A35 178ApAlication� Date• � a3 -�l 'oL . . T�c Ma� #: � `� �
AmourttPaid: oO.O � � ._. .� : G
Rec�ipt�: �2 3 � � � ' � � � . . Rarc�l�� � � � Q
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- APPUCkTION FOR SERV�IC�S �
SHALL BECOME INVALlD. �
1) Permit requested by: (Owner/agent/prospective owne�: ��
Home Phane: � �o r,23 �l- �v� Address: �
Bus�ness Phone: � �l�-a-/� - /,��h�
2) Idame and address of carrent owner. E �/�`.5
CC 5 _
�•
3) Property D�escription: Lot size: ��59 Township: D' %L Subdivision: � Lot#
Directions to th� oroaeriv (Induding ro�,d. na�nes and numbers): ,_�A�,, ,�
4) Proposed Use a Structure Description: answer �of the ilow}� �estions:
a) Proposed �F�dstin9 TYPe of Struct�re: ��t,�i'l/�1 ��1��fl1iDoM Width: /� Depth: �
b) Number of Bedroo � Numbe� of occupants or people to be served: � ,
c) Basemen� Yes �No _ Wil( the be plumbing in the basement? f�% o �
d) Garbage Disposak Yes _, No �
5� Water SupPtY Type: Private ✓(new _ or exis�ng �,�'ubiic_, Ccmmunity � Spring _, -
Are any welfs on adjoining property? Yes _ No ./If yes� ptease indica�e approximate location on the site plan.
6) Does the propetiy cantaln previousiy identifted jurisdictional wetlands� Yes _ No �
PLEASE NOTE THE FOLLOWING:
'➢ A PLAT OF ilE PROPE32TY OR SiTE PLAAI MUST HE SUBMITTED WITi�t THIS APPLlCA710N.
➢ PROPERTY L1NES AND CORNERS MUST BE Cl.EARLY MARkCED.
➢ THE PROPOSED LOCATiON OF ALL STRUCTURES MUST BE STAKED OR FLAC,t�ED. �
9 THE SITE MUST BE READILY ACC�SSIBLE FOR API EYALUATION BY THE HEALTH DE3�ARTAAENT STAF�.
i• hereb}� make application to the Person County Health Department for. a site evaluation for the o�-site se�rage disposai
system for ove-descn�bed property. 1 agree that the corrtents� of this appl'�cation are true and represent the ma�dmum
faalities be la n th prop riy. u derstahd ifi the site is aiter�d or the intended use c ang the permit shali
b� �. 1 �-3 v z_
Owner or Legai Representative � ��
Pct-�. rev. �a�7ro�
���� ..1� ��l.��� ��
�._--. � • � � � � � .ZL �
���a���,r,r,, ����Il �ZL��Il��
Tax Map #�� Parcel # � U
Existing Sewage System Report For: Mobile Home Replacement
�Addition Type• ��,1—a�5�-�'�
Requester: � I SD� �.�l.� l� I� QtN1 C Home Phon #�0�����56�.
o�c�i //�(l(� ��'(�; �;( Business # �����a5
�.T�.�._(� L a 7�7��—
Location: � i�, � � �n.� � 1 Y 'C�9�.Q�Ji� nl� �L1/ � T�L
� M �;� ri�� P�Q o�-, � ��a �
Original Permit Located: ' Water Supply: 2� -� a�L�
Septic System Designed For: ✓�sidential Business Other
# Bedrooms o� # Employees Other
System Type: 1�41��'i-►�13� Tank Size: Nitrification Line:
Date Installed:
On-site wastewater disposal
Pemiission is granted
Certified Operator Required: � V ( �
shows no visual signs of malfuncrion on � 2-- �%"Q'�
, - . . - . `��'�1i��'��I�IT'� %��'�' � . - � i
I HEREBY CERTIFY SAID PROPERTY QUALIFIES AS AN
EXCEPTION TO THE PROVISIONS OF THE PERSON COUNTY
SUBDIVISION REGULATIONS UNDER SECTION 16-1.
� __ _
PLANNING AND ON G
ADMINISTRATOR
_ ._— -
_-----
_____--
AP N84"23' 40"E��
� g6.04'
�_1S'�QQL_ DATE
STATE OF NORTH CAROLINA
COUNTY OF PERSON
I, �L�.J�__!=!vr��� REVIEW OFFICER
OF PERSON COUNTY, CER7IIFY THAT THE MAP
OR PLAT TO WHICH THIS CERTIFICA7E IS
AFFIXED MEETS ALL STATUTORY REQUIREMENTS
FOR RECORDING.
P=�,,�= "- --'u. �,----- L_I S'ZooL
REVIEW OFFICER��� -� DATE
•-- ---�
__�_
-'�
MP N88"44'24"E MP ` � - '
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�— 108.30' —P� — S84'25'08"E MP ` � \
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, �
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RECOMBINATION PLAT
TIMOTHY L. WILL
LISA R. WILLIA
WOODSDALE TWP., PERSON COUNT
JANUARY 2002, HAMLETT-JENNINGS &
212 S. LAMAR STREET, ROXBORC
JOHN J. JENNINGS L-305:
?� � 25 �$p ,pp
BAR GRAPN 1 inch = 50 ft.
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D.B. 357, P. 171 ` i � \� ��� �
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D.B. 159, P. 567
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