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��