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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposol
IMPROVEMENTS PERMIT No.
/ , L Date ��' � ' -�' �
Owner: /f'1 TD � . (� %� ,� � ,
Location:
�`} i� O �� L, - ' .✓�, _ itG.<
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Contractor: � k a ��
Water Supplp: Private � Pubiic
Sewage Disposal Facilities: No. bedrooms..�_ Dishwasher, Disposal,
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was achine, other sutomatic appliances
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Size of tank: �� .— Nitriflcation line:
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IN,S.T.�ILLATION IS COV-
ERED AND PUT INTO USE. //
/ ���
Date approved: Signe
Sanitarian
Well:
Sewage Disposal: Counter-C/%1�J� �` �f /�,�' �
aigne /' F�'�' f'',� �.�dc �
BY� (Owner • is rerresenta ' e)
. �
Certificate of Completion - �
Date Approved: �� ' � By;
S tarian
(OVER) �
Location of well and sewage disposal facilities sketched on back.
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Amount paid ol.-� �
Receipt ll ' 1G
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6� Date
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. Permit requested by: . . Dimensions or Proposed Structure: �
� � Width: `� � �
ow prospective owner/?� ent: - De th:
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Home Phone #:�
Business Phone #:
8. What type (if any, additions, expansions, or
replacement is anticipa[ed to the structure or facility
that this sewage disposal system is intended to serve?
Name and a dress of current o ner: 9. Water supply t}�pe:
- ��� � � _ private fr( . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ I`Io Q
If so, identify location:
y Description: Loc size:
Tax Map#: %7 . �� ' �
Parcel#: �
Township: -- !
Directions.to property: State Road #& Road
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10. Type of structureJfacility: Froposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: —
Garbage Disposal? Yes � No 0
Basement? Yes❑ No�l If so, # of basement fixtures:
�6 I�Iumber of occupants or people to be served' �i1 �
CLEARI;Y STA� ALL CORNERS OF TT3E PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Pet'SOn COUIIty Health Depaxtment for a site evaluaiioa fon ahe true l�f
sewage disposal system for the above described property. I agree tha[ the concents of th�s app
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. I understand that before an Improvements Permit can b�.
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no!
delivered a survey plat of the propercy to�the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shall become votc� and all fees paid forfeited.
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Signc� Ow�y�r or Authorized
perrnit Issued ❑ Signature Date
perrni[. Denied ❑ ~
p]at Observed ❑ �„
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SOIL SFRIES ' . . '
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SSVITAIILE p5-fROYISlONALLYSViTADLE t�tRtSUITA6LL
RECOMMENDATIONS/COMMENTS: �
STI� CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.) C1AMfPRUDOCSAPPSEC.SFIFWANCEPC
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3�2 62 ` :
Person County Health Department
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Existing Sewage System Report For: Mobile Home Replacement
�Addition � �� ����
Requestee: 1V1 Y� � CIQ� ��I Home Phone# ^ JTy2o/
��G'j S'e-+,.w �r ,l� B u s i n e s s# ,�y,��3 ��
hb'� �7c� vc�, l�� C. �-7.573 'rax ►�(ap# �
Location/Directions:
.3 S'S� S�e.k.o� /�.
Original Yermit Located
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Septic System Uesigned For:
ltesidetttial .__� Business Other (speciEy)
# 13edrooms � # Employees Other
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Uate lnstalled ���� �S Water supply w
`Pype of System � n ✓�
Nitrification Line 1�-�h(� (7L3 �
`Pank Size �puU ��•
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Certified Operator Required j�4
On site wasL-ewater disposal system showes no visually apparent
malfunction on � - 3 —�t 7
Yermission is granted to: (iL � ��e-e �
W t`� �`o �v►�n�j i
ficcording to the a tached site plan.
Comments:
Environmental Health S{��'S-. � ��Q/Z�� � !� A�
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