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.
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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.
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�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
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Subdivis' �
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� urhorized Sta.te Agent
Ta.g Map #� Parcel #�_
Section/Lot# �� _ _
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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
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