A40 161Application pate: � �3 I �
Amount Paid: o?�� .UG
Receipt #: l 3 N 3
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� Parcel#: I 6
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for Services
� Services Re uested
Improvement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 if> 600 d) ee is de endent on the e of system ermitted)
Mobile Home Replacement or Building Addition Permit Revision
$150.00 (if site visit re uired) $75.00
Well Permit (New/Replacement/Repair) Repair of Esisting Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
� Applicant Inf mati
Name: �iG . � � � . Phone (home):�� � ` `�J U`i' SSS�j
' Address: . � 1 ���d "o� C.. (work/cell):
2) Name and addr ss of current owner (if different than applicant):
Name: �h� k� h � i- ��' � ��
Address: SN i A-�.s R�
1�,,��C.� •t�-,�`t,\ c , 1� C-
3) Property Description: Lot Size: 3�`� �
❑ yes
❑ yes
� yes
❑ yes
Q yes
E� no
0 no
�Tio
C� no
Phone: 33�-5o�t -� 55S
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Does the site contain any�uriswcnona� weuanas�r
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other public agency?
Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
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4) Proposed Use and Type of Structure: , '� 5�� �,� �,�,y� �,,, �,,,.a,b Pe�w�'
�IFesidential '
ew Single Family Residence Maximum number of bedrooms: 3 / Occupants:
❑ 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 Well ❑ Public Water ❑ Spring
. Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
O Conventional ❑ Accepted ❑ Innovative 0 Altemative 0 Other ❑ Any
I certify that �the information provided above is complete and correct. I also understand that if the information provided is
inacc e, th is subseque altered, or the intended use changes, all permits and approvals shall be invalid.
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Signature (Owner/ L�gal Representative*)
* Supporting documentation required.
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Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A c�mpleted `L•ot Pre�%rrn_tion' form must accompany any application requiring a sitP evaivation.
(10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Site Plar.
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ress:
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Date:
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System Type:��ytc�C
Septic Tank: 0�O gallons
Pump Tank: � gallons
Total Linear Feet: 3�
Max.Trench Depth: 30 "
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Tax Map: ��
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Scale:
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Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Healt� with any questions (336) 597-1790.
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Additional Comments: __ �= 4V�ic�q� Ql� �y�� Ac gs'
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