A27 181The District�Heolth Department
�Ob CASWELL - CHATHAM - LEE - PERSON COUNTIES
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s W�iter. Supply and Sewage Disposai
IMPAOVEMENTS PERf�II l�I�o.
- . ; _ _ Date_�='_ �- f`— - .
� Owner:
� Q � " Location• �
P4 •
,
_ � -.. _
- - '. � .
,
_._ _. _ _,_._ _ _ :.. _ . _, . _
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a Cnntrartnr•� -`�_ i%I.J�1 .
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;�. Wnter Supplps,.Private - . � PubT
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_. .. .__ ___.. _ .........:. ..... . _ . . __
= Sewage Disposal FacilitiQs: No. bedrooms Dishwasher, Disposal�
,._ . ; ,
.__ _ _.
.: _ . ,. _ . ,
washing machine, other suto tic appliances � •
Size of tank: _��Q� NitriBcation-line:l.�i ��� � 3. �
Other disposal facility: .
Water supply and sewage. disposal facilities location, iristallation and :
protection must meet state and local regulations. ' ',"" "
Septic tank should be pumped out every 3 to_5. years and shall be maih- :
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTEI? 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. _ _ _
` �r� 4 �'1/.,'�l
: Date approved: Signe
Well•
Sewage Disposal• Counter- �
� aigned�
By� (Ow;
CertiSca2e o� Com letion
Date Approved: � �
(OVER)
Location of well and sewage disposal facilities sketched on back.
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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 msy be located
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Amount paid �_1.-
Receipt .4� ' q 1
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Improvements Permit. (EstablishedlRecorded Lot)
Impxovements Permit (Unrecorded Lot) -
Improvements Permit (Mobile Home Replace)
mprovements Permit (Addition)
Date }l��'� %
Reinspection of Existing System (Loan Closing) ;
_ Repair/Replace existing Septic System
Permit for New Well
_, Replace Existing Well
1. Permit requested by: .
� 7. Dimensions or Proposed Structure: �.� ��"'`s >
owner/prospective owner/agent: '1 � Width: _ ��i a�Y�oM `�'
� a a_,...... � ��� _ Depth: � L.� C' .0 Mh V..� K-00 M
ana 5'�rn- �4� • 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
ome Phone #:_
usiness Phone
Name and address of.current owner:
9. Water supply type:
private �. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
3. Property Description: Lot size: 1� a'"t' '
. Tax Map#: v2 �3� �� 10. Type of structure/iacility: Proposed: �Existing: Q�
Parcel#: � ���„ Type of dwelling:
Townshin• d �.� v e- �`�-� � House: ❑ Mobile Home: � Business: ❑
� Type of business:
ad 5. Directions to property: State Road #& Rc?3 Number of Employees:
ames,gtc.
� � ( � �... on (,� Number of bedrooms:
. Garbage Disposal? Yes ❑ No •
`-' �� r��-, ��n ��n.r' �no �_, I S�Ut� (l;t�►'��- Basement? Yes ❑ No�f so, # of basement fixtures:
W
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6 Number of occupants or people to be served• �_� �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOn COunty Health Depal'tment for a site 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 [he 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 be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS af[er the date of the evaluation of
the site by the Health Dept., this application shall become vo�.'d.�nd all fees paid forfeited.
Si�ne� Owner or Authorized
permit Issued ❑ Signature Date
Permit Denieci ❑ ,
Plat Observed ❑ "
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I. SIAPE (%) S S S S
PS PS PS PS
u u v u
2 SOIL 7FX7lJRE (12-36IN.) 5 S S S
ISANDY. LOAMY. CLAYEY. NOTE 2:1 CLAn PS PS PS PS
U V U U
3. SOIL S77tUCTURE (12-361N.) S S S S
(CLAYEY SOILSy PS PS PS PS
U U U U,
S S 5 S
3. SOILDFPfFi(IN.) PS PS PS PS
V U U U
3. RESTRICTIVE HORIZONS (INJ S S S S-
(IMPERVIOUS S7RATA. ROCK) PS PS PS PS
U U V U
6. SOILDRAINAG&GROt1NDWA7ER S S S S
IDCIERNAL R INTERNAL) PS PS PS PS
U U U U
7. SOIL YERMEABILiiY S 5 S S
(PERCOLOATION RATE� PS PS PS PS
U U U U
E. AVAILABLE SPACE S S S S.
PS PS PS PS
U U U U
9. STTE CLASSIF7CAT]ON(SEE BELOW)
SOII. SERIES
S-SUITADLE PS-PROVlS10NALLYSUITAIILE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� CtC.� C:UMIPRO�DOCSIAPPSEC.SM FINANCE.PC
Yerson County Hea1t11 Department
1
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Existinq Sewage Syste� Report For: Mobile Home Replacement
_�ddition
Requestee: YJ
� �� �-1 L o
V��C�. �iL z 7 5 �7 �
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Home Phone# ��S'S`75
Business# l9-'�0`�l a7 (p�
`Pax Map# " J�7 ���
Location/Directions: � / �
� � r2 `. n�1-.�, �r� � na.r' (� ��,� � ►�-� �' ./� /'.
Original Permit Located V
a
5eptic System Uesigned r'or:
Kesidential __�� Business Other (speci�yy
# I3edrooms __� # Employees Other `_
Uate '1'nstalled �--� D''g% Water supply �
'Pype oi System �C)� V '���,�O�jCZ%
T
Nitrification Line `IO� � �3 �
Tank Size
U � �
Certified Operator Required
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On site wasL-ewater disposal system sliowes no visually apparent
mal�unction on ���y/� �
Yermission is granted to: [ � �
Accordinq to the attached site plan.. ������`J1'1 �- - '
Comments:
EnvironmentaY Health Sut�G.
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DAT
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