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A26 31b' � � � 3 The District Flealth Department Orange, Person Chatham, Lee Counties SEPTIC TANfC PERMIT Date r Name of owner � Address and Directions ,: _ . - Person or firm doing installation: : Address No. of persons to be served bedrooms 1, 2, 3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine Minimum Requirements: Septic tank ' / Nitrification line: " Septic tank and nitrification line musi be inspecfed and approved by a member of the Health Departmen# siaff before any portion of the installation is covered. i Date Approved: P � Sanitarian � r ' By: ' O. David Garvin, M.D., M.P.H. District Health Officer Countersigned (Over) .4i , tr -, � � fi: NOTE: Make sketch of installatiori""showing loca�ion of house, septic tanks, privies, water supplies on �':�,adjacent property, etc. Write in measurements in order that installations may be located at later „>'' �' 'date �' � <� .� . ,;, , � « � t . . ; . � t ,... , ! .:,1�.� ' . � . �soiication Date: / ���3 Tax lfiap #: .' `�� �,mount Paid: 1 , 3 R�c:�itot #: 2 7. f�ar�e! #: � . � � � �� ��� .��� �I�I�..� �� . � � � zaz) - :---- X P�-r -,- � � ��-��- �a � � �asvs.a-oss---�-�- �osa.�.a71. 1E—�Laa.a.IL�a G v �,� r� �►PPi.1CAT10M FOR SERVICES CONSTRUCT SHAL� BECOME INVALID. . - ' 1) Permit requesteci by:_(Ownerlagerttlprospective owmer): L� � d`-� ei C.f�V�' Home Phone: � - � 7 � � Address:3 - u l. � � Business Phone: . X � � 2) Nam� and address of.cnrrent owner. �e� rA �,ou e. 3} PrapeelyDescription: Lotsize: ��c. Township: ��Ire ��S division: Lot# Directions to the property,�l�clud �ng �road names and r�umbers)�� c1 Gc� �� i�1 �u'o 2-Ef� ��� /0 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed . Existing Type of Structure: Width: � Depth: b) Number of Bedroom � Number of occupants or people�to be served: �_ . c) 8asemen� Yes�No Will there be plumbing in the basement? I�� d) Garbage Disposai: Yes ^ No � / . 5) 11Vater Suppiy Type: Private �(new _ or existing�, Public . Community . Spring _ . � Are any weils on adjoining property? Yes �/No _ If yes, please indicate a�proximate location on the � site plan. � _ .. 6) Does your property contain previausiy identifier� jurisdictional wetlands? Yes_ Mo_ Pl.Ee4SE PIOTE THE FOLLOWIPIG: ➢ A PLAT OF THE PR�PERTY OR SIl'E PLAN MUST BE SUBMITTED WITH THiS APPl1CATION. ➢� PROPERTY L1NES AND CORNERS MUST SE CLEARLY MAR�D. ➢ YHE PROPOSED LOCAilON OF ALL STR,UCTURES MUST BE. STA�D OR FLAGGEi3. ➢'rFiE SRE MIJST BE READILY ACCESSIBLE FOf2 Ahl EVALUATION BY THE HEALTH i'�EPARTMENT STAFF. � I hereby make appiication to the Person County Health Department 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 faciliiies to be placed on the property. I understand ifi the site is altered or the intended use changes, tfie permit st�all became invalid. �� � Owner or Legal Representative -�� Date PCND, rev. 06l27/02 ' .. t���;� ��/���(���\�� ` • - Y V •\��� ���J��'1lrTe'1@�W�i�L ��� • �� �/SiiL� VS.L" ' ' • N �} � t,�t �{- �rn i c, �'. t� �V er , Ta� iliIap # A�(o P�cel #�_, ub • • � Se�.onJLot# � 9-9-0� ; A,�a�� s��.