A41 24Application Date: 1 I' I� -0 7
Amount Paid: I a�U
Receipt#: lb 3 �4- �
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�� Application for Services
(Sentic Svstems and Wells)
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 if site visit re uired
Well Permit Rlacement)
�225.0 $� 1
Tax Map: /1 �( �
Parcel #: �
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0 Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
❑ Repair of Esisting Septic System
No CharQe
Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then tlie
Imnrovement Permit and the Authorization to Construct shall become invalid
Services Re ested by:
Name:
Address: C ��
/�� rl57
Phone # (home): .��0'�("^ �2`f'3
(work/cell): S�`u'
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: �, � Subdivision: Lot #:
Address and/or directions to Property: � � y, ,_�T�_ , �, ,
4) Proposed Use and Type of Structure:
Residential !/' Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes _ No _
Approlumate size of building foundation: Length Width
�ater Supply: -
Pnvate Well 1/ (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No v Yes (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparatiofi' form verifying that the properry is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Signature (Owner/Legal Representative): ' - Date: � /�i� U%
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map y � Parcel # ox/ Toivnship:
Applicant: F�a,�. � �,�,1,; �� P i�1
Subdivision: " Lot #
Location:_1�urc\\e (v�'�\\� �'� -�- �i � �� �'�\1 E2d -�-
- - o (�r-L 2 � �f3� �'a B� � 11 Rc-�
'�ype of W�ier 5u�p�y: � individual _ Community Public
�ec��aia��anen�:
Site Approved By:
Grouting Apprav By: � - �
Well Log: �
Pump Tag:
Well Tag: �
Air Vent: � �
�iose Bib: �
Casing I3eight: � �
Concrete Slab: � �
Liner:
�Installed by:
Depih set: _
Grouted:
I)ate:
Wate� �ample:
Well Driller• �VO��, �j 12 �� 0�']
Well Approved by: � D�te:,
�`y**See Att�ci�ecl Si�e Sketch*��*
Wells must be 10 feet from property lines. �
�Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any buiiding foundation.
Other conditions:
PCT�D rev Ol!27/0�4
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SITE PLAN
Name' �CIYY'k � �nl�'1��e'� Tax Map #� Pascel #�
Su on Secrion/Lot#
�5�m,� 0 1 \' a4�� Si
Authorized State Agent Date
System companenrs represent appmximare conmurs only. TLe contraaormust flag t6e system paar m beglnning rhe installation to
insure rhatpmpergrade is maintsined.
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