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A27 18The Districf Health Deparfinenf Orange, Persoa, Caswell, Chatham, Lee Counties SEPTIC TANK PERMIT Date � "' �/� _ 'l�t�z�. / qt Name of owner• l�d.f�� -�� s''J'1'll'1f i�l� ��— �?�'Y��'( Name of contractor: ��1� ��5�.�1 �71 � 11: �.C.T Address and Directions ..1��-� � ��{��G2rt�—l�i�� ' t'� �n I?. o P p14t1,., �!��43 Person or firm doing installation: � Address '� �•+1�n,bcr�h,p / 0� No. of persons to be served Bedrooms �,'1—�3; i. Additional appliances to be used: Disposal, dishwasher, washing machine 1� D �"1 � Recoxnmended• Septic tarLk I UQb C��U%^ .�, i � � 1 Nitrification line: Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspected and approved by a member of the District Health Departmen3 siaff before any portion of the installation is covered. Date Approved: ) - %�� L�,S By Countersigned Signer� Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer <Over) NOTE: Make sketch of installation 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. SUGGESTED INSTALLATION (Date ) FINAL INSTALI.ATION (Date ) (Road or Street) (Road or Street) � �� 0� ��ars��+i�a��i� '��■�■■■� '■��1��■�■■ ��■I��e�■■ ■��l�1��i��! .1.� /� ''i ` � �� The Distric Health Department Orange, Person, Caswell, Chatham, Lee Counlies Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. D t Owner: � ati"` Location: � , Contractor: � Water Supplp: Private � Public Sewage Disposal Faciliiies: No. bedrooms Dishwasher, Disposal, washing machine, other` automatic appliances Size of tank: �� Nitr c tio line: �� f�c,��a� �x6' 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 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 INSPECTEB AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE. INSTALLATION IS COV- ERED AND PUT INTO USE. Date approved: wen: Sewage Disposal: By: .• -.�.h/I��t�� .�-'.�.!ii'�'t �i".�`;�� Counter- signed (Owner or his representative) Certificate of Completion Date Approved: ��LL By: " Sanitarian • (OVEft) Location of well and sewage disposal facilities sketched on�baok. ' � 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 at later date. Note location of water supplies on adjacent lots. (1J (2) � The District Health Depc�rtment Orange, Person, Chatham, Lee Counties . SEPTIC TAI�K PERMIT Date � ' � � - � ame of owner LAM BE it� aa i.sT'� Cf/v � c,,r 6 and Directions % n .� L _F /`=�DF1� �if� /�f7 /o Loi✓9J S/Mf Person or firm doing installation: C• C• F�� Address f1/ 5�/� /�o�f�e�o No. of persons to be served bedraoms i, 2, 3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine Minimum Requirements: Septic tank �6 �� - ��-=-�A�R — �� C � E /�¢.�/� v� �/.� U 4� Nitrification line: / �0 � —� � L' Septic tank and nitrification line must be inspecfed and approved by a member of the Healih Department staff before any portion of the installation is covered. Date Approved: By: Countersigned !Over) % �anit ' n O. David Garvin, M.D., M.P.H. District Health Officer " NOTE: Make sketch of installation 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. ' �o � The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Woter Supply and Sewage Disposal IMPROVEMENTS PERMIT Date v Owner: � � � Location: � � � Contractor: Water Supplp: Priva e��a� Public Sewage Diaposal Facilities: No. bedrooms Dishwasher, Disposal, washing machi oth�r sutomatic appliances —� � Size of tank: — � Nitriflcation line: o D �3 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 