A26 62' � 1'he District I�-lealth Department
,
�. Orange, Person Chatham, Lee Counties
SEPTIC TANK PER►VIIT
�° b%Date " .._ ,. . ,' -
Name of owner � " �N
�„{-
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:
Nitrification line:
Septic tank ' '
Septic tank and nitrification line must be inspected and approved by
a member of !he Health Department sfaff before any portion of the
instailation is covered.
Date Approved:
P
Sanitarian ''`
By: � � � � �� '
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
1V�OT�: Make sketch of installatiori 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
_ date.
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PERSON COUNTY HEALTH DEPARTMENT
WELL SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # ��� Parcel # (p �--
Zoning Township �� (', V �� ; �
Owner/Contractor
Location/Address
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Subdivision Name
`'1'
�
Date
- c.c.. l I l �c.r�
1 , S.R.#
Lot#
A 1283
I SEWAGE SYSTEM SPECIFICATIONS �
Repair �/ Lot Area Size of Tank .S;c�-�-�`r1q—IL�00�__
SFD t� Mobile Home Size of Pump Tank N�4
Business # of Bedrooms �_ Nitrification Line 0�` �,3 �
Max Depth Trenches ► �
Pernut Void after 60 months. Permit Void if not in compliance with zonin regulations.�Si-bb �. p�,rn�ea .
Permits may be voided if si ' altered or intended se chan ed. �� 5G-� ��-� T � r1 P�0.G�,
Well and Sep,ti,c�Layout by������0 �' _ . i�„� �-� 4 �C•��ll-� I
Daterl--aa�$ Installed by
Approved
(���!'� J�-l=rG � u/JK-
WELL SYSTEM SPECIFICATIONS
Individual emi-Public
Public Repl ce e j
Site Approv �
Well Head proved
Grouting A
Comments:
Date
Installed by
Required Slab
Air Vent
auired Well
Approved by
�i
Tlus report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this permit The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental heakh specialist
is also not responsible for concealed conditions on the propetty or for statements in Uvs report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemiitsam Ol/95 rev.1.0
ORIGINAL