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� � � � APPLICATION �OR SERVICES , `='`'``'
�� �: �� s� s �¢ Ser��c�s°Requested: _ _ � � ����k �;� ��� xs
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Improvements Permit-(EstablishedlRecorded Lot) ._. Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
improvements Permit (Mobile Home R�
Improvements Permit (Addition) _
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; c>« � �l�)�
�) Permit for New Well
Replace Existing Well
yo��c 3� � V�1C,G1� �
- �::. ,.<.�, . ,..__. _
� Bacteria Chemical ._ Petroleum _ Pesticide _ Lead
1. Permit requested by: . n� 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent:
Pi�JJJ w�>�� -, Width: � �� �
Address: `F��" � � � � Depth:
� i-b +�� �� `- �- � � �� - 8. What type (if any, additions, expansions, or
replacement is anticipated to the struc[ure or facility .
that this sewage disposal system is intended to serve?
ome Phone #: �� �
usiness Phone #: S � � - �S � - � � �'�
Name and addre�s of cu ent owner:
l�Fhsa l ��1�-�
Property Description: Lot size: G•��
Tax Map#: /`�� /
Parcel#: �
Township: 0 �� v e �± � 11
Directions to property: State Road #& Road
mes,�tc. � � �
9. Water supply type:
private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No� If so, # of basement fixtures:
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 Pet'SOIl C011I1ty 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 facilities to be placed on the 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 after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
z Signc� O�v(er or �uthorized Agent
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;rmit Issued ❑ Signature Date
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:rmit Denied �1 '
I at Observed ❑ , , �
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RECOMMENDATIONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� e�C.� C:IAMIPRO�DOCS�.APPSEC.ST1 FWANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT �
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � �J Parcel #
Zoning Township '
Owner/Contractor ��_ ��o,� � vn� Date -� /-�j (,�
Location/Address �n nl.. �G� -�-, f�„f I-�,'l� P� v�
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area (�,� R'%�u�� Size of Tank '
Mobile Home Size of Pump Tank
# of Bedrooms Nitrification Line
� � ' � ' Max Depth Trenches
$ �i �i�� C.S S �W r1 :.:r1 �'`n`�O �",3v
�r
Permits may be voided if site is altered or
Well and Septic Layout by
Comments:
Date - Installed by
Well Permit Paid ❑ �E
iividual Semi-Public
blic Renlacem.etff
ell
Date
Installed by
t�? Approved by_
SYSTEM PECIFICATIONS
uired Slab
Air Vent
Required W og _
Well T
� Approved by.
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30'X l�d'
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This report is based in part on informafion 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 information
contained in the application. The environmental health specialist is also not
res�onsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro�permit.sam O1/95 rev.l.l
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D.B. 132, P, 438 c� c�
D.B. 132, P. 589 N
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OLIVE
HILL �
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VICINITY
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The District Health Department�
CASWELL - CHATHAM - LEE - PERSON COUNTIES
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Q,,� � Water Supply and Sewage Disposal
-� IMPROVEMENTS PERMIT �p-���
� :fl /I � �� Date L.G— 7� `'O �'
Owner: _
Location:
�ntractor: �
Waler Supplp: Private �_�public
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal,
washing machir�, other� tojnatic appliances
Si� of tank: Nitriflcayjon line� BD �s_�___
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 an3 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 AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
Certifica2e oi Completion ' �
Date Approved: �— r4' —/� Wgy; _ (� '�
S arian
(OVER)
Location of well and sewage disposal tacilities sketched on back.
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NOTE: Make sketch of ;nstallation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special prob]ems existing on lot. Wr.ite in measurements in order that installations may be located
at later dnte. Note location of water supplies on adjacent lots.
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