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 PORTION OF THE INSTALLATION IS COV- ERED ANB PUT INTO USE. Date approved: Well: Sewage Disposal: By $1$I1e c �� Sanitar' � Counter- (Owner or his representative) Certificate of Completioa . /� � /J/ Date Approved: � �" By: ' �J S 'tarian (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 supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located di��o� Da�e �D � �ouni Paid ��ei�t� 21 �I :' �'�e flil�� e�ee� �ountv Heaith Departmer� �mvironmental #ieaith Sectlon . A��I�.�TIO(� FOIt SERVICES • B� i�14� IPi�OR�+'�1�N 1P8 iFiE ��91C�'PYOIV FOR AA1 IMPROVEMENT PERMIT IS FALSiFlED. eHAA1GED. Of3 i�4� S8'P� tS .W9.TER�. i1�iiEN�iHE IiNPF30�@1�T PERMIT �ND AUTHORIZATION TO CON8TRUGT SHALL BECOME INi��l�. 9)��rr��k e�aa�� yr (�ea�sr/��9p�p�rs� ov�re�e�: i i�� /,��'"l� 5 i ��'e�` �� p��aa�� Phon� Addre� v �" �aasie�e� P��: � ,�x�rji--v /J_ : `L 7s7 � � - a� �I�� a� �� ff �a��ea� �a�� _ ��m � J _ . �� e�Q�a�y ��tpid�¢a� tae st�: To�: �'L:v�� %� LG �'�4ion$ 40 4��'a�'�s�tyy (le�� roa�d �m� a�d nuenbe�}: S_�' � 4) �e�� lJ�� a�� Rs�a� ��si�4d�no ae�� each of th� foqowring questicns: �) Pro� �, �ie� � b) S�dc Bt� Q l��dta9�e �. S��e Vilid� 0. Dota�9e l�lide ❑ c) Muea�r$e �fr ��eoaens: � P�umbeg of occupacrts or people 40 e) �er89�ea� Y� 0, i�o � lff �s. � off b�e�ai�a�4 f�e� � Ca�� Dis�L Y� �o P� � � Di�t�aa�� Pe�po�� SB�ar�:lAftd4h: Depth: be serued: � ��P �6fl(�� o �YFil�Q� �tSil� Q OP 9X�n� �o PubUe 4 CoRunun�lf 4 SP�n9 � � �� 2��'�' �°7, �� v�18� o�e a�o�ie�Q peop�rt�i YesgYNo D If yes, I�ation�` _ ��9�� le�� 1 ��aao ��c�. ( � c�¢e b� �log� t� ��rler of your p ce� P�as��fl�� a�fl�a�� AI la�novativ� �P (��)e �Y. �.� ��ORP9Eit� i►iVV� LJNES OF THE PROP�RT�e �5i'� `�t1E �RNERS OP � �ROPOSED STRUCTURESe �4�� `�7'A�B� ��l�il� P�T OR � P4AA1 TO 'THIS ��iCA�� I Qae� t� ��6s��ovu 4� Q�t� Pee�n Coam� 6�9ea1� Depa�tment t�r a s�e evaluaUon for the on-site �ura�e dis� �� 4&1� �►�-d �B�p�a9y. t et�e� it►ai tl1e ConBents of this applicat[on are true and rept+�rtt ltte �dmaa¢aa 4� ba p9�� oe� 4hh� peop�e�jy. I ua�d�rs4�e�d i� 9h� si�se is altee�ed ar the i� use changes. the permit sha0 beccme ia�vaitd. i�ra��e�� 46��ic a� aPPqc�4. 1 a�an respoe�f+� fmr identifying and maddn� Pcope�tY lines. comers and tt�atdrtg 4he s i t g a f�c i� peesaa9a9�1 og 4k�� P n Ceaau�l t�� B�parie�eni 4o canduct their �vatwaticna. l understand that I ae�a 9� �� t� H�1 � i�� P pea4g� �u�in� a¢�y wetlae�ds � dgsi� by the ArmY Co� a� Engin�- , 5 � 3/- � �� o� 0 �olication Date: � ` -O�J Amount Paid: Rec`iat �• ��: � �� T��- �aa.vsa.r.o�s:aa-�-� ae.as�a►.IL �E--�L�.av.IL�a APPLICATION FOR SERVICES Tax Mao #• ' 7�� ParaQl #: �� ) Permit requested by: {@ew�rlageM Home Phone: ' . Business Phone: �d 3- 3 s�'i � 7 f �� Address: <�'.R.�,,,2�., •�. ��-�.;�, � e : n �c. _ . Ce.�o��'+�� .�/� ��V�l�'9'� �+�,. 2) lVame and address of.current owner. ��•-Q��,�� .��",,,�` G'�<.,,�, . d � . q"l: C. 2. �.5'7 3 � 3) Property Description: Lot stze: Township:�'-k:-{-f/ � Subdivislon: � Lat# Directfons to the property (Including road names and numbers): • • 4) Proposed Use d Structure Description: answer each of the foilowin questions: a) Proposed ,� Existing . Type of Structure �'� Width: �� y'�� Depth: �f� � Pi �� b) Number of Bedrooms: � . Number of oc.�upants or eople�to be served: � . c) Basemen� Yes . No ZC Will there pe plumbing (n the basement? d) Garbage Disposal: Yes , No � . 