A40 203�
A�plication Date; �"�a2'��
A.mount Paid:
Recaipt #:
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APPLICATION FOR SERVICES
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Parcai #: �Q 3
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IF THE INFORMATIOM IN THE APPLICATIOfV F'Oli AN IiIAPi�O�lEMENT P�l2MIT iS INCORRECT, FA►LSIFiED,
CHAIVGED OR THE SITE IS ALTERED. T�lEiV THE IMPROVEiNiENT P�RIYiIT AND AU�H�RIZ,�TION TO
CO(VST6ZUCT SHALL BECOME INVALID. -
Prmit requested by: (Owner/agent/prospective owner): (� i i(� CC-Ci ��1
Home Phone: ��0 3 - `� ° �( �l Address: � �-c. � � � Q �
Business Phone: ,�iq 1� z tf Z ��j � vrv qn �� Cov ��'
, 2) Name and address of current owner: 1� ��- (L � N ►'K L C c� ;
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3) Property Description: Lot size: Township: Subdivision: r� ��✓�-�U IK^�ot# ��
Directions to the property (Incl4ding road� names ard numbers): _
C� / \ C M\\5 C�r� .i 5 ^^�
f� � ��,h--- I i n�tj i � S ,.�� �l{ � 1 N ei �� �V'� �.
� �� +-a ��,. r i-vr� L1 0,�-�-o�jor�u�c.t � ��y`� %�� `�'� � h �r
4) Proposed Use an Structure Description: answer each of the following questions: L)
a) Proposed _, Existing , Type of Structure: �� o� Width: Depth:
b) Number of Bedrooms: �,� Number of occupants or p le to be served:
c) Basement: Yes , No / Will there be plumbing in the basement?,��
d) �arbage Disposal: Yes _, No �l
5) lnlater Supply Type: Private (new or existing�, Public_, Community� Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
�site plan.
6) Does your property cantain previously identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
9 A PLAT OF Tl-!E �ROPERTY OR SITE PLAW iViUST BE SUBMITTE� 1NITH THIS APPL9CAT10N.
➢ PROPERTY L1NES AfVD CORIVERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES �iUiUST BE STA4CED OR �LAGGED.
9 THE SITE MUST BE READILY ACCESSIBL� FOR A(d EVALUATION BY iHE liEALTH DEPARTi11iENT
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 application are true and represent the maximum
facilities to be placed on the property. I understand ifi the site is altered or the intended use changes, the permit shall
become invalid.
�C�� �„� � �v o�
Owner or Legal Repres ntative ate
PCHD, rev. 06127/02
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� ]L.�-�Sr� " � 33C� �a-sr�t� � 3i'�_'� �Y.. � � � �,1H_'�J�S,t
�'ax Map #�,O_ I'arcel # a�
�xisring Sewage System �te�ort �or. Mob�e F�ome �te lacement �o� la x 1�
iC Addition Type:�Q
Re uester.` I��� �e �-<� �ome 1'hone# Sd3 " 9 �Y 5
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33 c, �m„c� „��- _ Business # SS '� -- a5�1 �
���w �C- a� 5'�-I
I.ocation• S'') S -°s � � �1.ht+..:� l% ��\o.c�_� �� R � �i �c•.'w �iurnr•u.
�' n„�- � 1" l.��r.,�c �,�. � —� �-, s+t-a.1.w•, � .
priginal g'ermit I.ocated: �u Water Su�ply: 1���
Septic System Designed For. �tesidential Business Other
# Bedrooms � # �mplopees ���
(�,�,¢J�1�u�a.Q .
System Type: "� 3l� � x� '�'� S�e�1 �o � Nitrification I�ine 3� x3
Date Installed• � Cestified Opesator Required: nq
On-site wastewater disposal system shows no visual signs of malfunction on �- a�•' v5 .
IDEmzission is granteri to: � � ���
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5 �- v.. coo"i�2 � •%V�s -
�nvironmental �ealth Specialis
Date: S`�Z/ '�r
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Name fi�►'c. � /Li + Tag yla� # �to Parce� # �23
�ubdivision �/a� TZu'v %v%a+�c � Se�on/Lot# a5
. PS �= ���as
Autho � d S te Ageut � . Date .
Syst,ern cara��ianents rep�es�at ap�ir�xisnate�santours onl, y. Tlae contractar naus�,�iag �die systena�isz�r to
beginning td:e installati�n #o insur� idica�tpm�iergrade is �saint�iased :
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Scale: i�o� � �
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��G�, ie�. 09/12/�3.
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant (V� „�}�+r r�l
Address �3 `�P,,Q� �ti( � CT County
Collected By ��.
r
Date Collected Time Collected �C� 8..�1J�
Source: �iWell ❑ Spring ❑ Other
�...
Location: �House Tap
�t�ie�n
pNo Charge �harge
pWell Tap
S � r-1�
❑ Other
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Total Coliform
FecaUE. Coli
Reported By.
bactreport
Results
Present Abse
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