A36 3Application Date: �/ e, l
Amount Paid: 1 0 0
Receipt #: �
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`�'?,) f �Jl�ll���l � Tax Map: �
� � ���� Parcel#: 3
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n for Services
Services Requested
0 Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) (Fee is de endent on the e of s stem ermitted)
� NTobile Home Replacement or Suilding Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
ell Permit (New/Re ent/Repair) 0 Repair of Existing Septic System
$300.00/$200.0 $75.00 {� i o.! E� Application: No Charge/ CA $ I50.00 or $300.00
1) Applicant Information: �
Name: M�2u E• y,J� ��,b r,1 Phone (home): �ot� 5�4�,7
Address: (�jJ�i���s �.�,�ll �.�.• (work/cell):
2) Name and address of current owner (if different than applicant):
Name:
Address:
�"�X -�o '�a..� w �s
W+.t.f�sw�SoN � Sr•1G
Phone: �(`�3'�,� 375�~�3�� `.¢�
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Properly:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ 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 vrays on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well � Community Wel( ❑ Public Water 0 Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the i rmation provided above is complete and cort-ect. I also understand that if the information provided is
inaccurate, or if he ite is sub quently altered, or the intended use changes, all permits and approvals shall be invalid.
� t t 2 Zo t3
Si at e(Owner/ Legal Representative*) ate
* Sup g documentation required.
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.
(10/11} Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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WELL PERMIT (New_Repair� L�,�G�
�--�---
Tax Map: _� �C� Parcel: 3 •
Subdivision: Lot:
Applicant's Name: /1� 1lhb �/
Mailing Address: 7 � � �
Phone Numbers: yD��
Location of Property:
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governzng construction and setbc�cks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit issued by:
Date• l�Z�i�
CERTIFICATE OF COiVIPLETION
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concretz Slab:
Well Driller•
Pump Installer:
Well Appraved by :
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspection:
F�HS/Date
Installer: ` Q . �
Depth: Z'
Grout: 2 z �� 3
Well Abandonment:
EHS/Date
Completed:
MethodlMaterial(s): _
License #:
License#:
Date:
Date Results Mailed:
Phone: 336-�97-1790 Fax: 336-597-7808
8/1/08