5) UUatgr Supply Type: Private ✓(new _ or existing�, Public . Communiiy . Spring _ . . Are any welis on adJoin(ng property? Yes No _ If yes, pleasa indicate a�proximate location on the • site pian. _ . �) Does your property contain previously identifled jurisdictiona! weilands? Yes_ No_ PLEi4SE NOTE THE FOLLOWING: ➢ A PLAT OF THE PRt7PERTY OR 51TE PLAN MUST BE SUBMITTED WR'H TH1S APPUCATION. D' PROPERTY UNES AND CORNERS MUST BE CLEARLY MARI�D. ➢ THE PROPOSED LOCATlON OF ALL STRUCTURES MUST BE, S'�A4�D OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBL.E FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. � I hereby make applicatIon to the Person County Health Department for a sife 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 ifi the site is aitered or the intendecf use changes, ttie permit shall became invaiid. � _.� --t� .. � � D te PCND, rev. 06I27/02 �7 ., , ,. t"y �� A 1717 PERSON COUNTY HEAL'TH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT Tax Map # Parcel # Zoning Township �/; V � /y%1 � Owner/Contractor l...cah-,heF� (�,F�Y1� Location/Address /t�� (�, __ �-�1�� Subdivision Name � �� t.�Y�� L �`� C �� p� � , � � �� a � O I t" � �, LOt# Date ��'�l -ZTO �.K.� - as t�uea O(��X�� Ia-�o L. I � 0� �u.i� � keNp I�- � � a,i l � � �o-�-. �-on-, a�� lou,� (�; �-pu,��pn s . � �' t� i% i5 ie �SreG� . SEWAGE SYSTEM SPECIFICATIONS Repair ot ea SFD 'le Home Busin __ of Bed�6�n _s� l� Size of Tank Size of Pump Tank Trenches �rmit �d after 60 months. Permit Void if not in compliance wi Pernuts may be voided if site is altered or intended use changed. Well and Septic Layout by Comments: Date Installed by. vidual Site Approved�,�i Well Head Approved Grouting Approved_ Comments: Approved by WELL SYSTEM SPECIFICATIONS Semi-Public � Required Slab teplacement �/ Air Vent � ,�- Required Well _ _ Well Tag � Date — Installed by , r Approved by This report is based in part on information 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 infortnation contained in the application The environcnental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted &om false or misleading statements provided to him in the application Neither Person County nor the environmentat health specialist watrants that the septic tank system will cocrtinue to function satisfadorily in the future or that the water supply will retnain potable. c:�amipro�pertnitsatn O 1/95 rev.1.0 ORIGINAL PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG Date: �- �� ' Owner: � — SR# ' � � Location/D'uections: - ��- �` � - � � � r� � �� u I�.�,r�� 'l � e�-�� c�l (�, � • Subdivision Name: `"� Lot # Drilling Contractor: c�e�t( � 2'.�.Q.�o � nc WELL CONSTRUCTION � Distance from Nearest Properry Line 1 v Distance from Source of Pollution ( G � Total,Dep.th:� Ft. Yield: GPM Static Water Level a.5—' Ft. Water Bearing Zones: Depth �Ft. F� F� Ft. Casing: Depth: From 4 to C`� Ft. Diameter: Inches TYPE: Steel - Galvanized Steel � If Steel, does owner approve: Y�s No . Weight: Thickness:,� � Height�Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . . Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: Grout: Type: Neat SandJCement / Concrete Annular Space Width Inches Water in Annular Space: Yes No � �. _ .. Method: Pumped . Pr:ssure � Roured � . . . � Depth: . Fr�m O �o �, O Ft. Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes � No � � 4 x 4 slab Yes i No . I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET FORTH BY�THE PERSO� Cv'vi�IT�' HEALTH DEPARTMENT. Z CC� S' nature oF Contractor ac