A40 223Application Date: i �- �� `� ( `��,� (� ������ Tax Map: ��
Amount Paid. 1 � � � Parcel#:
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Receipt #: � `� �-
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❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
obile Home Replacement or Building Addition
$150.00 (if site visit required)
D Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75 .00
tion for Services
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: s�� —a���
Name: 1 � 1� �1�1G
Address: $ 1
L 5
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: �'�� Subdivision:
Address and/or directions to Property: '
w�y�.0 L����c�,.�
Phone (home): ��-% �� �2 [ U
(work/cell):
Phone:
Lot #:
O�IN �S �p��
❑ yes ❑�o-:. Does the site contain any jurisdictional wetlands?
� yes ❑ no �` Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
0 yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property? ` �
� (if `yes' is checked, please provide supporting documentation) ��+�` U` e; O�,�
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4) Proposed Use and Type of Structure: Yj�Y� 0 N,. �'
❑Residential 3 �
❑ New Single Family Residence Maximum number of bedrooms: ,
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes � With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: ❑ New well idExisting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes 0 no
✓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
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
. I il
gnature (Own r/ Legal Representative*) ate
�` Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' 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)
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Tax 1VIap #: Parcel#: � � Address: ��� Ok � �� �
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Approval Requested for: � Mobile Home Replacement
� Buildi.ng Addition .
Applicant Name: ► �' �t�2, �� o ►�c�
Address:
�i'1-r,2 �S � �-e —
Phone #'s:��0`3 � �"3 ^B�C�
Pemuf Located: Yes _� No
Installation Date: �— Design flow: � 7 (gpd)
Current Contract with Certified Operator on file (if required): _�T_
Water Supply: �_ Well Public or Community
Wastewater system shows no visual evidence of failure on: �( 2� �( (date)
(Applicant's signature if site visit is not required)
Comments:
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Environmental Health Speciaiist
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Date
PP:son Co�n�� Environmental �Tealth, 3?� 3. �?orQan St., Suite C, RoYboro, NC 2 i�; 3
Fhane: 3�6-i97-??9C/ Fa;:: 3��5-�9"-7�0� � �v�:��v�ersoncount��.ize:
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SITE PLAN
Nam %C�"Q'e �� �� Ta$ Map #,��arcel # ��
Sub ' ' o Section/Lot#
r�uihvsizeu StaiC i�gcni t�ate . ,
System campaaeais neptrseat apprvadmnte contours oa/y. Tfie coatracmrmust9ag t6e systrm pdor m bPb nni q0 the iasta!lstion [v
:n�� thatpmpergrade ia mtintaiaed
http://gis.personcounty.nebconnectgis_v6/DownloadFile.ashx?i=_ags_map 1 ad9d10822c2... 11 /28/2011