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� The-;Distr-ict:-�Heal�th;-Depar:tment
-0range .erso : Caswell,-Chalham,,�Lee Counfies -
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� �11/crter �Supply and =Se�rage: Di"sposul
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�, a4 Owner: � •
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Location
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Contractor:
Waier Supplp: Private ; ` ��ni�ublic
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Sewage Disposal-Facilities�io.Jli� e�s� Dishwasher;:Disposal,"
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�washing machine, other au'tomatic appliances :_ �
::5ize of • tank: ��Z��-- �TitriBcation line: � � � X �
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Other disposal -facility ' - ` " ` " .
Water supply and sewage �disposal facilities location, installation and `
protection must meet state and local regulations. :
• Above recommendations based on information :received and observed
� soil condition. Septic tank- and: nitrification :line :MUST..BE INSPECTED
AND .APPROVED BY A MEMBEft OF THE DISTRICT HEALTH DE-
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PARTMENT STAFF.,before ,any portion of the .installation�,is. coyered �.
and put into use.
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Date approved• ��� ` � �
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Well: � r. �:
Sewage Disposal• � • Signe �`
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. .. �OVER) . ' .
Location of . vvell= and sewage disposal; facilities sketched oti .back.
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Amount Paid: . �
Receipt #:
0 Improvement Permit (Site Evaluatiou)
$200.00/$300.00 (if> 600 gpd)
obile Home Replacement or Bailding
❑ Well Permit (New/Replacem
$300.00/$200.00/$�75.00
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',��;���J Parcel#: 2 2
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IEaa�asoTM* �* ����.Il 1H[�mfl�lka
Services
for Services
O Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Eaisting Septic System
Application: No Chazge/ CA $150.00 or $300.00
1) Appticant Inf a ion: _L
Name: "C� d � r aa �I`� �.7�
Address: r5 � U �'
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2) Name and address of current owner (if different thaa applicant):
Name:
Address: d q cv�
Phone (home): �� I "Y� � '"Q�� ��
(workJcell):
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: ,
S,� 1 rl � �_ �:i 1a S
❑ yes l�no Does the site contain any jurisdictional wetlands7
'6�`yes ❑ no Does the site contain any existing wastewater systems?
�7 yes no Is any wastewater going to be generated on the site other than domestic sewage7
❑ 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)
1'Jl a 4) Proposed Use and Type of Structnre: ;
�Residential �
O New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfuncdoning System Will there be a basement7 ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
�Non-Residential
Type of business:
Maximum number of employees:
Tota( Square footage of Building: ��� ' � �'� � S ��� v �C �' °
Maximum number of seats:
5) Water Supply: ❑ New well �Existing Well O Community Well ❑ Public Water ❑ Spring
Are there any existing wells, sprmgs, or exisring waterlines on this property7 ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
��1�(��6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional O Accepted ❑ Innovative 0 Alternative ❑ Other ❑ Any
I certify that the inform tion provided above is complete and correct. 1 also understand that if the information provided is
inaccurate, the 'te i ubs ue tly altered, or the intended use changes, all permits and approvals shall be invalid.
�.
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� Signatur wner/ Legal Representative*) ~`�` Date
�` Supporting documentation required.
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC�27573 (336-�597-1790)
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Suilding Additions/ Mobile Home Replacements
Tax Map #; �� Pazcel#:� Address: 5�4 �/1 Da G�1 v�s K��
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ApprovaI Requested for: Mobile Home Replacement
� Building Addition .
Applicant Name: -_. J�I �'(', � c�Q (�fZ P�►-� G�
Address: Sa•^t.e aS ahv�
Phone #'s: Q �� �io', S� 5Q 2
Permit Located:
Installation Date:
� Yes No
Design flow: 3 � t� (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: (date)
(Applicant's signature if site visit is not required) ' -�
Comments: �=�h � SS � � �, !�-o b 4, ��JC � � � t 1� �-�
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Addition/Replacemea�t Approved
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En ' o ental Health Specialist
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Date C
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.oersoncountv net
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