A30 139�r��iic�tin� �a.e: � �� � � � 3 � I�' :Cc��t'�� Y �
Amount Paid: 3Cb . D �; •. l � ����' �b �
Receipt #: 1 q 3a�-2 �' � ����
lE��s�� �* ����.Il ]E���,.11�
0 Improvement Permit (5
$200.00/$300.00 (i;
❑ Mobile Home Replacem
i $150.00 (ifsite visit
Evaluation)
600 gpd)
t or Building Addition
.00
�lication for Services
Services Re uested
❑ Construction Authorization
Fee is de endent on the ty e
❑ Permit Revision
iaa hi42< � 3� _
Parcel#: �3� _
EMa� ( =t-o �
❑ Repair of Existing Septic System
Application: No Chazge/ CA $150.00 or $300.00
1) Applicant Infor ation: �
Name:
Address: 2 rfiv� �
7 .
2) Name and address of current owu r(if different than applicant):
Name:
Address:
Phone (home): 3� 5 1- 3� �%
(work/cell): $ � O o �S
Phone:
� 3D-
3) Property Description: Lot Size: 33 ��l Subdivision: Lot :�_
Address and/or directions to Property: b
r��e � l s L�¢
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes no Does the site contain any existing wastewater systems?
❑ 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 t�,i no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
i3�
4) Proposed Use and Type of Structure: :
�Residential �
� New Single Family Residence Maxim�im number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential � t� S
Type of business: G �
Maximum number of employ es:
Total Square footage of Building: `% Z �
Maximum number of seats: _�
5) Water Supply: New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any e'sting 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 Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative � Alternative O Other ❑ Any
�
I certify that the information provide bove is complete and correct. I also understand that if the information provided is
inaccurat h site is subse ue red, or the�intended use changes, all permits and approvals shal be i v id.
� ��t1
0 1
Si�nature (Owne L al Representative*) Date
'� Supporting documentation required.
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site e�aluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�597-1790)