A27 152'P''he District Heolth Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
W 4ter Supply and Sewage Disposal
IMPROVEMEI�iT'$ PERMIT No.
' Date � �,��
Ow�er: � �
�cgtion: __�
/ �-„
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Contractor:
Wata! Supplp; Private _ �� public
Sewage Disposal FScililies: No. bedrooms � `�'r ishwasher Dis
. posal,
washing machine, other automatic appliances'
Size of tank: � ,, Nitriflcation line: � �
Other disposal facility: ��
Water supply and �Wage disposal facilities 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY POftTION OF THE IN ALLATIpN IS COV-
ERED AND PUT INTO USE. ��
Date approved:
Well:
Sewage Disposal:
Hy:
or his representative)
Certiflcale o� Completioa �
Date Approved: `� By: r �
Sani ia
(O
Location of weil end sewage disposal facilities aketched on ba�k,
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
^ supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
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IN liCCORDJIN(' • 0�'�' 1 N/'U:.�;/17'lO/� _
�''�l %N REC�LAT I UN,s SE'r r0l� T/I BY CJI SWF. R(, ��C'I' 11 NU
TIf�1T TNtS WCLL W,1S. CONS*RUC7'ED
CN/IT/f/�ly-L6E-PERSO UTSTR,�Cr, /�E�. DEPT.
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'"" Si vn.t��r� �� Contractor "�-- b�._��
r pj� `---- Da t e
RE'.1SON FQR NO �, ' !JC•..il.Tl1 L`lipn/ZTh'F.'N7' IJS6
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Aooiication Date: � �T—°2 � �
Amount Paid: �
Receiot #•
Tax Map #• � a �
Parcal #• l � �
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APPLICATION FOR SERYICES
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Permit (Recorded Lot) - $200.00 ❑ Well Pertnit (NewlRepiacameM) - $225.00
Improvements Permit-$150.00
(Mobile Home ReplacementlAddition)
System Permit
5150.00/$200.00
Pertnit Revisio� f
for Sepdc Systems-
IF THE INFORMATION 1N THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Ownedagentlprospective owner): "� E-'/'
Home Phone: �S9'% - 9.3 /� � Address: �� - r �i.�21.1
Business Phone: � �
2) Mame and address of carrent owner. _,����1
. ,��� � ,�� v�� Cr�ek G2y i �2y .-
.�/2�ixhl�r�;1L�(' .��.� ��
3) Property Description: Lot size: %, �9�t�r�Township: i�' !ii �� Subdivision: B�'Gt ��r �i'ec�� Lot #Z
Directions to the prope_rty (Including raad names and numbers): .
4) proposed Use and Structure Description: answer eaclt of the following questions:
a) Proposecl , Existing� Type of Structure:��,�«i/f %flGt�. Width: •'��5� Depth: ��) _
b) Number df Bedrooms: Number of occupants or people to be served: v?
c) Basement Yes . No �/ Will there be plumbing in the basement?
d) 6arbage Disposal: Yes . No �/,
5) Water Supply Type: Private �(new _ or existing�, Public_, Community . Spring _
Are any wells on adjoining property? Yes_, No _ If yes, please indicate approximate location on the
'site plan.
6j Does your property contain previously identifled jurisdtctional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED� •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAiCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. �
I hereby make appiication to the Person County Health Department for a site evalua6on for the on-site sewage disposal
system for the abov escribed property. I agree that the contents of this appiication are true and represenf the maximum
facilities to be pi c on the property. I understand if the site is altered or the intended use changes, the permit shall
or Legal Representative
Date
PCHD, rev. 06/27/02
APPLICATION FOR• Date Received:
(� Improvements Permit () Subdivision Approval () Other
1.
2.
3.
Permit requested by: �,L/���-e_ �
Address :��,�Q c� � ���jN ST
Name and address of current owner:
Property Description:
Front
Lot size
���
Business Phone_�9����
�
Dimensions:
Left Right
4. Tax map No. Township(����e ���� Block No._
5. Directions to property: State Road No. & Road Names, etc.
�7 .U'_ `i o �o.Uss ��9%� �� ,a
i i
Rear
Lot No.
6. Permit requested for: New Installation�--- Repaired
Addition Renovation re-using present system
7. Number of occupants of people served �
8. Dimensions of Proposed Structure: Width Depth
9. What type (if any) additions, expansions, or replacement is anticipated to
the structure or facility that this sewage disposal system is intended to
serve?
10.
T�pe of water supply: Well es no: If no, name source of water supply:
Are there any wells on adjoining property?
If so, identify location.
0
11. T�pe of structure or facility: Proposed� Existing
Type of dwelling: House Mobile Home� Business
Type of business Number of employees
Number of bedrooms Number of automatic appliances
Basement Number of basement fixtures
12. Clearly stake all corners of the property and the corners of all proposed
structures.
I hereby make application to the Caswell-Chatham-Lee-Person Distr�ct
Health Department for a site evaluation or existing system evaluation for the
on-site sewage disposal system for the above described property. I agree that
the contents of this applications are true and represent the maximum facilities
to be placed on the property. I understand that if any changes are made with-
out approval from the District Health Department,the permit will be void_ Any
permit for a system is non-transferable without prior approval of the District
Health Department. Permits are valid for 36 months fr m date issue.