� �- . � D�� . � � s���� ��� �,�� �►. �� � �.��.����. ' •�����������a � W�ri Sj�. Mu�K�a fZc.c�r�,mc.r�d � C;asi� �tr-� . w� 2� �,'mc, F���s l� c t l c�: t!��-� S��� lo�.� _ . � . o1d w�i IS d�P��� - z�, . � � � � � ►�' � . �Id W�i� �b��d� 0 pU �,� �� t Z� e,�,lt�'i�ut� � Fi ! I ��Ccr►�cn�t 0 cn,t . 54' LP C� ,ys" 'J'An�K , s�: Nc��E t �� �� Z � t �o`�\d (� i��, �p� ����� 0� � ` . 1.� `'��' ��,t�`�� � `'� 1� �N�s ��� � `�S���M. J`{; �� �..�, ��. �9/�/a� � Q ��•5 ���' i s�� ���� �� �� � � � ���� �]Y��3C�0.�-re'�+-irft�7t ��'�d�II.� J.L 11GE:.'�.�L¢� � � , a � P��ri.� 1 P][.E�SE SEE A'�'TAC�D PI.AN FOR WEL]C. SITE LAYOUT Tax Map #: �_ 1'� # 3 I Township Appli,can� � ��X Qi' E�n i c. � Cx� UG� 'I'�e of Water Suv�lv ; V Individual Community Public. Res�wireffients: Site Approved bp ✓� � � J � �" �3 Gmuting A�P�Proved by �" 1 I'o3 Well Log �/ �'"� f `0.3 Well Tag, 1�]r v�lt Hose Bib CO]1Ci'�te S� Well Dri�ler. Well Approved Bp: �a�' . , G5� � X � . 3� . � Z, �C ��P QDI� ��tl '�°5ee Atcached Site Sketch'� Wells must be 10 fest from propertp lines. Wells must be 100 feet from septic spstems. � K«P W�( I S'0' rr��, LP Tk� K Wells must be at least 25 feet from anp bulding founciarion. Other conditions: ��� nCta �C.� � � ��` r rc�M ��Ci W � I �. I� Iu�l��f0 �Y G�,(�un�l an m�n.-� o F pld W c(1 � F�c.-�-� Contkm in��ior1) �D �(DW C�/1C� i'-{�� 0�1 S a� S��- S Kt tC. � r PC.�ID, rev. 09/07/Ol �--��� � � 1�� � ���- ,�.�. �.� �U.�.� � � � �`�_ C�` c� 1��� ��� �'r �•.s�h�'7ist �m 3tT.��7�:n.•�; u-n. �c:.c,�. li. �.C�.�•�.:n.11 �L�l:n. Owner: • � /� Location. = �� Subdiv�sion: ��;. ::�� .� ..�_� �_j ��:. ;>�1�t11J ��11M�C'-) J� cl �1 «_c •'�.�c !� %��r ;', n� D'cJi:b DU�lUOc��� WC� �Ob "1:�� ivlap � !';u'ccl 1; �_ Lot IE _� l���cil Coustz•uctioxi Distancc rrom ncaresc 1'ropercy Linc (Nfiniinum !(; �tee:t) V`f_��____....._ Uistancc froni Sc�tic Systcm (Iviiniiiwni GO icct) '� __ Total Dentli: _�/�� Ct Yicld:,�p _ GPM Static Wcite:r L�ve:l: _�6___.. C� Water IIcarinb onc�: Dcp[h r1 v�t / 6 J li /+f a_;�� _(t Czsiub: Depth: Prom l) lo il. llianu:tc�': (� il�, Type: Galvanized Stcel '� ^ �� Wei�ht: � � Drive Shoc: ./ Ycs (f'j�es" give reasai: _ Gzout: ':�hickness: �� � Ilei�;l�t abovc Ground: __/ >! 'Il No ��ily ��roblcm� c:iicouillcrul whilc sc:lti�i�; c:isiii�'? __ Ycs '�No I�Ieat: Sand/Cemcnt �' Coi�cccic Grave:l/Ccmcnt Annular S•�ce Widt!i �� inches 1%�,�ler in �aiiwl� Snace Y�s '�" No P� Metl�oci of Grout: Pumpcd I're:ssure: ' I'oured `�� Dcp�h i1'Xatcxials Uscd: No. �3a,r,s Portland ccmcnt Wc:i�hl t��l� 1 l3a!; _______._ !'ouiids l.t mixlure (sand, Sravcl, cuttici��) — Racio _� to � IU platcs: �Yc� No �6 1�F �lab �'cs _,� No Urillizi�; �.c�� ' .to Ft. �,c�c:llioit Ur:iwiub �'rom '1'0 ��o�•ivatiocx �Z - UL ' c��.r��� _� �- v � ( hereby ecrtify t�l�t chc aUovc in�on��ation is conect and cliat tl�is wc�'. tivas constructcd in accordancc with regulations sct �orth by thc Pcrso« Couiity 1•lcaltll Dc:partmcnc. Si�aa�tuarc o� Co��tra�to�• _�, ��) t�.__�_�_�l_ ��:��c —� _ ll—�3 ����n ►��� n� �� �l��