A30 104Application Date: /� v ��� �� ���% � ��T
Amount Paid: —��d , 0 �O �„ ,• � � �
Receipt #: `� � I I 5-S C�d, d' � �r � � ����
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❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> b00 gpd)
Iobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
ication for Services
Services Re uested
❑ Construction Authorization
(Fee is de endent on the tv e of
0 Permit Revision
$75.00
Tax Map: / � 3�
Parcel#: 0 �
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l O e0.te �� rM i�
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❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
� 1) Applicant Information:
Name: ro•►..t w�:��ie��1
Address: 1�11 SK,'.� ���e.�S �Z�
i�i..�s�� tr.,•�� S
2) Name and address of current owner (if different than .applicant):
Name:
Address: .
Phone (home): �3 G S�"r S- 4 y 20
(work/ceil): ___���t• 36i- I(� z'Z
Phone:
._
3) Property Description: Lot Size: 1,3� � Subdivision: � Lot #:
Address and/or directions to Property: _ 6�� � \3.,,�1••,rc�,,� ��
❑ yes C�'no Does the site contain any jurisdictional wetlands?
C�es [7-r� Does the site contain any existing wastewater systems?
❑ yes C�"no Is any rvastewater 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:
C�esidential
❑ New Single Family Residence Niaximum number of bedrooms: 3
❑ Expansion of Existing System If expansion: Cunent niunber of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? 0 yes . G#-rro With plwnbing fixtures? ❑ yes ❑ no
❑Non-Resideotiat � 8 �, 5/ �
Type of business: Total Squaze footage of Building: _ _
Maximum number of employees: .- Maximum number of seats:
5) Water Supply: ❑ New well C'1 Existing Well ❑ Community. Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no.
�G) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 certi, fy that the information pravided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is szrbseqtrently altered or the intended use changes, all permits and approvals shall be invalid.
Representative*)
* Supporting documentation required.
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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.
(10/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:� Parcel#: j 6� Address: Q� � t r � ��,� a R �-
A roval Re uested for: v Mobile Home Replacement
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Building Addition
Applicant Name: � LJ
Address:
Phone #'s:�-}� SR�1��Zd �R - �9 =f�� 22
Permit Located: Yes ✓ No
Installation Date: ? Design flow: �Q (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: /-3 I— l3 (date)
�Applicant's signature if site visit is not required)
Addition/Replacement Approved
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Enviro ental Health Specialist
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Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net
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Section/Lot#
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Sys�errz cumponen�s represent i�p_praxirraate�contours c,nly. The contractor must,�xg the syste��arior t�
begin�ing the insta�Qra tQ srasPs�-e that prnpergnxa% a:r r.�uirtaarled �
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