A28 209Application Date: � 3—v � Tax Map #: �� �
Amount Paid: I_� 3 �
Receipt #: e? `1 6 9 1 Parce l #:
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APPLICATION FOR SERVICES
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IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVE�%IEI�7 PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit requested by: `(Owner/agent/prospective owner): � o o►� ,g;s �� ��7 u i►n P�1 r� e S
H o m e P h o n e: S� ( 9 � 7 J' q � M � k e A d d r e s s• r 7� 6 T h c 1� e c s1 0 ,� �
Business Phone: _N4 9-d�7 �uMptir�'eS�i �oX1�nrU lv C �7�7�f
µo,u c o; t c o. '
2) Name and address of current owner: .� an.� P
a�
3) Property Description: Lot size: � Township: Subdivision: Lot #
Directions to the prope� (Including ro d names and numbers): 9 u4�e t2 � c
2 i2 � ►2 " e� 1-�e-S �e,� � 7 I.��
n�,.., n. ,�.�.. L n n 1rn cS � v- � v e+.� a v � t�a ti•�. 5l e 11 o c,J k� c u S�t
4) F�roposed Use�nd Structure Description: answer each of the following questions:
a) Proposed _, Existing _, Type of Structure: S t,�1— M� Width: Depth:
b) Number of Bedrooms: � 2- 3 Number of occupants or peopie to be served: �_
c) Basement: Yes , No � Will there be plumbing in the basement?
d) Garbage Disposal_ Yes No ��Qre w�-� (�
5) Water Supply Type: Private �(new� or existing�, Public_, Community S rin
� P 9—
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED.
➢ THE SITE MUS'fi BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
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 if the site is altered or the intended use changes, the permit shall
become invalid. .
Owner or Legal
Date
PCHD, rev. 06/27/02
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Buildin�;�l�.�ditions/ Mobile Home Replacements
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Tax 1VIap #: ocz4
Approval Requested for:
Parcel#: Z�A �
�_ Mobile Home Replacement
_____ Building Addition
Applicant Name: �•+,�+�„� %-i�� �kT � e�
Addiess: � '�!'�-,, Tti. o� 4lrsa� r i�
��.,-,�, �vc z-�s)�/
Phone #'s• �5+3$ -�7�, _ 5�-1 �73' F�• D.l C.�.
Permit Located: r„�_ Y� ✓ No
Installation Date: r.� � • Design flow: 2�-!t� (gpd)
Current Contract with Ce�icd Operator on file (if required): nc3.. .
�Vater Supply: _� Well Public or Community
Wastewater system sho� m�o visual evidence of failure on: -1 r Q.�- (��)
(Applicant's si�e if.site visit is nat required)
e
dition/Replacement Approved
Environmental Heal S�p�'c:i � .
11/15/OS ��U�
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Date
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Name �cr�s �w�...oLn'es Taa Map #A�2$ . Pa:tcel #�_
Subdivision � Sectian/Lot#
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� Autb.o � ed te Agent � � . Date .
sy�,,, ���� ;�,��t �pro���contours onYy: The contracctor must flag the system prior to
beginning the instulla�tion to insure thatpro�ergnade rs maintained .
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PGHD, rev. 49/12j01