A41 25Application Date: /2 07
Amount Paid: ��,�°U
Receipt#: �
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Application for Services
(Septic Svstems and Wells)
❑ 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 (Ne e lacement
$225.00� 5.0
Tax Map: _�
Parcel #: O Z
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Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
❑ Repair of Egisting Septic System
No CharQe
Important: If tl:e inforn:ation in the app[ication for an Improvement Permit is incorrect, falsified, or the site is altered, then the
ImnrovementPerntit and t1:eAut/:orization to Construct shall become invalid.
1) Services Requested by:
Name: L� oN F. t��qv,nu,.�
Address: �-}8o Tan \ � `t���
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Phone # (home): S� � - � � y 3
(work/cell): � � � �y 9 ( �F i
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: 3z oc� a ks v►-t � l 1 (� �a� _
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�r� �-J� ls7 Soc.�f�. �i /�bk b �.ro
4) Proposed Use and Type of Structure:
Residential �_ Business/Type: Other
Number of bedrooms Z / Number of people served (seats/employees):
Basement: Yes No �(with plumbing: Yes _ No � Garbage disposal: Yes _ No X
Approacimate size of building foundation: Length '� b r Width 3 o'
5) Water Supply: Q�pla�z���/ -
Private Well '�C (Proposed ✓ Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes x (please show location on site plan)
Note: A completed application must also include:
➢ A pladsite pla�: of the property that shows property dimensions a�zd the size and location of all
proposed structures.
➢ A signed copy of tlie `Lot Preparation' form verifyi�:g that the property 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: � 2 '3-�7
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map A�f � parcel # a� Township:
Applicant: L P�,., I-14 m �; n
Subdivision: Lot #
Location: _Ni,rrl4e 1�•\ill� 2rJ —'r �-v, CQ-4P Mi I I �rl -9, I��,n�
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�ype of �at�r ��a�p�y: }� Iudividual _ Community Public
Rec�uia�ement�:
Site Approved By: � �
Grouting Approved By: /Z oT
Well Log: � �'
Pump Tag: �
Wel� Tag• �
.Air Vent: '
Hose Bib:
Casing Height: �
Concrete Slab: � �
Well Driller• ��/�,,
Well Approved by:
. *'���See Attaclaed Sfl�e S�Ceic���**
Liner:
�Installed by:
Depth set: _
Grouted:
I3ate:
Watea� Sample:
Wells must be 10 feet from property lines.
��ells must be 100 feet from septic systems. �
Wells must be at least 2� feet from any building foundation.
Other canditions:
Date:.
PC�-ID rev Ol!27/0�
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SITE PLAN
Name _ 1.-�L'k1 �Q��.it'l Tax Map # � � Pascel # o�
�division Secrion/Lot#
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Authorized State Agent Date
System companents represent appmadmate conmuts only. The contractormust tlag the system prior m begiaaing the iastallation m
iasure that propergrade is mainrained
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