A25 153'✓
The District Health Departmenfi
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT �o
� Da e - �
Owner: ` ��
Location: � �a't-� �
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c�v► .�Cr� j2.lC�,_ `� �
Contractor:
Water Supplp: Private �'�� Public
Sewage Disposal Facilities: No. bedrooms 3 Dishwasher, Disposal,
washing machine, other sutomatic appliances
Size of tank: ���� Nitriflcation line: �� X3
!
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 HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:_�—
Well:
Sewage Disposal: -, -
� / 1 '4
Signedll/�� `'��fiLvc"^'
Sanitarian
Counter- �
aigned
(Owner or his r present ive)
Certificate of Completion
Date Approved: � � B :
anitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
i 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.
' (1) (2)
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WELL PERM2T
C,aswell-Chatham-Lee-Person Counties
DATE ZSSUf,� 1�DATE DRZt"�: y R�/� COUNTY: v��
OWNER: �� r. _ �►n. � ) T,�T=� . �� /�i�
:lEI.L CONSTRUCTION
Distance from Nearest Property Liae Diatance from Source of
Pollution
Total Depth: . Yield: GPM Statie Yat Level: FL.
Wtster Bearing 2ones: D}Rih:� �.��. �.
.Casiag: Depth: Frans�_to FL. Diane : lnches
TYPE: Steel Galvanized Steel
If Steel, does ovner appz+�� Yes No
Neight: Taickness: JC�� Helght 1►bove Ground: lnchns
Drive Shoe: Yeax No:
Were Problems Encountered u� Setting De Casing? Yea_ No
Ii 'yes' give reason:
Gront: Zype: Neat San�i Cement: Coaerete
Annular Space FtiCth [� lnsbes
Water in Anaular Space Yea No ��
Method: Pumped sure Poured
� Depths iYom Lo � FL.
' MaLerials Lseo: No. Bags Portlaad Ceaeat laeiqht of
1 bag lbs.
=f mixture (aan�gravel, eutiinqs) - Ratio: to
ID Plates: Yes�No Chlorinatioa: Yes No
4 x� slab Yes Ho
(Denth
Prom to ormauon Descivtion
I HEREBY GERTZFY THAT THE ABOV£ INFORlSASION ZS CORRECP TFiAS TFiZS
WELL ilAS C�NSTRUCTED IN ACCORDANCE k TH GUSsAS KS SiT RSH 87
CAS:7ELL-�TiiAlf-LEE-PERSON DSST. D
. 51gnaLure o: Coa:,:act Daie
• � FOR HEALTH DEPARTTSEhT USE ONLY
REISON FpE Np IltSPECTIOti:
• Saniia:aan's Sianattire Date
Sketch well locatinn on reverse side. Use establisbed refereace
points. .
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Amount paid )00.00
Receipt .�� ' 1 I 3 Z
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Date
,. <:< ..,.:, �.:..� -:.... . _ ___
vements Permit. (EstablishedJRecorded Lot) _ Reinspection of Existing System (Loan Closing)
Iml�ovements Permit (Unrecorded Lot)
ts Permit (Mobile Home Replace)
Repair/Replace existing Septic System
Permit for New Well
i Im�rovements Permit (Addition) I Replace Existing Well I
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1. Permit requested by: . 7. Dimensions or Proposed Structure:
, ��
owner/prospective owner/agent;.�F � v �-i" ���`� � Width: ✓?�b - �
Address:/� 2 U����or_z,✓J-c'_��Fn �=!� Depth: �-i � �-�� r
��/�p,Q� �/I� 2�S� 3 - 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?
Home Phone #: 336 Sys-��53
usiness Phone #33�-50 3_-.S7�S!
2. Name and address of,cunent owner: 9. Water supply ty�pe:
private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes �i No j�.
If so, identify location:
W
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iption: Lot size: � �• � -- - = �z
Tax Map#: h` .;��_ -
Parcel#: �1 S.� �
Township:�t�.��>�Gl��m _
Directions to property: State Road #& Road
ames,�tc. _ _ _
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Number of occupants or people to be served: �._
10. Type of structure/facility: Proposed: DExisting: Q I
Type of dwelling:
House: ❑ Mobile Hofie: L� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: __�.__—_
Garbage Disposal? Yes ❑ No Q�
Basement? Yes ❑ Noi�'If so, # of basement fixtures:
— L
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF AL
PROPOSED STRUCTURES.
I hereby make application to the PeI'Son COunty �ealth Depat'tment for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit sha11 become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
�
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Signec� Owner or Authorized Agent
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date , ,
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1. SIAPE (%) S S S S
PS PS PS PS
U U U � U
2. SOB.7'IX7iJRE(12-361N.) S S S S
(SANDY, LOAMY. CLAYEY, NOTE 2:1 CLAY) PS PS PS PS
U U U U
3. SOiLSITtUCIURE(12•161N.) S S S S
(CLAYEY SOlLS1 PS PS PS PS
U U U U.
3. SO1L DEP7'Fi (1N.) S S S S
PS PS PS PS
U U U U
S. RF.STR1C17VEHORtZONS(M.) S S S S
(IMPERVfOUS STRATA, ROCK) PS PS PS PS
U U U U
6. SOILDR/UNAGF/GROUNDWATEA S S S S
(FJCJIIWAI, & Q�TiERNp1,) PS PS PS PS
U U U U
7. SOILPERMEAB1LTiY S S S S
(PF�tCOIAATION RATE� PS PS PS PS
U U U U
E. AVAILABIESPACE S S S S
PS PS PS PS
U U U U
9. STTEMSSIFICA710N(SEEBELOW)
SOIL SERIES
S•SUITAIILE PSPROVISIONALLYSUiTAIII,E U-UNSUITABLE
RECOMMENDATIONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, praperty lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� etC.� C:V1MfPR0�DOCSAPPSEC.STIFWANCE.PC
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; �xi�ting Sewag'e Syst
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Fteq�lest�'� : ,�'T�^1
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L4C�tianlDi�ec;tionss
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' Q�i.�insl k�er�t�;t Local3e
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Caunty Heal.th Depart�ent : �
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Repert For: Mc�bile Kame � RepL4aa�zstent _;��"
��Addition � '
�,'���,.-! y� �P.� Hoine pMone#i����'�
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Business# �.�J�3`"�J'7 �
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"'� f � 'tax Map# �„r�'���.,
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�eptic SysCem �le�ign�di k'nr: - .
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� . � Eiesa.dential � � �3usiness oth�z {speciEyj'. �
- : : ; � . � -
� # t3�droor�s "� � �#� �mplayees Other . :
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' ` V�ater supply • �
, : t�at� instal.led �.�,g 9 . L� .
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r cat on �xne �
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Tank Szze �} ��
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