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0� Person Courtty Health D6p: �-�,,-�^-� ��� '�'"''r�
A m o u n t� p a i d 3'7�. -- .-�5 S. Morgan Street ��-- �' � 3 ��
Roxboro, N.C. 275?� l 1- I�-9�J
R eti.�e i p t l� � 6`i G a2 �O;rrier'-+�J2-�3-�6 D a t e
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� 7,r� APPLiCATION FOR SERViCES
' ii K C� t 1J L t ..r. R �N' ..:. e y�y�a� :': .e i.•, ry�.� : .:..r�Xrlyiit�iC�.e� � ....i+� "� S.rrr..,fn � f�:'^7 s S. `� ��,y�.'�'��,i.,
�.�. :' �,y �.� »if �,.. '�'Y''ltt L.«�� ��� < s�T . �Sr. 'fs����er�i �Reques�ed�� .H;.� f tT ' � rf �� .".,r� ..:k�1L' a7t�, -. ai:. y.�t;..� �
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_ Improvements Permit.(Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
1. Permit requested by: . 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: Er.ts Width: �' /DD fi/7 00 os-F
Address: ��N�c.onl �'nr1u2�.TE.�.wG. Depth: =' �5o w a, ,t
ome Phone #:
usiness Phone #: � ,��_ -�'3
. Name and address of,curren[ owner:
0
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water supply t}'pe:
private Q: public ❑ cammunity ❑ spring �
Are any wells on adjoining property?Yes ❑ No j�
If so, identify location:
Property Description: Lot size: 19.05 � � -
. Tax Maptt: .� - 34-
Parceln: Zb�
Township:_�t�_.�3�D
. Directions [o property: State Road �& Road
[ames,�tc.
6. Number of occupants or people to be served:
10. Type of structure/facility: Proposed:�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: �
Type of business: CoNc�Te �i2�ai�r" �'�d''�T'
Number of Employees: Co'/a
Number of bedrooms:
Garbage Disposal? Yes ❑ No C�
Basement? Yes ❑ No� If so, # of basement fixtures:
� No P�ss Wo'�✓Z- �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Health Department for a site evatuation for the on-site
se�vage disposal system for the above described property. I agree that the contents of this application are [rue
and represent [he maximum facililies to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvemen[s Permi[ can be
issued, I rnust present a survey plat of the propeccy to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within GO DAYS after the date of the evaluation of
the site by the Health Dept., this ap�plication shatl become void and all fees paid forfeited.
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�lE�.v1._ �EP_Er.l i. �ti1G.
wner o Authorized Agent
, 821. ����