A25 66The District Health Department
Orange, Person, Caswell,_,�h h,aix+,..S�. Counties
I�,Fi��ZOVEIr1ciV I .� �r'Ltc��r�F�
Water Supply and Sewage Disposal
TheiDistricl�{-lea��►a�epnrt��--3' 7�
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Owner:
Location:
Contractor: �.._c�/�m y �� 1 S —
Water Supply: Private —�� Public
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Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other automatic appliances
Size of tank: + Nitrification line: ��� � 3�
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PAftTMENT STAFF before any portion of the installation is covered
and put into use.
Date approved: � .
Well:
Sewage Di p sa •� Sign
Sanitarian
By:
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Coun rsigned
CERTIF CATE OF COMPLETi�,�:y
ro
Location of well and sewage disposr�efQi���t��s�d�H�epautmb��k.
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.
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�lnplication Date: �' — � �^ � � Tax Map: �/� `Z�
Amou+�t Paid: ���— Parcel #: �o (,
Receipt#: � Q Q 6
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Application for Services (Septic Systems and Wells)
Services Re uested
O Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 if> 600 d) Fee is de endent on the e of s stem ermitted)
Mo6ile Home Replacement or Building Addition � Permit Revision
$150.00 if site visit re uired $75.00
0 Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
� 1) Services Requested by:
Name: �� c�a p E L L E LcJ / S Phone #(home): C33 4� 5 s�- y�� o
Address: 3�i,6 ra /2C'j� � C C'� ��/m n-� i2� (work/cell): (33l07 �o y- 37 5 i
_�� �r.���o �v c a � s � y
2) Name and address of current owner (if different than applicant):
Name: S'� r� E
Address:
3) Property Description: Lot Size: /�/' • Subdivision: N��" Lot #:
Address and/or directions to Property: ACQoSS rz�A7 f>2o�i 3 �i�
�/1 C'��ir c�qyToiv az.1"�
4) Proposed Use and Type of Structure:
Residential � Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes No �(with plumbing: Yes No �
Garbage disposal: Yes No
5 Water Supply: �
Private Well (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No _� Yes (please show location on site plan)
Note: A completed anplication must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
. / �.-
Signature (Owner/Legal Representative): ' � Date : � —��-2��
,
10/08 � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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J.Y.�:a��1.��.���.fi�.1�i:.(i��i�.�a�..� �3. J.L(�i¢�.���J116.
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�uan�a�Il�a� �da�g�n�aa�/ IVg�d�fl�ce ���e fl���n�������n$5
Tax Map #: /�cJ
Approval Requested for:
Parcel#: � �
V Mobile Home Replacement
_ Building Addition
Applicant Name: I" \� �{2 L�2W i S
Address: ,r -
r 75
Phone #'s: 33Le- 5`��' 9dl o �3�, -�6�1- 3751
Pemut Located: V Yes No 7
Installation Date: �2 -3- 73 Design flow: • (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: �/ Well Public or Community
Wastewater system shows no visual evidence of failure on: �-i9-/ � (tlate)
(Applicant's signature if site visit is not required)
���°��0�1�3���a���e���n� Ag���°�d��
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Enviro ental Health Specialist Datz
11/15/OS
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Name � i �� 2 LQ w i 5 Ta.g Ma.p #` 2 Pa:�cel #��e
Subdsvisio Section/Lot#
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Authorized S�ta.te Agent Date
System cnmporaents ne�iresent upproximate �cvntours o�ly. ?'he contrac�tor r�aust, flag the system prior to
beginning the instaTlr�hion to ansure that ps�npergmde es maintaaned
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aecome�nmton surver ror
CHARLIE MORRIS OAKLEY, SR.
Wnninqham TY+P•, �0^ �O,NG
July,l99T SColp ��'�
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Ernest fl Nbod, Jr., RL.5.26q9, Roxboro, N.C.
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10 �S� $4-