A25 21� The Dis rict'�e��th D par�ent
' � CASWELL -_�HATHAM - LEE - PERSON COUNTIES
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Water Supply��n�Sewage Disposal
IMPROVEMENTS PERMIT ., No
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Owner: ---�� "-�
Location: ��
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� Contractor: j� �AJ -:-':. �- Ar��-�e.
� Water Supplp: Private Pubiic
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Sewuge Disposal Facilities: No. bedrooms . Dishwasher�. Dispo�
wnstung machine, other automatic appliances ��"� '����= `
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Size of tank '� Nit flcation li ' _ '
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� � Other disposal facility:
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y�bJ�VIC�"Y�u1rC�% -Z� ,x��i`�'wi`�� X��.�(I!Cf� ���� .
Water supply and sewage ciisposal acilities loc�f� taliation and ��
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
t:tined by owner in such a manner as not to crnate a public health hazard. �
Septic tank and nitrification line MUST BE INSPECTED AND AP-
P'Fi.QVEI} BY A MEMBER OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY PORTION OF THE ,IN57�� TION I COV-
ERED AND PUT INTO USE. ` F '•. :�,"
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Date approved• Signed `+� f'�� " .s ' '�.=�•'.�
Well: ,� Sanitarian`
Sewage Disposal•
By:_
Counter- �
�;e�a�•c.�c,�. . ?�«,s:i,l.;;�:•,.
signe�
(Owner or:his rep'resentative)
�', Csrtificate o� Completioa
, Date Approved: �� B • �
ni arian
(OVER)
L,ocation of well and sewage disposal facilities sketched on back. .
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Aualication Date: 3�� �� 7 � Tax Mao #: /'t'� �
Amount Pald: I �.�C�
Rec�tpt #: 17.4 6 �- ParcE! #: � �
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Y , APPUCATION FOR SERVICES
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IF THE IWFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALS1FaED,
CHAiVGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATIOId TO
CONSTRUCT SHALL BECOME INVALID. �
1) Pertnit requested by: (Owner/agent/prospective owner): �-0.hir' �. �S-��S � I
Home Phone: �S q a- 174 ���21--- Address: ��( /Vt C ee S M. i l � �G .
BusinessPhone: �3�i ����i_g�3�' �eM��'a N 2.�3�3
2) Name and address of currer�t owner. �-a M�
3) Properiy Description: Lot size: ��- Township: Subdivision: � Lot #
Directions ta the property (Including road names and numbers):
. 3�1 lu �e A�l � I
4) P'roposed Use and $truc#ure Description: answer each of the following questions:
a) Proposed , Existing , Type of Structure: Width: Depth: s
b) Number df 8edrooms: Number of occupants or people to be served: _.
c) Basement: Ye� . No Wiil there be plumbing in the basement? �- �
d) 6arbage Disposal: Yes � No _ �
5) Water Supply� Type: Private _(new _ or existing�, Public_, Community� . Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
'site ptan. _ . �
6j Does your property contain previously identified jurisdtctional wetlands? Yes_ No_
�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPL1CATiON.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLA►GGEU.
➢ THE SITE MU$T BE READILY ACCESSiBLE FOR AN EVALUATIOPI BY THE HEALTH DEPARTMENT
STAF�: � .
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
faciiities to be placed on the property. 1 understand if the site is aitered or the intended use changes, the permit shail
become invalid. -
Owner or Legal Representative
� ! � -a�
Date
PCt;D, rav. D6127/02
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PI,�SE SEE .ATiA�yD I'�N FO�d WE�,L S� I��I�iJ'I'
Tax Map �
Applicanf: _
Subdivision:
Location:
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Parc�# �_ Tovvnslup:
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7
Lot #
Type of iWater Supply: _ dividual _ Community Public
Itequirements:
Sita Approved By: _� �
Grouting Approved By: o o�'
Well Log: _ /!�J `% �
Pump Tag: . .
