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A32 108
�l�-I1 � JAN-04-2011 11:16AM FROM� '' T-747 P.001/001 F-199 � Amo��t Paid: I�(� � Q� Parcel #: 3a— �'O�j Receipt#: 3 � Z t'�-'�' 8�� ����� � ���� �� o \ u ������ �v '►r�asva�r�essa�•+r+�•�u�ad-io.0 ����.co.�l�� Q��f.l � � �au�,� Appli�atiop �ot' Servi�es (Sepric Systems and Wells) 1) Scrvices Requested by: �a �� Name: � (+4C/7D� (-ia�-S Phone # (home): 3�6-o��g" Address: '� � S C�-r,4H,q,�.�-/�� -/{_ '� (wark/cell): �� �n r►� a� Tds� �N t- ,,� 7�- ��.._ ��'1 �1Jo�� O WN� 2) Name and address o�f, �rrent owner (if different than applicant): Name: Y' � P�° ��l�� /IAolir 0. '�alr��-� Address: ��S v_.��/ S ��►r'r^ tZ t-�t�-���� �.; 1� S �1 c� 3) Properry Description: Lot Siie; ���'� Subdivision: Lot #: � ��►.�'�.�, �. �� Address and/or directions to Properry: � �^ �-L '�} �?' � � �. �� :� �- 4) Proposed Use and Type of Structure: Residential � BusinessrI'ype: Other Number of bedrooms � / Number ofpeople served (seats/employees):� Basement: Yes No �C_ (�vith plumbin�;: Yes No _� Garbage disposal: Yes No � Watcr Supply: Private Well� (Proposed �xisting _� Community ell: P.ublic Water System: Are there wells on ihe adjoining prope[ties? No Yes (please show location on site plan) Note: A completed avolication must also include: ➢ A pl�t/sile plan of the property that sliows properiy dimensions and the size and locatinn of all proposed structures. D A signed copy of t/ie `Lot Preparation' form verifying t/tat the,property is ready to be evaluated I am submitting this application to request services from the Person County �ealth Departmcnt. I understand that if the information provided is incor�ect or if the site is sabsequently altercd, or if thc intended use changes, all permits and approvals siaall become invalid. Signature (Owner/Legal Representative Date : — — � t0/08 Person Counry Eovironmental Health, 325 S. Morgan St_, Suite C, Roxboro, NC 27573 (336-597-1790) �� � �. ► � �►. v 1 1 �� � � �1.J � � � 1�711L4�1.7L"$D.TC�.7L3k.'71.�']C�L�.ac�A.11 ��'c�U.11.�.� �uildi�g Additions/ l0�iobile �ome Replacements TaY Map #:� Parcel#: l� � Approval Requested for: � Mobile Home Replacement _ _ Building Addition Applicant Address: Phone #'s: . �r<< �'Ta n Pernut Located: Yes � No ? Installation Date: G� �'ya�.� 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: $� t (date) (Applicant's signature if site visit is not required) r � SS� �� � s� � Ge � S�` S c.J � � � � �r oc� r- � %2 w v�Q.�,,P �',� D GF..r .. Addition/lteplacement Approved �1 � C.J�''"'�✓ � 8' L E ronmental Health Specialist Date � s�� �ATn: PIN �i 996�00370624 C lvl �� e� E a s t � Survey(ng Planning Sud�ivl�lon Design CHARUE N RE(�t: 16835 MONK RO 602 EAS? NASH STREET �u REfERENCES: gpR�� HOPE, N.C. 27882 (Z5Z) 478-5005 o a`SIIE' D.B. �63 PG. 2T!' � o D.B. 183 PG. 54 �\ �� a� �.9. 