A26 27B 1440
PERSON COUNTY HEALTH DEPARTMEN'�'
WELL AND SEWAGE SITE, LOCATION IlbD.'ROVEMENT PERMIT
r"' I�Tot for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shalt be issued until Authorization for waste water system construction
. has been issued.
Tax Map # � � � Parcel # ��%
Zoning Township D/r'✓e i l
Owner/Contractor Date .�- �� 9 �7
Location/Address nl S 2 -�' �.: ��uG / a �t �—
S� 133� J_ ��ck �,�,,,,ye on IPi�' S.R.# /
Subdivision Name ___ Lot#
l, ; SEWAGE SYSTEM SPECIFICATIONS
� Repair Lot Area � Size of Tank �i � �.,o
SFD Mobile Home Size of Pump Tank r�/�}
Business # of Bedrooms Nitrification Line �,' s�i,,,c �
�� D r��i �� u� D�uM.�+n� Max Depth Trenches
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V Permits may be voided if site is altered or
� Well and Septic Layout by �
a Comments:
�
Date
Installed by,
ell Pertnit Paid ❑
Site
�mi-Public
Replacement
Installed by
,
� Approved
/
SYSTEM SP � CATIONS
Required Slab
Air Vent
Requir ell Log
by
This report is based in part on information provided the homeowner or his/her
representative im the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained io the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleadiag statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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•1mp vro ements Permit. (Established/Recorded Lot)
Impxovements Permit (Unrecorded Lot)
I provements Permit (Mobile Home Replace)
_ Improvements Permit (Addition)
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Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
„_ Permit for New Well
Replace Existing Well
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H
it requested by: .
ro�pective ownec
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;ent: � � v i1�l1
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�ra��r�� � � � .�� �
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ome Phone #: '�I'7�=�'i��_
usiness Phone #: �`� `�' s `� � �'
Name and address of current owner:
�
ion: Lot size:
Tax Map#: � ��-.�
Parcel#: �
�Township: �- �� ��-e
. Directions to propercy: State Road #& Road
[ames;�:tc. � �: P -� � ��
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n.�?�� �i
7. Dimensions or Proposed Structure:
Width: � � ��� ��
Depth: � �-� _ ;
ff�C�at txpe (if any; �additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water st
private �j .
Are any w
If so, i�.en�
i��
c 0, communiry ❑ spring ❑
t �joining property?Yes ❑ No j�
�
10. Type of structurelfacility: Proposed: �Existing: Q I
Type of dwelling:
House: � Mobile Home: L7 Business: ❑
Type c,f business:
Number of Employees:
� Number of bedrooms: _ _
L Garbage Disposal? Yes ❑ No 0
Basement? Yes❑ No�] If so, # of basement fixtures:
-� (�5 Number of occupants or people to be served: � ' � '
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOn COuntj� Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree [hat the contents of this application are tnle
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 Pecmit 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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Signc� Owner or Authocized Agent
permit Issued ❑
permit Denied ❑
Plat Observed ❑
►. s�oeecR�•
Signature
SOD.TFXil1RE (12-36IN.)
�NDY.IAAMY.MYEY. NC,TE 2:1 Ml�
SOIL Si7LUCiUAE (12-36 INJ
uv�r son.s�
SOIL DEPT}i (WJ
. RFSTRICiIVEti�'?Ri7ATiS(iNJ
Q.tPERVIWS S'TftATA. ROCK)
i. SOILDRAINAGFJGROUNDWA'iER
F�CTFRNALB WiERNALI
CTFRN
1. SOII. P£RMFABI1lTY
;PERCOIAATION RAI�.i
6. AVAIIJIBLESPACE
STfE CIJISSIFICAT70N(SES BELOw)
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SSNTAOLE PS-PROVLSIONALLYSURABLE U•UKSUCtABLE
RECOMMENDATIONS/COMMENTS:
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, we[ areas, fil'
areas, wells, water bodies, slope patterns� C�C.� C:WM[PR04DOCSU�PPSEC.SMFWANCEF'
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The District Healfh Deparfinen�
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Date �`�' � f ` �E��
Name of owner: � � � � � � r �
Name of contractor: � r�� Mr� ► t't n� G� h
Address and Directions ���—� �X b r� ,� i
`/�:--� ��Ca-...F � � � � � ,. .
Person or firm doing installation: �
Address
No. of persons to be served Bedrooms 1,�3� 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine � CZI"�1 C7 �
Recommended• Septic tan � �
Nitrification line: �O � �
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecfed and
approved by a member of !he District Hea13h Depaztment s3aff before
any portion of the installation is covered.
Date Approved: � � � –
By:
Countersigned
Signed
Sanitarian _
O. David Garvin, M.D., M.P.H. '
District Fiealth Officer
(Over)
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NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on �` '
adjacent property, etc. Write in measurements`in order that installations may be located at later
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION '
(Void si�cty (60) months from date of issuance)
. DATE:_�2�- � �% IlViPROVEMENT PERNIIT #: �C�
TAX MAP #: 2�o PARCEL #: -2 %
OWNER/OWNER'S REPRESENTATIVE: (n�� � Sumv�e r
LOCATION/ADDRESS:
13 � 2 � Sr�.-�- _
� �-� S�# r 3 3 � , .2^ �+ �r,� � � � � h lP,�=.
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR
ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
0
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #�. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Cond' ions:
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Person Requesting:
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