Well Tag: � -
Air Vent: ` �
Hoae Bib: �
Caeing Height: '
Concrete Slab: • � � ' � �
Well Driller: t� l/GtnS
Well Approved by:
*�**�ee.Attached 5ite Sketch****
Liner:
7nsta1led by:
Depth set: _
Grouted•
Date:
Water Sample:
Wells muat be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:,
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PCHD rev 01.�27/0�
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N�me � � Sf,e .
Sub 'ofl -
� . Authorized State Agent
Taz Map #.���.Pa�xcel #�
Section/Lot#
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Date . � �
System cnmpo�ents nepresent a�iroaaimate�contours only: The cont�wctor must, fTag the syste�n prior to
; beginning the installation to i�sure thatpr�opsrgrrrde rs �raintained _,
tny�,rf�,e....,.,._.. _� ..�._...........,.,.,._. r._ , � .. ...._...,.r .. ,
,�_: � .. . ..�.n•».....w.w...r.........».........�.,...,,,r.........w...,►.s.�r��.
-. `� � , 800K �' PAG� '�� �: �. . �.:
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OwnCr: -___L-12.r.
Locaticn: _��
Subdiviaiota:
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(ry�rr � �' � n �.r I,�% l�__.L_.�� �'� S
D� L�0'��l �3 ' s?- � � � ,� ........,
�Gront La6
_ Tax Map(,�� Fnrccl # _�
Lot
W�JI CoaetruMios�
I�istauce Frorri ncf►rtat PropetZJi Line (M�nimum' tQ ft�ct) �
Diytsnce from S�ptic Systcrn (Minimum 60 feet) ✓
1'ntal I3opth: � a_ ft Yicld: �._ �iPM Slatic Water Levei: s S ft �
1�Vater Scaring Zoncs: Dcpth � ft�� v R ft ft ��
Cssis��: "
Ucpth: From _ Q us� ft. Dian�ter: .b j� in
Tyge: Galvunizcd Stcel
Wcight: ��_. Thicknese: 1�,� �ieight above Ground: �� in
i�rive ShUt: ___ t/Scs No r�,ny problcma cncounterr,d whil� sctiing casin�? �_Yce t/i�o
[f "yes" qive ttason: ____w_.____ .____._.�_ --_
Grout:
Ncat: San�iCernent � Cancr�te �veUCemcnt
Annutar Space Wid2h „� ut�i�ss W�a r in Annular Sp�cc Yes t/�10
h�[�chcxi of 4rout: Yum�od __� PrCaaure ��/ Pr�ut�.i _�_ I)tpth �_Q to ��? Ft.
1Vl�terfaDB U�ed: r
%Io. Bags Fartluncf c�mcnt `,TVci�ht of 1 B�g �� �'o::nds
If mrxture (s�r,d, gravci, c�ttings; �-- itatio �� ta I
ID platcs: __ �� No n x 4'l�b �Yee No
Llac�r: _.._ �__.
Depth: ____ Daee inat�licd: r� Grouc• _,...._...._.__._ Inmtailed by:
[?rtidinQ Lag l.oc�tttot� Drxwfi�g
1 hcr,�by certify t�.at the above info�mation ia cone+et and that this weli was constructed in acaord$nce with re�uiatior�s ast fcx*�}
by the person Counry iical[h Ucpartrnettt, �
Si�u�ture of Cuntractor ����h ��!"�---- IU �"F,� Y)atr ���� �
Purnp inAtxt�ntent
Pump In���llation Contr�ctc�r. �t�fc Rs$ietr�tian Numbc�r:
Pump De�th: � _._._ h _ ....____._...__._.
�fi Static Watec I.evcL ft
Pump M�ke & MadCl; ........---.__..____._...�. - Pur:1p Si2c and Rating: _.__,. .. _._-- P-----_._.. 8i��
1 ticrrEjy cCrtify tltat thia pun�p was ir�stailed atsd the wcli head cvin��letrd accarding to tl�e Peryon Caunty �'dell a��sles in �r:ftr.c.c
�n chi� date and that a copy of this record has bccn �xovidcd ta �c well owner.
Puinp 3nsiatler SiQn�eture U�te: PCHI) rev 01/2"'U;