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A35 150
Application Date: ��`�'�`'��j� �('7' �( Ta� Map: � 3� Amount Paid: _ � ���� � v� Parcei #: %� Receipt�'. C r�'�� � � „� — "– . �--���_� ������ � ������l1 lf��irn.�ruir-a�lrnuanat+uad..e.n.]I �E-�C29.LR�1L1fT Applicatian for Se�-vices (Septic Syste�s and Welis) Services Requested Impmveroent Permit (Site Evaluation) Canstruction Authorization �200.00/$300.00 (if > 600 gpd} (Eee is dependent on the type of system permirted) Mobile Home Replacement or Suilding Addit'son Permit Revision We[l Permit {NewlReplacement/Repair) Repair of Existing Septic System i j aervices itequ ten y Name: ��� � YiiC- �C. Yi Address: �� �i.l {il !1 . N C `� Q�r�R'-� �t� ��t - �-(�a C.� Phone # (home): �{ (work/ceEl): �_(Q S'�,Gi"� ��(c� _ 2)Narne and address of current o�vner (if different than applicant}: Name: S C.V' �!'ti° Vt (/1 • Address: ' �`�cS�rrY-� . S�C . 3} Property Descriptioo: Lot Size: Subdiv�an: Address and/or directions to Property: �j� 1{-{��.c Vv��c.� tk.�..� s rn< <ti ,�.rt� #: 4) Proposed Use and Type of Structure: ` , Residentia] BusinesslType: flther i.�1 C�l �'�L I Yt-S �b��• Number of bedrooms / Number of people served (seatslemployees): Basement: Yes No (with p(umbing: Yes No } Garbage disposa.l: Yes No 5) Water Supply: Private 1��e11 (Proposed Existin� ) Community Well: Public Water System: Are there ��ells on the adjoining properties? No Yes (please show location on site plan) Nofe: A cornpfeied applecation must also include: � A plaf/site ptan of the property thaf shows property dimensions and ihe size and location oj�all praposed structures. � A sagned copy of the `Lot Preparation'1'orm verifying that the properiy is ready !o be evaluatert I am submitting this application to req�est services from #he Person County Health Department. I understand that if the information provided is incor if the site is equently altered, or if the intended use changes, all permits and approvats s3�a11 becom ' alid. ., .CC7QifAt111`P fnWfIPT/T.?U'.i� RPt1TPCP. Yatitr • -natp ���/ I �.�t( i � � 1 �'d �99Z168066 I��d I��� dLl�LO l6 £6 ��W � � ��� � � �: a d� ���''' � . �.�v+. � b � 1 � � � s1. V 1i � J:t_.:.-l.m�l.�-7i.ar'{�,.ii.li�l11.[{��ia3.t�.�t�. �"'��'.:c�Q.11t�.�t �UEIl��IlEfl� r'���E$Il�IIfl�I PVg��Dl�c� �I�HYfl� ������E�BIltEflfl�S Tax Map #:�,�,,� Parcel#: � Approval Requested for: 1Ylobile Home Replacement � Building Addition (5w i r�min c� Poo1 � J Applicant Name: �1c�5� �n l�V�en n Address: g00 b rv C Phone #'s: Perrnit Lacated: Installation Date: Yes V No —7 Design flow: ? (apd) Current Contract with Certified Operator on file (if required): Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: �- �-/� (date) (Applicant's signature if sits visit is not required) Comments: �o �6� �� i�— a r�,� u r�c� ,� n�_ � ���n�ao ���a���a���� �������� �— Z3—�( Envir ental Health Specialist Date 11/15/05 ����,�� ���� V � . � ,�p T� �`Q ^~ t/ \l � ly, � l���u-�,r,,,�,.,,��.¢�.11 ]HC��.11� �I'I'E S�TC�I Name J�15r��� �N1r� �� �� Tag Ma.p # A 3S .Pa�cel # I� C� Subdivis�n Seciion/Lot# ���, _- -�-�_3-II � Authorized State Agent Date System components re�bresent approximate �contours only: The contractor must flag the system�rior to beginning the installat�ion to ansure that pmlbergmde as maintaaned � «.�`��.��:� ,� ���' �� � � � ,".{;� .� �'�if �� i ��� r �4 4� �'�a "�i.�'s��.� �>�it �x ��, � °� � , P"=t"" � �w � � w�.�. � �� t ,� ,e} .. b�,� � � � � t' 21$� �� �'` ��x ; � �` `��,� 4� ` i°� � � �;"s' "tjy�' ,� � *�,s�,� ��, � � F�a �t C � � ,b , },� ' ��, „ .t. 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