A30 21�rad����oa ��te: 3 �
Amount Paid: �
Rec�ipt #:
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d
Mo i! Replacement or Building
$150.�site visit re uired�
0 W t INew/Replacement/Repair�
$300.00/$200.00/$�75.00
�� , � �'QP 1Flapc /`�
�r� � � �������� 3
�,► ���% Parcel#: �_
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Services
for Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revisioa
❑ Repair of ExisHng Septic System
Application. No Charge/ CA $ I50.00 or $300.00
1) Applicant Information: �
Name:l.v' '
Address: G�i o�t n'�� o s m:<< '6� �
�.� c z�n �
2) Name and address o current owner (if different than applicant):
Name: �
Address: 7 O �
�� l�}�c, (�1 � 27 S'7 `-�
3) Properly Description: Lot Siz�: ,� a C(eSubdivision:
Address and/or directions to Property: 7 O�
(� h kh- ��.� � 1 � � � �f
Phone (home):
(work/ce11): q (� �13c� 7 0 26
Phone:_ �/�
#:
❑ yes C3�no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
O yes Ca ao Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C�t'no Is the site subject to approval by any other public agency?
❑ yes L'1—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: ;�,I -ew p�� ��
esidential �
❑ New Single Family Residence Maximum number of bedrooms: I Oc�pants:
❑ 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
CINon-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: � New well Existing Well ❑ Community Well ❑ Public Water 0 Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any knovm ground water restrictions or sources of contamination:
�,6) If ap�lying for `Authorization to Construct', please indicate preferred system type(s):
�2onventional O Accepted � Innovative ❑ Alternative 0 Other ❑ Any
I certify that the information 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, all permits and approvals shal! be invalid.
��
S;i�gnafu(re (Owner/ Legal Representative*)
'� Supporting documentation required.
3-11-� �
Date
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 applicatiou requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N� 27573 (336�597-1790)
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Buildiag Additions/ Mobile Honne Renlacements
Tax Map #: A 3� Pazcel#: �' Address: � 780 ��r1► N�(�'� ��ci
.�-ox��-� nl c_ a 7.� � y
Approval Requested for: Mobile Home Replacement
�Suilding Addition
Applicant Name: W� i 1� o.� 'R� c��
Address: G�{ 0 4 M ao re ' �,t ; t l �
(Zv .,,. ��e� �- . � ) C. � � S 7 Z-
Phone #'s: `� l �[ - 7 30 - �o � �
�
Permit Located: Yes `�o
Installation Date: Design flow: (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: �'IZ /� (date)
(Applicant's signature if site visit is not required) .�
Comments: `'� x � � c��c.
Addition/Iteplacement Approved
Environmental Healt Sp alist
3 /� �4�
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www�ersoncounty net