A26 40SEWAGE DISPOSAL RECORD
_____ �Prs �'�_______County Health Department
Name of Occupant _C' 0.__�0 �.✓ a v-'�__ W_ ✓C
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Location of Building__�jCvP _ l�`��
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Name of Owner__�` _� `_�° w� ��--- W____ C____ Date of Installation___ _�� `___ -_____.
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Type of Privy Constructed_________________Number_______________ New or Repaired_________________-
Septi� Tank__ ��y e'_�d��--- Date Inspected_____________ Permit No._______ Capacity__���'��� _
(concrete, inetal,-etc.) ,
Numbers of Users_____v_�---------------- T3'Pe Secondary Treatment__ ��� ��
-- -� -'e -----------------
Source of Water� Supply____�ei �-------- - -
- - ----�--------------------------� ---------
Contractor or Plumber__�°��c�'d �' `�'��',�`'� -���ddress__!�_��� � '� �------------
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APProvedby -- ---------=-- -- ------�G "------------------------------ ---------------------
Remarks __
N. C. STATE BOARD OF HEALTH
(Over)
10M 2•40 FORM No. 207
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adja-
cent property, etc. Write in measurements,�in order that installations may be located at later date.
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Application Date: ��-� � � L'
Amount Paid: 1�.6b
Recsipt #: �
Tax Map #: F� ��
P�rcEl #: � V
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUiHORIZ�4TiON TO
COR�STRUCT SHALL BECOME INVALID.
'iJ�Permit requested by: (Owner/agent/prospective owner): � � �
Home Phone: ,�-G �- o? o� Address:
Business Phone: ,� Ra a�� l •� '�
2) Name and address of current owner: a-c+.w-¢-
3) Property Description: Lot size: . oa Township: Q_��c�G�LP Subdivision:,
Directions to the proper-ty (Incfuding road names and numbers):
Lot #
4) Proposed Use a Structure Description: answer each of the following questions: /
a) Proposed _, Existing , Type of Structure: �. � c� Width: LI O Depth: 6 O
b) Number of Bedrooms: Number of occupants or people to served:
c) Basement: Yes , No Will there be plumbing in the basement?
d) �arbage Disposal: Yes No _
5) llVater Supply Type: Private c/ (new _ or existing�, Public� Community_, Spring _
Are any wells on adjoining property? Yes_ No � If yes, please indicate approximate location on the
"- site plan.
6) Does your property cantain previously identified jurisdictional wetlands? Yes_ No�
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PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF TI-IE PROPERTY OR S1TE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
9 i'i-IE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY TFIE HEALTH DEPA►RTMEiVT
STAFF.
I hereby make application 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
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
or Legal
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Date
PCHD, rev. D6/27l02
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