SEPTIC PO Box 65 Lillington, NC 27546
Telephone Number 910 - 893 -7525 O� 2 �rT- Z
Fax 910 - 893 -2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date: G( -22 - P
Applicant Name: W ..
Address: I tZ L �, �-� P • / e.>.son tsL c2
Telephone: 4i q_ 1 q b- (9c.1 z_
Property Owner: )L P n., Phone: 9(9 - O4
Lot Address: '19 • bl l.a,.,e..
Name of Park: t =„ !.�. Lot Number: ) 3
Parcfl: 07 /, 043 04 PIN:
SW DW TW (Size N x '7n ) # Bedrooms Year t
%Lotr co t`nny : Pr os �i�a.._ ?re mtfe #
Progres
Specific Directions to Job from Lillington:
There is a $100.00 charge for this service. This certification is subject to revocation if the
intended use of the septic system changes, or if false information is provided on this
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
y
5/07
NAME: APPLICATION #: 1 ‘ 9 7 ' {2 ' ` J � j1, G___
This application to be filled out when applying for a septic system inspection.*
County Health Department Application for Improvement Permit and/or Authorization to Construct
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT
PERMIT OR AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. The permit is valid for either 60 months or without expiration
depending upon documentation submitted. (Complete site plan = 60 months; Complete plat = without expiration)
910- 893 -7525 option 1 CONFIRMATION #
❑ Environmental Health New Septic SystemCode 800 -
• All property irons must be made visible. Place "pink property flags" on each corner iron of lot. All property
lines must be clearly flagged approximately every 50 feet between corners.
• Place "orange house corner flags" at each corner of the proposed structure. Also flag driveways, garages, decks,
out buildings, swimming pools, etc. Place flags per site plan developed at/for Central Permitting.
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating property.
• If property is thickly wooded, Environmental Health requires that you clean out the undergrowth to allow the soil
evaluation to be performed. Inspectors should be able to walk freely around site. Do not grade property.
• All lots to be addressed within 10 business days after confirmation. $25.00 return trip fee may be incurred
for failure to uncover outlet lid. mark house corners and property lines. etc. once lot confirmed ready.
• After preparing proposed site call the voice permitting system at 910 - 893 -7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health inspection. Please note
' confirmation number (liven at end of recording for proof of request.
• Use Click2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
E nvironmental Health Existing Tank Inspections Code 800
• Follow above instructions for placing flags and card on property.
• Prepare for inspection by removing soil over outlet end of tank as diagram indicates, and lift lid straight up (if
possible) and then close back down.(Unless inspection is for a septic tank in a mobile home park)
• After uncovering outlet end call the voice permitting system at 910 - 893 -7525 option 1 & select notification permit if
multiple permits, then use code 800 for Environmental Health inspection. Please note confirmation number Given
at end of recording for proof of request.
• Use Click2Gov or IVR to hear results. Once approved, proceed to Central Permitting for remaining permits.
SEPTIC
If applying for authorization to construct please indicate desired system type(s): can be ranked in order of preference, must choose one.
(_) Accepted { Innovative (_) Conventional {_} Any
{_) Alternative {_} Other
The applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question. If the answer is "yes ", applicant MUST ATTACH SUPPORTING DOCUMENTATION:
{_ } YES ( NO Does the site contain any Jurisdictional Wetlands?
{_)YES { NO Do you plan to have an ff systc r now or in the future?
{ { NO Does or will the building contain any drains? Please explain.
{ 1 — NO Are there any existing wells, springs, waterlines or Wastewater Systems on this property?
I { — } NO Is any wastewater going to be generated on the site other than domestic sewage?
(_)YES {_) NO Is the site subject to approval by any other Public Agency?
{_} YES {_} NO Are there any easements or Right of Ways on this property?
{_ }YES I_) NO Does the site contain any existing water, cable, phone or underground electric lines?
If yes please call No Cuts at 800- 632 -4949 to locate the lines. This is a free service.
I Have Read This Application And Certify That The Information Provided Herein Is True, Complete And Correct. Authorized County And
State Officials Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Understand That I Am Solely Responsible For The Proper Identification And Labeling Of All Property Lines And Comers And Making
The Site Access}bl$ So That A Co • to Site Evaluation Can Be Performed.
/ _ a -.- �S / Q
- 22-/
PROPERTY OWNERS OR 0 .. NERS LEGAL REPRESENTATIVE SIGNATURE (REQUIRED) DATE
11/09