A25 86.,
�
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
I� OVENiENTS PERF11T � l�io`<�
j��l � a� �"� U "�,
Owner:
Location: r ��-
_ _'_i�. -. -
Contractor: -
Water Supplp: Private Public
,• --�-��
Sewage Disposal Facililies: No. bedrooms �— Dishwasher� Disposal,
washing machine, other sutomatic appliances �"^`"""-"-��
Size of tank: -'�✓�'�,`�,.�_. NitriBcation line: ����
b> �1. ��_ _ �,��,�r�1
Other disposal facility:
Water supply and sewage disposal facilities locati3ii, 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 HEA TH DEPAR ENT
STAFF BEFORE ANY PORTION OF THE I T LATION IS OV-
ERED AND PUT INTO USE. � f
�:
Date approved: Sign � ��
Sanitarian
Well:
Sewage Disposal: I Counter- - {����
aigned ll� G�`"f'"'""� �Y�.��'GJ�'wt'
B3'� (Owner o is representative)
;�
CerYiScate of Completion
Date Approved: "0 1� k� By:
S tarian
(OVER) �
Location of well and sewage disposal facilities sketched on back.
NOTE: �sketch of installation showing lot size shape, location of house, septic tanks, —es, water
supplies, e c. ote 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.
. .. �
DD_
,, Amount paid IO6.
Receipt l� ' 117
' Y ��
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�.
Improvements Permi[. (Established/Recorded Lot) _. Reinspection of Existing System (Loan Closing)
Impxovements Permit {Un�ecorded Lot) Repair/Replace existing Sep[ic Sj�tem
✓improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition)
�
H � �: � � � `��° �x '�x`�, ':� �,�.-��,r� t .
O 3 ����"�,.�� >. `�� ��,��..�� : �
a
,_ Bacteria _ Chem�cal
_ Replace Existing Well
_ Petroleum � _ Pesticide � _ Lead
- 1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: ,�. Width: � g x��
Address: �--� �� i � . %�►�, 6 `� ��! "ck�^ : ' ` Depth:
- "`� �`''� 8. What type (if any, additions, expansions, or
� replacement is anticipated to the structure or facility
W that this sewage disposal system is intended to serve?
�Home Phone #: - �� �'
usiness Phone #:
a _
w
�
z
:�and a Ss of,c�rrent owner: 9. Water sugply ty pe:
. , : � privated�public ❑ community ❑ spring ❑
� � Are any wells on adjoining property?Yes ❑ No�
t, �' � "� If so, identify location:
3. Property Description: Lot size: c J' 1``
4. Tax Map#:
Parcel#: � g�
Township• � �,�.1—.—
5. Directions to property: State Road #& Road
ames,gtc �
�3 3 6 ���y� Q _��.� j-�
6. Number of occupants or people to be served:
�pe of structurelfacility: Proposed: �Existing: Q I
Type of dwelling:
House:�'�vlobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOII COunty Health Department for a site evaluation for the on-site
sewage disposal system foc 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 shall 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 Heal[h Dept., this application shall become void and all fees paid forfeited.
� �
����� �
Siencc� Owner or Authorized Agent
permit Issued ❑ Signature
permit Denied ❑
Plat Observed ❑
Date - .
�
..... .��+j ... .. . bv ( £aCs' �y: § . '
�'��'ayi°��E�`,z ?�',�,'��r .t: ; t ' CI'ORS$JTE EVALl1AT ON s"'•,ti.v:s:, t r 'S1. t A}�j� 1 '�';,y . ' ARFJ�'2 '4L' ?� pc1 ' �a �
� K.6 S(? . ..........:. G�:...'.S .. W. a...r Y uY.•b..?F^� .,H�i�u,� 4' �h..4 �... ....:. k ..>.�... af6 b...... i..)i'� M�!��,��,.ni:F�. Q�'w.,.af$i1.l�.�4 l. �.:•�,`y.
1. SLAPE (%) S S S S
PS PS PS PS
U U U U
2. SOIL7'IX7VRE(12•36IN.) S S S S
(SANDY. [.OAMY. MYEY. NOTE 2:1 CI.�I� PS PS PS PS
V U U U
3. SOiLSTStUCfURE(13-361N.) S 5 S S
(CLAYEY SOILS) PS PS PS PS
U U U U,
3. SOILDEPIFI(IN.) S S ' S• S
PS PS PS PS
U V U U
S. RESIRICTIVE HORTZONS (IN.) S S S S
(D.iYERV10US STRATA, ROCK) PS PS PS PS
U U U V
4 SOILDRAINAGE/GROIJNDWATER S 5 S S
(DCff7WALA WiFRNAL) PS PS PS PS
U U U U
T. SOR,PERMEABIISiY S S S S
(PFRCO[AA710N RATE7 PS PS PS PS
U U V U
d. AVA7LABLESPACE S S S 5
PS PS PS PS
U U V U
9. STfEMSSfF7GT10N(SEEBELOW)
SOtt, SERIES
S�SUITABLE PSPROVlSIONALLYStJITADLE U•UNSURABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies. slooe �atterns. CtC.� C:V�MIPRO�DOCS�APPSEC.S�t FINANCE.PC
,
1
L'erson County Healtli Department
Existing Sewage System Report For:
Requestee:
✓Mobile Home Replacement ;��'�"
Addition �
' � � �(�,�, Home Phone# ��=�d�
�, Ivli � �Business#
�=��i7'��� . 1 �� 01� .��-l? Tax Map# o[,rJ'' c��
/ '1
Location/Directions:
Oriqinal Permit Located v
Septic System Uesigned For:
kesidential ✓ Business
# Bedrooms � # Employees
�
Other (specity)
Uate rnstalled - Z- Water supply
'Pype of System
Nitritication Line `�"�� � �3 � r
Tank Size
Other
���.
a--; a,� �-Cvl�
_ J ` ��� l )
Certified Operator Required __
On site wasL•ewater disposal system showes no visually apparent
malfunction on `��a�g �
Yermission is granted to: �; � �� �{�
According to the attached site plan..
Comments:
Environmental Health S�.
�
DATE
. ,/
07�07�199B 10:09 5971799 PLANNIt�G AND ZONING PAGE �3
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Building Additions/ Mobile Home Replacements
Tax Map #: ��
Approval Requested for:
Parcel#:
Mobile Home Replacement
�L Building Addition
• � • � � • � ,�.,a-
-
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Permit Located: ✓ Yes No
Installation Date: �r 1r,7-8� Design flow: �Ot� (gpd)
Current Contract with Certified Operator on file (if required): �1�
Water Supply: �� Well Public or Community
Wastewater system shows no visual evidence of failure on: �o'�'? �olo (date)
(Applicant's signature if site visit is not required) �' - a.u�.�-
Addition/Replacem�nt Approved
��� ���
Environmental Health Specialist
11/15/OS
�/�9�0�
Date