A31 189Application Date: 10 O� ��
, Amou�t Paid: a-vo, o p.�„- Z P
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Receipt#: ^�?� 7 � 9
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Application for Services
(Sentic Svstems and Wells)
Services
�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Aome Replacement or Building Addition
$I50.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: A 3 !
Parcel #: ��
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Existing Septic System
No CharQe
Important: If the information in the application jar an Improvement Permit is incorrect, facs j',ed, or the sile is a/lered, then the
ImnrovementPermit and theAuthorization to Consiruct shall become invalid
1) Services Re uested by:
Name: � 1 �
Address:
� 7
Phone # (home): � � � - � - 8� � 8
(work/cell): - -
2)Name and address of current owner (if different than applicant):
Name: �SLI 1'Yl �
Address:
3) Property Description: Lot Size: o�
Address and/or directions,to Property: ��
4) Proposed Use and Type of Structure:
Residential ✓ Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):�-
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No �
� Water Supply:
Private Well ✓ (Proposed Existing _�
Community Well: -=''�Public Water System:
Are there on the adjoining properties? No ✓ Yes
#:
(please show location on site plan)
Note: A comnleted 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. The
information provided is accurate. I understand that if any site is altered or the intended use changes, all
permits shall become invalid.
Signature (Owner/Legal Representative): O`�• Date : Iv "�' v�
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Must install septic system on contour.
Must not install septic system during wet conditions.
Septic system must maintain all proper setbacks.
Any questions call Environmental Health Dept.
336-597-1790
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SIT� S�TCYI'
Name �-�i.�•� p S ii'i �� Tax 11�lap #{t 3 � Pascel # � g 1
Subdivisi Section/Lo��-} �
�'`�'� ��� ��.�b �
Authorized State �ge�t/�� " � Date
sy�, �n,�oo� �p�s�r app�����u� onty. The rnntnscYor mutt. fZaS ihe'�"7e»sprior io
hegimm�g tlte instisllation to ansure that j�ropergnade is maintained,
, ���, i � �./ � 1LLJ 1S. �1. Ll.�' � �
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���� �'�E�I��' (1'aTevv�Re�air�
'Tas iblap: .� 6�� Parcel. �� 9
suba����on: �ot: L o�
Applicant's Name: �c? M P� �} 1�'
NYailing Address: p o 6o x. � 5/
/.Zov�P�-, a-� �" � N G 3- 7 S��
Phone Numbers: �f 19 - 4 7> - S c� �o� g�� -6l `f --SS' � I
Location of Proper#y:
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Permit �onditions:
1) See attached site plan for proposed well location.
2) All a�plicable State and County Negulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/C'omments: -' �Sp p � i� ��"C�' � -
P��ni# issued by: � ' l�ate: 1/ O�
C���'�+'���T� ��+ ��lYIPI�E'�'IOl�
Neev �e�l ��spection:
EHS/Date
Location: '
Grouting:
Well Log:
WeII Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Weil �riller:
Ptunp Installer:
�ell Approver� by:
Date Sample Collected:
Person County Environmental Health
�25 S. Morgan St., Suite C
Roxboro, NC 27573
�iner inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abancioament:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
i)ate:
Date Results Mailed: `"
Phone: 336-�97-1790 Fax: 336-597-7308
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