A27 1B�I
The Disfricf �#h Departmen�
Orange, Person, Caswell, Chatham, Lee Couniies
SEPTIC TANK PERMIT
DatP ,�� — �'� `� 1�% !�
Name of owner: a f'1S{ ���l��"t/ ��'
r
Name of contractor: �
Address and Directions �
rl __ .. �^ . _ . .
Person or firm doing installation:
No. of persons to be serve� ' Bed�oo � 1,'2�� 4.
Additional appliances to be used: Disposal, dishwasher, w�
machine
.�—
Recommended: Septic ta /
1
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line musi be inspecied and
approved by a member of the Distric2 Health Departmen! staif before
any portion of the installation is covered.
Date Approved: � — �� _�
By:
Countersigned
Signed
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 INSTALLATION (Date )
(Road or Street) ,. (ftoad or Street)
1.�
Application Date: �- "�- � �
Amount Paid: ---1V, l ,�
Receipt #: � � �v.
� ! ���+5� ������ Tax Map: ,a a '�
,_..: �.,,� � � ���� Parcel#: , � � �
�" aavnn-canannacsa4riIl II—llocu��la
Annlication for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit reauired)
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
❑ Well Permit (New/Replacement/Repair) I�Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: I
Name: ��/�( l� �r'� O 1,J �� Phone (home):
Address: / � � l„ Ro6c: �� t� i�/ I�;a (work/cell): � 3 � '�"9 � - i `� ��
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
� �Y �-5
3) Property Description: Lot Size: 'o��_ Subdivision:
Address and/or directions to Property: I a.. S`' �
S
#:
L�lno Does the site contain any jurisdictional wetlands?
F" o Does the site contain any existing wastewater systems?
o Is any wastewater going to be generated on the site other than domestic sewage?
�o Is the site subject to approval by any other public agency?
�no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
C.�esidential '
�` ew Single Family Residence Maximum number of bedrooms: �_/ Occupants:
DExpansion of Existing System If expansion: Current number of bedrooms:
�Repair to Malfunctioning System Will there be a basement? Dyes �= o With plurnbing fixtures? Qyes Ono
Qton-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
i�� �4 1v F4 fu
5) Water Supply: �1ew well P� xisting Well p� ommunity Well OPublic Water pt pring
Are there any existing wells, springs, or existing waterlines on this property? Dyes �no �
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', lease indicate,�referred system type(s):
�° onventional �' ccepted �R ovative �� lternative L�iJOther �R Any
I certify that the information provided above is complete and correct. l also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�� �q�r� .2 a r-/ 7
� Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
f'` Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
�� A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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