A31 79Application Date: -l2.'� ��� S( ������T Tax Map: �_
Amount Paid: f 50, 00 ' Zce! -••�,�- ��� Parcel#: ��_
Receipt #: 1 g 3 33 �_ � - � �' � ����
�.aava�•cDassa�caa4:sa1 �f'S�r.ral��n
tion for Services
Services Reauested
❑ Improvement Permit (Site Evaluation)
i$200.00/$300.00 (if> 600 eodl
E( Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (NewBeplacement/Repair)
$300.00/$200.00/$75.00
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Char�e/ CA $150.00 or
1) Applicant In rm tion: �_`,/
Name: a,� �1(JX.�
Address: ; O ,
2) Name and address of curren owner (if different than applicant):
Name: �- � '
Address:
3) Property Description: Lot Size: �, Sub i isi
Address and/or directions to Property: �
Phone (hom ):
(work/cell):� � -
Phone:
Lot #:
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❑�Y es LCYno Does the site contain any jurisdictional wetlands?
0 yes ❑ np- Does the site contain any existing wastewater systems?
❑ yes L9� Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �� Is the site subject to approval by any other public agency? _ ,
❑ yes 0'no Are there any easements or right of ways on this property? (�� ,�l�..h �/j
(if `yes' is checked, please provide supporting documentation) ` � „,",�Zj
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4) oposed Use and Type of Structure: ,� <� "�'"' .
esidenhal
e19�1 w Single Family Residence Maximum number of bedrooms: �/ Occupants:
❑ Expansion of Existing System If expansion: Current number of bedr oms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well L7 Existing Well ❑ Community Well ❑ Pu�bl�' Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? �0 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 ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccur te, the s�te is subs quently altered, or the intended use changes, all permits and approvals shall be invalid.
� ��
Signature (Owner egal Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A compteted `LotPreparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #: A�_ Parcel#: 1�'- Address: 89L.B I-iu���e. Ni�((s �,
_��u�d�
Approval Requested for: � Mobile Home Replacement
Building Addition
Applicant Name: � 0 '�
Address: �5�..(a5�' Ri1P �' < Q�I.
���i /�l �I� �/G 275� 1 _
Phone #'s: s9� - Ks3g �c��{,�, 1�.►,�s� 541-��2t GFa�I
Permit Located: Yes ✓ No
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: y��-! 7 (date)
(Applicant's signature if site visit is not required)
� v � . • � -' --
Addition/Replacement Approved
/
Envir ental Health Specialist
�{ - 2 7-17
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net
Site Plan
Tax Map: �31
Parcel: �
�--�—
� Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. I
2) Contact Person County Environmental Health with any questions (336) 597-i i90.
Additional Comments: