A30 8Application Date: � 2-'g'� � Tax Map: �j(�
Amount Paid: �,� 7j�' Parcel #: -- g�'
Receipt#: �
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Application for Services (Septic Systems and Wells)
Services Re uested �
❑ Improvement Permit (Site Evaluation) ❑ Copstruction Authorization
$200.00/$300.00 if> 600 d (Fee is de endent on the' e of s stem ermitted)
Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
� Well Permit (New/Replacement/Itepair) � ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Services R quested b: �
Name: Phone #(home): '�`�- SS�i - S'7 7 Z
Address:.3c,�5� e,c� � (work/cell): �3Cc-58�-gC��.�'7
SeH►w� t�l-C� �73K3 .
2)Name and address of current owner (if different than applicant): �aY��` GYaY
Name: � `�
Address:
3) Property Description: Lot Size: l, vU Subdivision:
Address and/or directions to Property: /[�Sci �� SSe�� f�o��
4) Proposed Use and Type of Structure:
Residential ✓ Business/Type: Other
Number of bedrooms Z / Number of people served (seats/employees):
Basement: Yes No ✓ (with plumbing: Yes No �
Garbage disposal: Yes No ✓
5) Water Supply:
Private Well ✓ (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No �_ Yes
Lot #:
(please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all
permits and approvals shall become invalid. .
Signature (Owner/Legal Representative):
Date • ���
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map #: ,3 �
Approval Requested for:
Parcel#: �
t/ Nlobile Home Replacement
Building Adciition
Applicant Name:
lY
Address:
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Phone #'s:� - .S�1Z �/�vl,) Sg3 - ��(0 7
Pernut Located: Yes V �o
Installation Date: � Design flow: ��D (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: l 2-' Z( —I Q (date)
(Applicant's signature if site visit is not required)
l���n�o���p�������� ����°o���
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Envir nmental Health Specialist
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Date
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Name �l i����l �a P, � �� � Tag Map # �D � Pa:�cel #�_
Subdivisi� - _ Section/Lot#
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utho�ized State .Agent Date .
System cnmponen�ts r+e�resent apprmximate�contours only. The cnntrrrctor »aust, flag the systenalbsior to
beginning the installation to ansure that pm�bergsr�de as maintained
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