A27 102�
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The �istrict Health Department
� Orange, Person, Caswell, Chathafix, L•ea �Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PERMI No.
Dat � –
Owner: _
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Location:
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Contractor: � ���-+
Water Supplp: Private � Public
Sewage Disposal Facilities: No. bedrooms �--� Dishwasher, Disposal,
' ashing machine other automatic appliances �—
� ,
ize of tank: ��}C�!'' j'l,� Nitrification line: _ �
Other disposal facility:
Water supply and sewage clisposal faciliiie's location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE• I�FSTALLATION IS COV-
ERED AND PUT INTO USE.. ���
�'. ��'� 3 r � ;
Date a roved: Si rie ���
PP g
V Sanitarian
Well:
Sewage Disposal:
By
Counter-
(Owner or his representative)
Cerlificaie of Compl Yi � t' (
� i ?�
Date Approved: ' � By: `
+ � S nft rian
,'
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
suppli�, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
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�t�v ��v���� A 001016��
PERSON COtJ�1 ='•HEALTH DEPARTMENT
4 WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Tax Map # Iq �'7 Parcel # jGS2
Zoning Township
Owner/Contractor G1 r1 �Pa ►'`` Date �' -� �f��
Location/Address ' �� �,,� �3n� �� � �f i7� sf S%�� /30G
S.R.# �
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS �.I.'��
Repair Lot Area
SFD � Mobile Home
Business # of Bedroom�
Size of Tank %h s�n;tl % �('� (i �'�('��+J
Size of Pump Tank Nt �
Nitrification Line / �� �X 3 �- -
Max Depth Trenches �
Permit Void after 60 months. Pernut Void if not in compliance with zoning regulations. ,N,` �;r
Permits may be voided if site is altered or int d u c nged.
Well and Septic Layout by /�� ,,Q Gn.,� _
Comments:
Date
Installed by
Approved by.
1 ` WELL SYSTEM SPECIFICATIONS
Indivi ual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date
Installed by.
Approved by.
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pemut The
environtnental health specialist is not responsib(e for false or misleading infocmation contained in 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 Srom false or misleading
statements provided to him in the applicatioa Neither Pecson 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 potabie. c:�amipro\permitsam O 1/95 rev.1.0
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