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A34 31Application Date: � �� TaY Ylap: � 3 � Amount Paid: Farcel �: 3� Receipt#: _ ��-�� i � �� J�� [� ' � "`=— �� c� �[Cr'�� r��s �` i�i �e Yµ► r �t ' "1=3`S ':LS �C�?33'�r-vr.L':�ShTI�..=II.11 1L�LUF:�> ��9.:1tZ � ^ � V �io �� 1��lic��on �o�' �e�'vi�� (Septic Systems and Wells) / Ses^�ic:s �e uested � �mprovement �ermit (Site Evaluation) ❑ Construction Authorization �200.00/$300.00 (if> 600 2 d) (Fee is de endent on the e of system ermitted) ❑ 1'Iobile �3ome �tepiacement or �uilding Addition I �J Permit Revision $1�0.00 (if site visit re uired) �75.00 C�eil �ermit (ldew/gteplacement/�Zepair) Repair of Exisling Septic System $300.00/$200.00/$75.00 No Chartre �) �ervic�s Re uested by: Name: � -��-Nu � �2-�� Address: 8 a- �. 2.0� cQ • rl'�6 Q_o. ' Phone # (home): (wark/cell): `i 1 `� - � ce � - o � 51$ 2}l�Taine �nd aa�cir�ss of c�arr�ut owner (ii dif�er�ni than applicant): Name: �Nc. R,l.,,, a- 5�..�,� 'A n� ti�--�'�-��S Address: � P�-L �.� � �,,,F,t...G � .0 • �I 3 �) �r�g�es-dy �e�cra�tnon: Lot Size: Subdivision: Address and/or directions to Property: 4) �'roposed Use a�'Type oi Stpuchere: Residential i/ Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes � No (with plumbing: Yes No _� Garbage disposal: Yes No � 5) VVater Supply: Private Weil �roposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? T10 Yes �ot #: (please show tocation on site plan) 1'T�ate: �4 completerd tcvulication mus� c��so include: ��lat/si�e pl�en of ths �ro,p�rty �t,�iat s,�aow� ��o�e�y di�aaensions caa�d tlae siz� ncrad iocntion af rall proposeai structures. . y A 5ag�teci capy �f tlae `.�at �r��aratior�', f'or�ra veri�yi�ag t6aai tAie propes�ty i� rPssdy io �ie evaluuPesi. � arra saabmitting thas �pplacatfon to re�a�e�t 3ervicss froe�a the �2r�on Cau:aiy �e�iti� �epaa�#IIne�t. � understamd t�a� ai the infaa��a�tion �e'ovidetl is incaa-r�� or i�f �he �n#e is su�s��uesnt�y a➢te�-ed, or i�' �he �nte�sded u�e c�anges, �i� per�aa�ts aaad approva3s sha11 becanae invalid. - ,� � �ag��h.��-� {Owner./Legal ReprPsentative): V.�/L�Jd�1 ,� liti-ir.� ��¢-�. p��_�at� : U y �� U`� 10iO3 Person County invironmental Health, �`?5 S. �iior�an St.; Suite C, R�Yboro, NC 27�73 (336-�97-1790)