A27 1AAp�iication �ate:
Amount Paid•
I�ecaiat #•
"fax Ma #: /"�' � /
Parc�! #: ` "
P�rson Caurntv Health Department , _ . .
�nvironmentai Heaith Section . �,: � . __ 4 _ ... .._. _
APPLICATION FOR SERVICES
1) Permit reques �,Y O�m er/ entlprospective owner)•ll` �
Home Phone;,�7-�� Y Address: o- a
Business Phone: � �
2) Name and address of current owner. /'�� �• /i- c
� o � o ,Q o v,��
3) Property Description: �ot s�ze: �Y7/rJ Township: ��J� �7'-�"
Directions to the property (Including road names and numbers):
v ��,
� �sr�
4) Proposed Use and Structure Description: answer each of the following questions: �Q
a) Proposed 0, Exisfing �
b) Sticic Built 0, Modular �, Single Wide 0, Double Wide ❑ �
c) Number of Bedrooms: d) Number of occupants or people to be served:
e) _Basement: Yes ❑, No �7 If yes, # of basement fixtures: "
�.: _ �:.'�.��^'�id�^ ^±: Y,� �, �'� ❑ _ . . . _ , . _ _.... . � � ......
g) Dimensions of Proposed Structure: Width: Depth:
5) Water Suppiy Type: Private 0(new � or existing �), Public �, Community �, Spring 0
Are any wells on adjoining property? Yes ❑ No � If yes; location
6) Please Indicate Desired System Type: (systems can 6e ranked in order of your preference)
_Ccnventional _Modified Conventional _ Alternative. Innovative
Other (specify):
CL.F��RLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACIi SURVEY PLAT OR SITE PLAN TO THIS APPLlCAT10N
i
� �
/ �� � /
�
, /
I hereby make application to the Person County Health Department 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 faalities to be
placed on the property. I understand if the site is attered or the intended use changes, the permit shall become invalid. I understand
that as applicarrt, i am responsible for identifying and marking property lines, comers and making the site aa�ssible for the
personnel of the Person Courrty Health Departrnent to conduct their evaluations. I understand that I am responsible for notifying the
Healt artment i m roperty contains any wetlands as designated by the Army Corps of Engineers.
.^ ��
Owner or Legal Representative Date
PCHD, r��. �a�uss
u
0
P4
The District Health Departme�nt � -�
Orange, Person, Caswell, Chatharn, Lee,' Couniies
Water Supply and Sewage Disp sal
ate � �
Owner: •��..•� , / S
Location: �.��
p, Contractor: � �—�tLL= �'-S
�
� Water Supply: Private Public
�.
i
Sewage Disposal Facililies: No. bedrooms
washing machine, other automatic appliances
Size of t'nk: Nitrificati��on
,,..,1.1.�. � � � n /.. 4 � � ., ! v' /_ ,
Dishwasher, Disposal,
Other disposal facility:
Water supply and sewage disposal facilities location, `installation and
protection must meet state and local regulations. _
Above recommendations 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 DE-
PAR.TMENT STAFF before any portion ;of the installation is .cbvered
and put into use. '
�i
Date approved: ^
Well: rF
Sewage �os ' —
By:
IFICA���F CO ,����N
The District Health Department
c . �
ountersi ' d
(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
at later date. _
�.
,.. � �� .