A35 164Anplication Date: J�I 3-03 Tax Map #: � J�
Amount Paid: ' O, � U ? G
R2ceipt #: � 7� S I Parcel #:
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APPLICATION FOR SERVICES
IF l'HE IPlFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS IIVCORRE� FAL51FlED,
CHAPIGED OR THE SITE IS ALTERED THEN THE IMPiZOVEMEfVT PERMIT AND AUTHORIZ�►TION TO
CONSTRUCT SHAL� BECOME INVALID.
1) Permit requested by Owner/agent/prospective owner):
Home Phone: �il�r —,.3�-� ^7/�/� Address: 3/6 �' �► � _
Business Phone: 9/4`- 78i- �Z/aQ . �i �.� / , .
2) Name and address of.current owner: �be� �%p �v:�� V�� v� •
3) Property Description: Lot size: Township: Subdivision: �Q t
Directions to the property (Including road names and numbers): �,'(� � /�lc ,�,��5 �I ; / �C .
4) Proposed Use and Structure Description: answer ac of the foilowi�}g questions: r
a) Proposed _, Existing _, Type of Structure: �G`�,r�m _�e►, _ V�(idth: %C��a�pth:o?�%.�p°
b) Number of Bedrooms: � Number of occupants or people�to be served: oz
c) Basement: Yes , No � Will there be plumbing in the basement? -
d) Garbage Disposal: Yes J No �
5) V1later Supply Type: Private � ew _ or existing�, Pubiic_, Community , Spring _
. Are any wells on adjoining property? Yes_ No _ If yes, please indicate a�proximate location on the
site plan.
6} Does your property contain previously identified Jurisdictional weilands? Yes_ Ido v
PLEASE NOTE THE FOLLOWING;
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFfED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
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 appiication 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. � �n
er or Legal Representative
� � /�
Date
PCHD, rev. 06127/02