyl
# eedrooms ,� # Employees Other _
Uate lnstalled ��`t�`O o Water supply �vQ=
�ype oi System LUnU�`I-�d�1Q �
Nitrification Line ����� �1 �4-�� ��/1 UQ�1�2�
Tank Size
�0 �/�
Certified Operator Required ! V �
On site wastewater disposal system showes no visually apparent
malEunction on `�/ � I -L �
Yermission is granted to: 1 ��,�►Q.. �� �. ►i1��
According to the attached site plan.
Comments:
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