A32 364, C f ll ��� ��
Application Date: o� -� �' I 3 .�- �
AmountPaid: a00•00 re�� ~�':+�
Receipt #: 3 p � � ����
lEv.�cavnn'aDaaaxaac�.7ndan..I� IH�a�i�.Il.�.:Ln.
Application for Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 eodl
❑ vlobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (NewlReplacement/Repair)
$300.00/$200.00/$75.00
Tax Map:
Parcel#c
eQli ►,� 0.,�„,
`1-� M e�-1- — Yo U 1�
Services Re uested
❑ Construction Authorization
(Fee is de endent on the t e of�st�m permitted)
� Pcrmit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
_�pplicant Information•
Name: ,,�J� Q�n;� j �orris
Address: ai �,�, Ci ro � �,t (ZCI.
.�u r� 12- itl� �i � S� n� C`, j`7 5'-� I
2) Name and address of current owner (if different than applicant):
Name: j)a 12 E_ /1 �o r�� � s
Address: y3 � 0.1 rr v,�- ('..� �'o ��e. Cl�c,� � �.
i��d �� ,�lis . ,� e Z�syi
3) Property Description: Lot Size:"' acr�s Subdivision:
Address and/or �irections to Property: ��,- e;�-�
7'0 �or►-is Faw��l� Cewt�� /��PJa c�'�.-�c}�4
❑ yes [�'no Does the site contain any�ur�sdictiona wetlands? ��
❑ yes C9 no Does the site contain any existing wastewater systems?
❑ yes C�no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C�no Is the s:te subject to approval by any other public agency?
❑ yes l�'no Are there any easements or right of ways on this properiy?
(if `yes' is checked, please provide supporting documentation)
Phone (home):
(worWcell): %/9 - 7Zi/- 8�� `l5
Phone: �'/ 1 q-% Z y-$� �l 3
Lot #:
4) Proposed UsQ and T��pe of Structure:
Cd'�tesidential
C�New Single Family Residence Maximum number of bedrooms: ,��
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfun�tioning System Will there be a basement? ❑ yes Ca'no �Vith plumbing fixtures? ❑ yes � no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: C7�New well ❑ Existing �Vell � Community Well ❑ Public V►Jater ❑ Spring �
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes L� no
If applying for `Authorization to Construct', please indicate preferred system type(s):
C�Conventional ❑ Accepted ❑ Innovative � Altemaii��e ❑ Other ❑ Any
nt e
��
�,-o
I cert� that the information Provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is suhsequently altered, or the intended use changes, all permits and approvals slzall be invalid.
Signature (Owner/ Legal Representative*)
�` Supporting dociimentation required.
Z z sr�� �
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `LotPreparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
•ConnectGIS Feature Report
Page 1 of 1
�� Welcome to the Person County GIS Website. ConnectGlS has been prepared for the inventory of real
property found within Person County, and is compiled from recorded deeds, plats, and other public records.
Users of GIS system are notified that the aforementioned public information sources should be consulted for
verification of the information in this system. Person County, Mobile 311, ConnectGlS assume no legal
responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983
NAD.
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