244 PG. 277 � � PLAT 9/S2/3 \ � c�., BREEZE RD ��` PLAT 9/52/4 \ 3 P.C. 2 PG. 85—A PIN � 998000278812 � MARTIN L TORAIN dc � CURRE7�IT OWNER: IRON PIPE MAR11N L. TORAIN �c p��j63 PGY 277 \� FOUND VICINITY MAP I�1'Y'S AUSHA F. l.1rWVS PLAT 9 52 3 CONiRO� 485 RUDYS FARM RD. �� �N� SYM80L LFGEN�: HURDLE MiLLS. NC 27541 PARCEL AOORESS: • IRON R£BAfi �"f (IRS) 485 RUDYS FI1RM RD. O IRON STAIC� FOUND (ISF) HURDL.E t�A1LLS. NC 27541 ��j� � PK NAIL F�OUND (PKF� ZONING = RC � py, A PK NAIL SET (PKS) SE'1'BAdCS: �L \ j f� COMpU7ED POlN7 (CP) .�_ % ' o �toNr a5' P �► �y \ c� SIDE 20' /� DO � wpoUED R�AR 25' / p , � a� E�+ \ �j 5.82' �0 �$� ��� �._____.�, \ �'� RI08�99$OOOTI1FaRD ENCROACHIAENT � �,� u � ti �O \ � 0.9. 249 PG. 633 J,•- -� � p� PIAT 13/663 IRON PIPE �- •j� � \ FOUND �_ PIN �! 998000370524 �. COR ERL r� ACC. ��� 43. 541 sq. j't. � �r'p� �RON ) J J� �.oG. ,���t 1.000 acres \ '��, ST�ucE � SIIELTER� , • -�� � / /� ,�G �`Z UTiLIlY ��� � s�,�i��l,Q�Q /�) �POLE � �i � r ��4,r, tit -�. F� � , �s�nc � �g��o �� ��° / c.� . � �� ; ��'b , TANK,� �,Q QQ-�GP � UGHT �... �6+, �_�.� �' . �j� / � �'j' ' ACC. � �' POLE /,:.:_'.:;:: :��:-.. "�-t�,.� ' �HU _ ,� ,� � .. ...�=F;;-;:,::c�i:. . BIAG' � � •� t.. ...;;.;:::- / "� ' '`z` 89.92 �. ,' � /_.::j' 7:::;'F:::�:;y;�::: � ��, �, -{ :T. 1 � i ,,;� : r;t•.::.5_.:.:,k;. � i �� ,,� ��t; �:7::i;?<��" / i ) :?::. . PRO. h , < � � . :: : �-: +;:i :j-�,�;�- � ti � ca � ,ri::2-=�_.,_; ... H41dE � � ,�) �, ,G , .:-��:;- �; z... � �• .'T:�]'�_F::}::_�:' � � i �, ,. -:}�:z:3:.F--�:.�- y EX. HOME , .. : •3::_s.;._f:�: :k:�� a6'� i IRON c�l �C � �`s� �-: s= -�.. ��.... TO BE , �1 � : ::y ;�=:�{:: ..t:.- ��: S7AKE a � :+_::;E:: -�� REA�IOVED / i . � c., ) �O �j {'�'� � / ' � .. i+� c FOUNO � �'. � �j e9 �� 's�. � e' w�o� � s' w�oe ,' ' �h� � ; GRAY0. ' p�'� O i •� a � � 21.89 \o, p �VE / SURf�CE � 5/ �' ; � � �'1 � � � � . � � ...: \ / �' , �/� '� �r ��ry,'1 VI�IL ,' � � 9� �, �; �, �4► ry,�'� I. TfD S. HaPK�NS CERTiFY ''y'� \, '.... . ,� Gj �}t�, v 1NAT 7HI5 MA4� IS 11 TRUE �� ��� ; �� Q� �'`� ��� PG ry�"� QG- REPRESENTAi10N Of ALL Of �D_ � .; •� � � � ' �' ��`� ,tieP` -r�E r�o��rr o�ieo� � � ,�' _ � ; ; Q ,� iN OEED BOdK 7S3 PAGE b�: \' ,��� � � Q0' 277, PERSON COUNIY � �.. . �...�, �� L� ` REGISIER OF DEEOS. AND ii� �, .� � 11iAT ENCROAC1i1rtENTS. IF iRON � '.��. ::�.-' ' '. ' �� ANY AT 1NE ?I�AE OF THE STNCE � . 25' ; PiN � 9984�4379356 SURVEY 11RE SHOWN. SET � �" ,; ", �; :. �' MARiHA GLORIA B. BURN�iiE 50' ACCESS i � D.B. 244 PG. 277 EASEtriENT � � PLAT 9/52/4 . S TO � � �.. . : . ' i � MS ��1s S.R. 1515 i /-,,. �... � � � ��Ih�;,r.: � � � � �,�a��`��N.CAn�i�='�.,,, � ,'G� / � sT� � SITE Pi.AN ' \�p �.�S:i '�rp � % `\ �1 Z�J� �/ w d1 � / ��i�d , : -�� : _ ,� � � � , FOR � � n' � � i � iV N / ��::.: ��:�,:;:, �; �: � � m -. l MARTIN TORAIN ��, . �:-e � i � y ;�• .f�.R. SPllc� SET AT Y z fi _ '•.'�p .��, o� � ., .� 1HE �N1FJ2SECnoN � `-- � � Bushy Fork Taur�+..g1+.�P � UR,:::,�;-. ,• bF RUDYS FARWI RD. ����4� • � U��`�� AND A 24� C1AP. .P�TS09't L`09IlL�'}J. Ncrth CaroL�na � �`� ,� Y a p Raoos�deat In Pbt Bb. ? At Py. 85A , . � � p � teo f-7'—�Of f 4 � � � ' Z4" CMP $oa�: 1' � �0•