PYb 2185 SI ��D
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Instructions for Having Property Evaluated
for A Septic Tank System
Read all instructions before completing application.
Answer all questions on application.
Mark all corners of property so that each lot line may be found.
Ma.rk desired location for residence or building showing all corners.
Mark desired location for driveway.
Mark anq other desired structures (such as garages, other buildings, etc.)
Mark any existing or future restrictions which may interfere with locating or
installing septic tank system (such as water lines, buried gas lines, buried
electrical or telephone lines).
Provide plat of property to be evaluated.
The Sanitarian will contact you by telephone or mail as soon as possible to
give you the results of the site evaluation.
Sanitarians may be contacted in the office between 8:00 a.m. and 9:00 a.m., and
between 1:00 p.m. and 1:30 p.m. Phone
Return application either by mail or preferably in person. Please call the
Sanitarian for an appointment at the above mentioned hours.
Mailing address:
FACTORS - SITE
1. SLOPE (%)
. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
. SOIL STRUCTURE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(�ternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
8. OTHER (specify)
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S - Suitable
RECOMMENDATIONS/COMMENTS:
AREA
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S.
PS
U
AREA 2
PS - Provisionally Suitable
AREA 3
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
U - Unsuitable
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
AREA 4
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas, wells, water bodies, slope patterns, etc.)
.
�
8
Person County Health Oepartment
�;xistinq Sewage System Report For: Hobile Eiome FtepLacement
_�Addition�(,�i�CPGj�
✓ ✓
Recruestee: .��� f�� Home Phone# %�7 ���
7i%f� �2�G���-P� ��I�IT_ B u s i n e s s n �4�1�
�cl� ro r d � �� / � 't aX M a p n � � (� �
Location/Uirections:
1(Ji1 �/1�t i a rn ✓�i- i�
.�
Original Permit Located '
Septic System Uesigned ror: _
Etesidential _� I3usiness Other (specify)
# eedrooms � # E;mployees Other _
Uate '1'nstalled 1�����7 Water supply
Type ot System ���� � �
Nitrification Line "Ti/�� � ��
Tank Size
Certified Operator Required �' �
On site wasLewater disposal syste�u showes no visuaily apparent
malfunction on % ��i ��
Yermission is granted to: /�CGi� �� ��i�� � —
According to the attached site plan.
Comments : ����D 5' o� r�ito�� -FUr�v►� �,� /��� r� �/�rc �'��� l�
�c,���� -�
nvir nment
�'�' ' � �'I]f��'��
�,. ,.; � ��,�
��,� - i �/r �
" ':.�- �.v. ..-._ i
,z�_
TAD E
0
.
�pplir,ation Date: ��� � ��
• 'Amount Paid: I G ���
FReceipi#: �,� 1
l��
Person CountY Health Department
Environmental Heaith Section
. APPLICATION FOR SERVICES
Tax Map #: �"2 �
Parcel #: �� �
IF THF INFORMATION IN THE APPLlCATION FOR AN IMPROVEMENT PERMIT IS FALSIF(ED, CHANGED, OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME_INVALI_D.
1) Permit requested by: wner/ gent/prospective owner): �.�tie.�' �+�r��/�-
Home Phone: c� Address: v' _ c � Ktvi�
Business Phone: �'S 7-4 3/D !�Y � r�;e m
2) Name and address of current owner: S�-�, cs
3) Property Description: Lot size: /. 77 �ownship: I i v� j�;1 f
Directions to the property (Incfuding road names and numbers): 5"7 N �'o • Lvr-� s 3{ax� ��
I:i- �+ n.�. Qi� %jc�,n.v.Y,e Q f� r� L ��Cuv
4) Proposed Use and Structure Description: answe� each of the foliowing questions:
a) Proposed d, Existing 0
b) Stick Built C3�Modular �, Singie Wide �, Double Wide G
c) Number of Bedrooms: ,�_ d) Number of occupants or people to be served: �_
e) Basement: Yes 0, No 6� If yes, # of basement fixtures:
� Garbage Disposal: Yes Q; No ❑ /`�r�� \
g) Dimensions of Proposed Structure: Width: � Depth: ,� _< �-i 1!' q1�' >
5 Water Su i T e: Private G� new � or existin ❑ Public Commun' 0, S nn 0�
) P P Y Y P � 9)� a � Y P 9
Are any wells on adjoining property? Yes � No � If yes, location
6) Please indicate Desired System Type: (systems can be ra�ked in order of your prefe�ence)
Conventionai Modified Conventional Altemative Innovative
Other (specify):
-% CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system foc
the above-described property. I agree that the contents of this application are true and cepresent the maximum facilities to be
placed on the property. I understand if the site is altered or the iMended use changes, the pertnit shall become invalid. l understand
that as applicant, I am responsible for identifying and martcing property lines, comers and making the site accessible for the
personnel of the Person County Heafth Department to condud therc evaluations. I understa�d that I am responsible for notifying the
Health De artm t' y property contains any wetlands as designated by the ARny Corps of Engineers.
_ ���
"O er or Legal RepresentaGve Date
, PCHD, rev. 10/12l99
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