A29 261Application Date: 8 �
Amount Paid: ,�n0 ,Ov
Receipt #: 176 � �
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Anolication for Services
Services Re uested
(Site Evaluation) Construction Authorization
(if> 600 end) (Fee is dependent on the type of
Tax Map: 02 �
Parcel#:
, z Replaczment or Building Addition � Permit Revision
$150.00 (if site visit re uired) $75.00
Well Permit (New/Repfacemzn✓Itepair) Rzpair of Existing Septic System
$300.00/$200.00/$75.00 i Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: � � �_ � � 6 �
Name: �01J � C.6LM� Phone (home):
Address: � _ _ _ (work/cell): � R —
2) Name and ac�dress of current owner (if different than applicant):
N�ne: Phone:
Address:
3) P�°operty Description: Lot Size: 1�� Subdivision:
Adciress and/or directions io Property: � �)
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
0 yes ❑ no Does the site contain any existing wastewater systems?
C7 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 agency?
❑ 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 �
O New Single Family Residence Maximum number of bedrooms �/ Occupants:
❑ Expansion of Existing System If expar:sion: Current number e ec�rooms:
� Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Build•.ng:
Maximum number of employees: _ Maximum number of seats:
5) Water Supply: � New well ❑ Existing Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Consiruct', p[ease indicate �referi-ed system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any
I cert� that the injormation 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, ull permits and approvals shall be invulid.
* Supporting documentation required.
� �
ate
• Permits are valid 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.
ri nii sl PPrc�n r`�,�nt� Fnvirnnmental Health_ 325 S. Morean �t.. Suite C. Roxhor�. NC 27�7.� (336-597-179(11