A27 9Application Date: � -� � � % Tax Map: � a %
Amount Paid: I �. O U Parcel #: �
Receipt#: � � � �� D �
� ,.:_.�--�`� � �' I��I�� ��T
C.�- T = �= � � 1�r��r°1���
.J.E��..r )Yl1�Y']L 3L: 4:D ]LT..11'l1LT_K'.> JLT.'�..l:p..�l. I�W.II Q!.7.YR.LL.'Q::.�LT.
. Application for �erwices �
(Septic Svstems and Wells)
�ervices
L Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d)
obile Home R�eplacement or Building r�ddition
$150.00 (if site visit required) �
0 Well Permit (P1ew/Repiacement)
$225.00/$125.00
G Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
❑ Repair af Existing Septic System
No Charge
C � 1�� `4-a
�1/l e�� � d ��
Important: Ijt/ie inforn:atioit in the applicatton for an Intprove►nent Pernstt is i�tcorrect, falsifted, or the site is altered, t/ien tfie
Improveme�:t Permit and the Authorization to Co�estruct shall become invalid �
1) Services Requested by: �
Name: � �1�� �L�--��_
�
Address:
' x,,�,�,.,�1�� �� � ��
Phone # (home): Rq — S �
(worlJcell): � —��-�(
2)l�aane and address of current owner (if dif%rent than applicant):
Name:
Address:
3) Property Description: Lot Size:
Address and/or directions.to Property: �
I 1' � -
: � •'
�
� z s+��
4) Proposed Y7se and Type of �tructure: /
Residential __� Business/Type: Other C��OoN� 0.�1� ( 61��/ �u�r��
Number of bedrooms �_ / Number of people served (seats/employees): 3 O)( a 0
Iiasement: Yes �� No (with plumbing: Yes �� No _�
Garbage disposal: Yes No '�% .
5) Water Supply: .
Private Well � (Proposed Existing _�
Community Well: Public Water 5ystem: �
Are there on the adjoining properties? No Yes (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site p[an of the property that shotivs property dimensions and tlze size and tocatinn of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�zng that the property is ready to be evaluated
I am snbmitting this application to request services fpom tbe I'erso� County Health Depaptment. The
inforanation provided is accurate. T under�tand that if any site is altered or the intexaded use changes, all
permits shall becoine invalid. � �_ „
Signa�ure (Owner/Legal Representative):
06/07 Person County Enviromnental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
F
�� �
� 1 �
�./�ti ti } 1 .i � � � �� � �
11.���.�70.�i. ��a.::a.�� �r�7i.�Y� � ,�i��
��c�g Add�ttio�/ �obiie �oan� �e�iac���nt�
Tax Map #:��
A�proval Requested for.
' • "" ' ��
Mob�e Home Replacement
� Building Addition � '
Applican# Name: r-
Adciress: � ' 7� '/
� , o vro G 7� .3
Phon� #'s�: (lf) S99 - 5'0(� _ 5�1 -
Pemut Located:
"Yes v No �
Installation Date: -? Desiga $ow:. 2 D (gpd)
Cuaent Contract vvith Certii Operator on �1� (if requize�: .
W��r Supply: Well � Public or Coinmunity
Wastewater system shows no visual evidence of failure on: /D�S-d � (date)
��. (Applicant's signat�ue if site visit is not reqnired)
� ' o,.lrr,u e
' � �a�cia#ioa�/Itepiac�n�nt A�proves�
. � .
En ` ental� Heaith Spe�i.alist -
11/15I05
. �d_9 07 .
Date
0
J
9
. . � �,
`-���• .� �.1L1�� `� � . .
. �.-. �,�Ly �
- �- � S� �Q•��I��
1E�.-�.s-�,.,, .,.,.,, ,v�� ]E-���.�.�. �
� ��'�. ��."7'� • .
' '� �%/v . : .
�3II]E �mmB�f YI�l1l�2Y5Qj1 � T�1� # ��7 P3�C� �'`r /
Su�d�uision � • Se�on,/Lo�#
. . , . . . , /�`� d7 �
� A�o� S;t�Age� � � . � • Daa�:e 1n 7�.�;r.-he(. /7
, : .. �
� .
'. Sysi�as c�iara�#s s�s�s���ar�...-���c���rs ant�. 37:e ca��s��, jta�� s,�. rst�r�iaz�or�
� b�g�g. � z��oma i� �a�e #�et�e�-g�ade� is s��ec� .
� . . � • . • . . J6� . .
. �-� �
� � • • � �� �����h I%�
• . �' �Y��1�111� �. � .
Scale: ��or��
TT�{�L
�1
�
�
p ,�',"��, re�r. Q9 /1� / �1