A28 215Application Date: 3' � �-� 3
Amount Paid: l Q, 0 v _
Receipt #: � 3 �} 6 l _
�-�yas.23
0 Improvement Permit (Site �valuation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
�150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
�..��� ) f �1l.e���l V Tax Map: /4 � g
..._.. ."�,r- ������ Parcel#i 21 �--
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ication for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of system�ermitted)
❑ Permit Revision
$75.00
0 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: M� 17, s�t @ Y' � �N'f'
Address: [ �.
•�� /�Lr.
2) Name and address of current owner (if ifferent than applicant):
Name: �,tLL CLi4
Address: ,3
vu o. , C'. � 7s 7
3) Property Description: Lot Size: ��_
Address and/or c�irections to Property: _
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Phone (home): 3 3�•$�6 3- q? S�
(work1ce11): ('�CL 3 3 4 S6�F — 1%'!a �'j
Phone: 3 3l0 515 3 3 7 a�'
Lot #: ��.r_�� C
❑ yJs [4�. no boes the site contain any jurisdictional wetlands?
l9 yes ❑ no Does the site contain any existing wastewater systems?
❑ yes [B� Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �Lr►o Is the site subject to approval by any other public agency?
❑ yes �o Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
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4) Pr osed Use and Type of Structure:
esidential �
❑ New Single Family Residence hlaximum number of bedrooms:
❑ 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: �(� �' lo lp
Maximum number of seats:
5) Water Supply: ❑ New well xisting Well � Community Weil ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted � Innovative O Alternative ❑ Other ❑ Any
I certify th 'nformation provided above is complete and cor-rect. I also rtnderstand thnt if the inf'ormation provided is
inacc te, or if e site is subsequently altered, or the. intended use changes, ull permits and approvals shall be im�alid.
re (Owner/ Le al g�*)
ting documentation required.
� //-13
Date
• Permits are vatid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/1 l) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Suilding Additions/ Mobile Home Replacements
Tax Map #: A a u Parcel#:_ � 15 Address: 't a Ra�nas Ron�
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Approval Requested for: X Mobile Home Replacement
Building Addition .
Applicant Name: �A+�s tJ 5�►E wR. l,A6t�.rkt� C�, Mats�ro.� �+�
Address: l� q c�r �� �.r+v.�, oc,��E
'r� r+4��. �.,awf a �
Phone #'s: 331.� Sa3- g151, 33V- saa - t�tb5
Permit Located: Yes x No
Installation Date: Design flow: � 4a ?? (gpd)
Current Contract with Certified Operator on file (if required): � A
Water Supply: X Well Public or Community
Wastewater system shows no visual evidence of failure on: 3 J�s j�3 (date)
(Applicant's signature if site visit is not required)
Comments: p�rc��� �o�. It, x l,� Moe►� �lar� ' Ma,�+a�..\ s�rtAc.t�s :
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Addition/Replacement Approved
0�.4.1- Q ..Z► �
Environmental Health Specialist
3 �3 ►3
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www_personcounty.net
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SITE PLAN
Name MAd��� W�Vtori Tax Map #/� Parcel # Z �-� �
Subdivis'on Section/L t#
3 13 �3
Authorized State Agent ate
System campanents represent appmximate contouts only. The contracrormust tlag the system priat to begtnning the installstion to
Insure thatpropergrade is maintained.
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