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A29 46Application Date: �'`30 '�'Z Amount Paid: I 0.0 Receipt #: , � � S �/ � C�-°�� 2 !1 Ao 0 Improvement Permit (Site Evaluation) �200.00/$300.00 (if> 600 �ad) \Mobile H�me Replacement or Buitding Addition $ I50.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 `-.�,?,5,� ������ Tax MaP: � z►9 . ^ � � ��,� �y Parcel#: 4 co IC:.�rnwaa-uDanicxaap=nd.s.1� ���ao�s..11dl�a. tion for Services Services ❑ Construction Authorization (Fee is dependent on the type of system permitted) 0 '�ermit 1'.evisicn $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: � o Q o P� s r�-NN,r t�! � o�� Address: q � � ��c-r-c,� �-rn�r ��_ �n �t � n �2 n � � 7 -'Z 5 �] '�' 2) Name and address of current owner �if different than applicant): Name: Address: _ _ Phone (home): (work/cell): � � ,�� �, c�oo� e.�— � Phone: C-e-�� � �O�- 02 g�� C�j ( -f-o u�( 3) Property riescrip�ion: Lot Size: 4•00 �,�,-�Subdivision: ta ,a.. Loi #: w i� �� Address and/or directions to Property: 3/•i- -r� f„r..'� ...� 6� ���� t� c¢9 TJ WA�4.� I�STF.2�S �Tu U N ( Trc�`S STLR� �DI�� �21�t�s Ow.f /��cT ❑ yes �no Does the site contain any jurisdictional wetlands? ar 5 rC,�1 G�fes ❑ no Does the site contain any existing wastewater systems? O yes [�no Is any wastewater going to be generated on the site other than domestic sewage7 ❑ yes C7'no Is the site subject to approval by any other public agency? ❑ yes C�o 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 Singie Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Cunent number of bedrooms: ❑ Repair to Malfi:ncticr.ing System `A'il] there be a bas�ment7 ❑ yes ❑ no P.'ith �lu:nbing fixrsres? ❑ yes ❑ r,o ❑Non-Residential Type ofbusiness: t''R�vh'r� c�.. u('� Maximum number of employees: c�S Total Square footage of Building: �('� a Maximum number of seats: 3 S r-o +� 5) Water Supply: ❑ New well �xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional 0 Accepted ❑ Innovative 0 Alternative ❑ Other O Any I cert� that the infoYmatinn prnvided above is complete and correct. I also understand that if the information provided is inaccurate, or i, j the site ts subsequentiy aitered, or the intenaed use cnanges, aii permits and anprovais sr'taii ne invaiia. �—� W � �.RJJ 6-�„ T�3 . G] c�z� ZZ j� Signature (O�er/ Legal Representative*) * Supporting ocumentation required. 5- a 9— � z-- Date 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. i�ni> >� n,.....,..., n.-.....+.. �....:.-..«.....�.,*.,1 LSo.,i�1, 27G Q A/(nrnan Qt C„ita (' Rnvhnrn 1�T("7757Z (Z��_SA7_17QI11 � � � � i � ` V.. � 4 . . .. ll : � �L.J � � � . tt./ �arn�n.���n�n,c�mi.��.� �c��.���n. Building Additions/ Mobile Home Replacements Tax Map #:��, Parcel#:�_ Address: Z i Z7 7 A�proval Req�:ested for: Applicant Name: A�dress: Phone #'s: 5 qq - ob�le Hom� Replacement Building Addition C Z Permit Located: ' Yes � No Installation Date: —� Design flow: ? (gpd) Current Contract with Certified Operator on file (if required): Water Su 1: v Well Public or Community PP Y ��Vast�water system sho�vs no ��isual evidence of failure on_ �y - �{ -( 2 (date) (Applicant's signature if site visit is not required) Comme�ts: Addition/Replacement Approved Envi nmental Health Specialist c d -s-� Z Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 wwwpersoncounty.net `���,� / - .�f..1��� V � �_ T t _~ � � ��� 1� „a� �• � ,m ,,,�,, ,� ,m��.11 ]E-3I �.�.11 �]l� SI'I'E ��'I'C�I � , I .. Name T X k�:YD `� �1 {' �1� l.i ��7 Subdivis' � _ -' . � urhorized Sta.te Agent Ta.g Map #� Parcel #�_ Section/Lot# �� _ _ �,; - `� � 1 Date System cdmponents represent iapprmxistaat`e �contours only. The confractor s�aust flug tlae syst,e9ra�iraor to beginning the instadlation to ansure that prflpergs�ad� i.r nraintained ��� a � � �. a� ' � � � � �+,�}"`� 5F �:i ��-�`� � i .�.�^�n,'�a�W rt��� .. � ��' y. � r� e �� .� � .. � < � +.rsa„�"""�'�'�,. ; �iT} ��'..a; � *sk"' ���' ' '� .�i ,�, %.. } y i {d . ��g�t ��, �* �� � , � � � � # � �A�� � �� � >� � ���' � . �� K t� . � , °�, � � . "� �. � � .. . � ! � � t . ._ ����* �� i � � :� � ���� � � � �.. ��� �°`�: �� �� � �. �, _� �; � �,= ��� ' `���: �' � ��' �r:�`�; �� � � � � ��'� �` �� � . � �� .. x.�..�..,��' . `lt� � �»�'�'«x. �:+ � ` ��x�i�l � � y� •. ' p � ! 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