A28 87A �lication Date: �fZ�f"�
Amount Paid: �2D-0• Ca�D
RPCE1� �7 ) �-
Tax Man #:
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APPLICATlON FOR SERVICSS
Parcal #•
--. __ . . _.... . ... .�__ .-_ - - - - ----- �-e�� C�
1) Permit requested by: gentJprospective owner): Po.,-.. � �
Home Phone: �(� � -8'ySC� Address: 5 6 e
Business Phone: � � !� � S��- � �11 � r ?�Z��
2) iVame and address of current owner �c,, � �. `� �
. `
�� ��h��� Nc �757�-(
3) Properly Description: Lot size: cs� � Township: C� '� ��\
Directions to the prooertv (Includinq road names and numher5):
Lot #
4) P'roposed Use and Structure Description: answer each of the foilowi�9`questions:
a) Proposed i�, F�cisting � Type of Structure: Mo � �� a f` i�� �� � Width: ��� Depth: �. Q('
b) Number of Bedrooms: � Number of occupants or people to be served �
c) Basement Yes,}�, No _ Will there be plumbing in the basement?�' ,�s
d) �arbage Disposal: Yes _, No�„
5) Water Supply Type: Private X(new � or existing�, Public_, Community� , Spring _
Are any wells on adjoining property? Yes_, No ?� If yes, please indicate approximate location a� the
�site pian.
6) Does your property contain previousiy identifled jurisdictional wetlar�ds? Yes_ Nq%�,
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKEDa �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAfCED OR FLAGGED.
9 THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION 6Y THE HEALTH DEPARTMENT
STAFF. �
I hereby make application to the Person County Health Department fo� a siie evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represenf the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permii shail
become ' v id.
� ' � Q��J�1� 2�-D�
�
Owner or Legal
Date
PCHD, rev. 06127/02
� g-16 0 7 -
A iication Date�_° `�f'�' . a Tax Mao #:
Amount Paid: 2G'G. ���
Rec�iat #: 'r� ��,=;— ` Parca! #:
3100 ��
� ���� ��
�� ���,� � � � � �Jl�''I��Y' �,' �2.�
' O 1 �i°, �aae-a.a-amaa.�.�,. �a�m.�.m.� ���.�.'�a C � 1 �o,�"
� � �
APPlICA7'10N FOR SERVIC85 �
IF THE IMFORMATIO(d 1N THE APPLICATION FOR AN IIIAPROVEMENT P�RMIT IS INCORRECT FALSIFiED
CHANGED OR THE S1TE IS ALTERED THEiV THE IMPROVEMENT PERMIT AND AUTHORIZ�4T10N TO
CONSTRUCT SHALL BECOME INVALID. -
C�
1) Pennit requested by: ec gentlprospective owner):_�o, '! �-� :�����
Home Phone: ��(� �- �y- �ys � Address: 5 G�
Business Phane:'�� i� — S��- 3��11 ' � r �.�
2) Nlame and address of carrerrt owner. �c. ��. � ��-�
. �1
� . c` c� �1.� C y
3) Properiy Desc�iption: Lot size: cc - Township: C3�'.;eH�\
Directions to the prooefir (Includinca road names and numbersl:
Lot #
4) propvsed Use and Structure Description: answer each of the followi questions:
a) Proposed '�, Existing � Type of Structure: M� �;� � n_ r- �n �� r� Width: l�%� Depth: �f�
b) Number of Bedrooms: _�� t� Number of occupants or people to be served: �
c) Basement Yes�, No _ Will there be plumbing in the basement?��5
d) 6arbage Disposai: Yes ,� No,,�,
5) lAlater Supply Type: Private X(new � or existing,�, Public� Community , Spring _
Are any wells on adjoining property? Yes No � If yes, please indicate approximate locatiori on the
'site plan.
6� Does your property contain previousiy identfied jurisdictional wetlands? Yes_ Nq�
PLEASE NOTE THE FOLLOV111NG:
➢ A PLAT OF THE PROPERTY OR SIT'� PLAN MUST BE SUBMITTE� WITH THIS APPLICATION.
9 PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARl�Da •,
➢ THE PROPOSED LOCATiON OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
9 THE SITE MUST BE READILY ACCESSiBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEIVT
STAFF. �
I hereby make appiication to the Person County Health Department for a site evaluatio� for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represenf the maximum
facilities to be placed on the property. i understand if the site is aitered or the intended use changes, the permii shali
become 'pi'va, id.
\ C��w � .� '�.- -,;; _ r`�
-- � ��.�-;�\ '�- � „�-1'
Owner or Legal Repre�ntaltive
�I/`^ � ` ~ v M � �L.7 �V7
.J`� �
Date
PCNo, ��. as�z7ioz