A31 4Application Date: �' �'D `1 Tax Map: 1� 3 �
Amount Paid: 1'�' p, OD Parcel #: �_ `
Receipt#: S 702 5�00
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Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) Fee is de endent on the ty 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/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charge
1) Services ueste� y: °
Name:
Address: /
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Phone # (home): �— (9 �
(worWcell): �CJ(.�—U(.�C�
2)Name and address of c rent owne i'fferent than applicant):
Name: !`
Address: �'
3) Property Description: Lot Size: ��USubdivision:
Address and/or directions to Property:
Lot #:
4) Proposed Use and Type of Structure:
Residential � Business/Type: Other � �l JJ rCb IU� �� X 3�
Number of bedrooms _�_ / 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
(please show location on site plan)
Note: A completed application must also i�tclude:
➢ A platlsite plan of the property that shows property dimefzsions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifyi�ig tl:at tl:e property is ready to be eva[uatec�
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 si is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): w ��`-�� Date : �( `��
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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W�LL P�RIVII� (New_Repair�
Tag Map: � � Parcel• �
Subdivision: Lot:
Applicant's Name: Q G(✓��" "�'""�� o �Q`���
Mailing Address:
Phone Numbers:
Location of Prop
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Permit Conddtions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.�
3) Permits expire � years,f-om the date of issue.
Other �onditions/Comments:
Permit issued by:
1..�
Date• ( ( j�% !
C�RT�'ICA�'E OF COMPLETION
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Weil Albandonment:
E S/Date
Completed: 9j310
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Method/Material(s): C� • � 1� � ��� �
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Well Driller• �Q ✓✓h2-�" � License #: ,
Pump Installer: License#:
�Vell Approved by:
Date Sample Collected:
Person County Environmental Health
32� S. Morgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed:
Phone: 3�b-�9Z-1790 Fax: 336-597-7808
8/1/08
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�ui�di�a� Ad�ation�/ I�o�i�e �offie �e�lac��ae�ts
Tax Ntap #: 3 �
Approval Requested for:
Pazcel#:
Mobile Home Replacement
� Building Addition
Applicant Name: �. � �-C+� � o � �Q � ���
Address: � � � ' �� S J��
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Phone #'s:
Pezmit Located: !` Yes No
Installation Date: —7 Design flow: � (gpd)
Current Contract with Certified Operator on file (if required): k%__ Q_
Water Supply: �_ Well Public or Community
Wastewater system .shows no visual evidence of failure on: �1 � (date)
' (Appl'icant's signature if site visit is not required)
Comments: �'M, S$ i 0
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� ���itio�ep�ac��ent App��vesd
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' onmental Heaith Specialist
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SITE PLAN
Name VIYC �/tQ-�- �' I!K� Taa Map #� Parcel #�
Sub ' ' n Section/Lot#
Authorized State geat Da e
Syatem companeats rrp�es�r apprvximatr avnmurs cmly. 78e coanacmrmust9ag tbe sysum pnor m begiaaiag the iasr111ation to
insrue diatpmpetgnde Is mamtained
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