A29 105Application Date: � 2� 7
Amount Paid: 0 , 0
Receipt #: j $ 336
----�
�� �f �07
Aa
Improvement Permit (Site E
$200.00/$300.00 (if> 6(
Mobile Home Replacement�i
$150.00 (if site visit requ
Well Permit (New/Replacem
$300.00/$200.00/$75.00
�1��,�r ������ Tax Map: _�29
,r,.,���. � � ��,�� Parcel#: !b �
1-G'y.�n�aa-�sn—�•TMaaes.n¢mIl. IHI�.s.IL¢.)Ln.
for Services
Services Re uested
�luation) Construction Authorization
(Fee is de endent on the e of
Building Additio Permit Revision
. $75.00
pair of E�isting Septic System
Application: No Charge/ CA $150.00 or $300.00
x 1) Applicant Information:
Name: o �cU 1� � v i 5 .
Address: �-� r� I��Ssi c- I�c.�r� 1�
Qv x ho,ro /t .0 - 7'1 �-✓ 7� -
� 2) Name and address of current owner 'f different than applicant):
Nari1e: ; r t
Address: J(„( � f-�rs�� %5 5�� t �4 _
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: i�
Phone (home):
(work/cell): _
Phone:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands? �
❑ yes ❑ no Does the site contain any existing wastewater systems7
0 yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency7
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: .
❑Residential '
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes 0 no With plumbing fixtures? � yes � no
�Non-Resideatial
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats: _
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water 0 Spring
. Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes O no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ �Y
1 cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature ( er/ Legal Representative*)
* Supporting documentation required.
Z-�
Date
Permits are valid for either 60 months or are non-expiring when accompanied by aa approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site e.valuation.
(10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
1
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�II;71.�V]]�.•��Il�..._.]C�h�,;i:]CIl.'��.�!- ���k11��5u.
Building Additions/ Mobile Home Replacements
Tax Map #:�_ Pazcel#: 1�� Address: %�� � 5��2 Y�,
o ��w
Approval Requested for: Mobile Home Replacement
. �_ Building Addition
Applicant Name: �-� i� 8 � o � v;
Address:
Phon� #'s:
�
Pemut Located: Yes � No
Installation Date: �c. �c�✓� Design flow: {��'�c�'1(gpd)
Current Contract with Certified Operator on file (if required): ��
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: 5�-t� t (date)
(Applicant's signature if site visit is not required)
Comments: �-�+'n�i s5r w► ��Ou% �� � �s r� �S r Cv
Addition/Replacemea�t Appr6ved
✓+� � w2�
Enviranmental Health Specialist
S-(-1
Date
�0•
Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 v✓ww.nersoncountv.net �
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SITE ��62
Ro�.,,w.
VICINITY MAP
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PROPERTY OF
R l iA A L L,EN ADCOCK
911vs HIII Twp.. Peraon Co.. N. Caro!!na
SspfemDer /986. Hall - Homfelf 8 Asaoc.
$C0�0 ��� a �QQ'
!O o' 0 !00' 200'
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Neal C, Hamfsfi RLS 2466
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un��.� �� .. �`�/A NORTtI CAft�LI�A, P�RS�M COUNfY �
;�: ,�? . q celolv:.e 4 �e•o5 Ar� ��.xea� c�►wMt,Err __., certi(y
�� - •• • that under rny superois(on and
�. ,�r,(S4t[d�tiY:.
l dllCC�100 thi5 tt1�j7 W85 df�Wfl i(ORl
— �"'�� '�'� • an actual tieiJ surv� pnd that tlr.!
. 80' RIW
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��— lo NC. 49 —s-
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LEOEND
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o ��o� ..�
�t � nall laund
nf pnaU od
pmal��maltaal potnl
' error oi closure is �.t�,.oc� r_._�
Nlitness rny hand and seal this
,,NN�uuu�ry�� za �IBy Of� JEPiEMBER � 1! e�
,� �oQ��1 Cf,�����•�� � a �� ��. � 1�.
' � � �� f • lfrr
;� r'';��." .''Y,�� 12egisterQra Land Surveyor
f SkAL •�'�
� y.,� �•Z,,65 �,� F NUi2fH CIIRULIMA, PEI2SON CUUMfI
WENDY LYNN CONa
�� ��o�'�.;,�,�::..''��� 4�, � __.__ _�
Ptutary Public du hereb/ certit/
,,/�������������,`�`��,, �h�� NfAL C_NAMLEtf _i_
S:irvryor, p^rsonaliy appeared �
. ��,,,,,�,,,,,, ; t� torr. mu tliis day and ac�snowiedged
,,,,,�`�pV �Yf�rl���.,,, tlu: Jue execution of the foregoing
�� r " ,, L„ ;' instrumer�t. '�'litness my hand �nd
� tf����f�ft� , nolarial sr:al tlii,.26 day af
} . .. �EPfEMBEA 19 B8
;„ �'�� U1.�G °j . M'y, k1omrnission eKpires_ e-ia_eo
. %p'�'p �''� ... ....� � ;••'`• �'�J.IddP�.t�.S�� �.wt�_C��
�'%'y COUtI�y•.•'' 1��tary Pubi4c � o
•�-,...., ,... ..
fMIS PLAT WAS iRFPAREO IN ACCORDANCE
WITH 6. 8. 47 - 30 AS AMENOEO.