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paid ��U�, �
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Person Courty tiaalth Der:
325 S. Morgan Street
Ro:cboro, N.C. 275?v
Courier �2•L3-15
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Date
Improvements Permit-(Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
ImpFovemencs Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
lmprovements Permit (Mobi�e-�amg-F��place)
Permit for New Well
Improvements Permit (Addition) I_ Replace Existing WeII �
Pecmit requested by:
owner�pr
Address:
ome Phone �: �91' S3� 2—
usiness Phone R:
7. Dimensions or Proposed Structure:
Width: 8 X 3 d- ��.
Depth:
8. What type (if any, additions, expansions, or
replacem�ni is anticipated to the structure or facility
is sewage
system,is �,nte
Name and addreSs of current owner: ��` 9. Water supply type:
' � private"� . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes� No
If so, � dentify� locatioF : ��.�n� ^��-� �" �
3. Property Description: Lot size: � 3-� a�
4. Tax Map#: ��.'�B'
Parcel#: �
Township: � a�-- _
5. Directions to property: State Road #& Road
Names,�[c.
� ii c�D (������ _
. Number of occupants or people to be served: �_
�
10. Type of s�:�e�elfacility: Proposed: �Existing:�
Type of dwelling:
House: ❑ Mobile om�Q B�usiness: ❑ ��.�
Type of business:
Number of Employees:�._
Number of bedrooms: � �%�
Garbage Disposal? Yes� No �
Basement? Yes ❑ No�I.If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Pet'SOn COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described propercy. I agree that [he contents of this application are true
and represent the maximum facilities to be placed on the property. I undecstand if the site is altered or the
intended use changes, the permit shali become invaIid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the even[ I have not
delivered a survey plat of the propercy to the Health Dept. within 60 DAYS after the date of the evatuation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
�
z - _- - Signcci Owner or Authorized Agent
Person County Health Oepartment
Existing Sewage System Report For: ✓ Hobile Home Replacement
, Addition
Requestee: V���I L� L' �R'.'7�� Hou�e Phone# '
�__��������^{� �. Businessx
�D�,!/.bV Dr !/l.t� 2�573 'r ax Map n�� �U r�
Location/Uirections: (St°(� G(,y,��/(�
Originai Permit Located ,
Septic System Uesigned ror: _
Kesidential � f3usiness Other {speci�y)
� I3edrooms _�� # �mployees Other _
llate '1'nstal.led Water supply
.� „ � .
. - • - II/Il�ii/./I/1�//1%/L��V%!►/IL
.
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Tank 5ize
Certified Operator Required !v l �7
On site wasL-ewater disposal system sliowes no visually apparent
malfunction on ��_l�— `��
Yermission is granted to: �� r ��5/��
According to the attached site plan.
Environmental Health .$�C.. (� �
DATE
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