A23 123. z.
Person County Health Department �
Sewage System Improvements Per�m� iv'
Date:.�-1-=-�=a-o-This Permit Void After�Years �
Owner: � SR# _.�—
.� 4� Call vr�
Location/Direclions: , ,
Subdivision Name:
Gi�'!a:/Lot #
Lot Sizc: �� a�' �`' T of Dwelling:
Walcr Supply: Privatc: —�- �►b�►�. Communil :
Bedrooms: 3 Garbage Disposal _._----
Basement Basement Fixtures_____---
INFORMA���IE BY
owner or rcpresentative
Sanitarian:
REPAIR:_---- �EVALUATION_----------
Size of Sepac Tank: _,��2Q-- g�lo� Si � of ump T :_—
Niuification Line: �
Depth of S�one: 12 inches
Max Depch of Trcnches:
Altemative Systcm: Conv. Pump LPP Pump
Remarks:
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
�CERTIFICATE OF COMPLETION
Contrac[or: ,_ _ _. _. �
----------- �
Sewage System location, installation, and protection must mcet state and local '�
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall bc maintained �
by owner in such manner as not to create a public health hazard. Septic tank and �
nitriFication line must be inspected and approved by a membcr of the Person Counry
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intendeci use change this pemut is subject to revocation.
(G.S.130 A-335F)
L.ocadon of sewage disposal sewage system sketched on back.
.�[� '�_ J�G1 Se (O ER) %, Y�j c� q v C.2
�� rC2d j�Y
�, �e. �c,� of /d-f `� � �
RO
'�/S/Gz- - ���✓�=S t- svP�rG-, ti.,/G .�,/�r,c�� � '*T.'��`?
d
� �Z�� t5 �� �i ; c.��; ( r� vc
�/L�r� uil��t�S � u/a�k �un.,-hGy';
� . �� � , �
• M�e(� }x� � '� ,�
1�-� � � �
�2�� j � , ��
-�. 'r-��s-Q �'l'�� t,�t�d-�>S � sis� es� �����
�C �
�- e � ���
��
� � �, c�/a d-e� s 5���.� Q "' ��7 � l.� �, �Y��.��
� f , � 1, �;���.�Q ; ,� ,.�k-
. � �
�--,��.s�� ���.���
�. - ������
��a�wn�c^Q�aasxn�aa�.en.� g'�ma�.Il��n.
Applicant:
Location:
Permit Valid for �Fi
Type of Facility: '�
# of Occupants � O
Proposed Wastewater Sy
Proposed Repair: �
Permit Conditions:
Years
# of
s
Owner or Legal Representative Signature:
Authorized State Agent: /%
Ta�x M��� � P�rcel �
S���nc�i'ivi�s�ion ' � i =
Fh���se Sect+ioniLot # .
�
Improvement Permit
o Ezpiration
New �Addition
ed Daily Flow �o
Water Supply
p.d.
Type:
Type:
Date: -� G Gy
Date: !p'--�/ �-c�/
The issuance of this perntit by the Health Department in does not guara.ntee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Perinit is subject to revocatIon if the eite plan, plat or the intended use changes. The Improvement Permit is not affected
by a change. in ownershfp of the property. This permit was issued in compllance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Dlsposal Systems' (15A NCAC 18A .1900).
Authorization to Construct Wastewater System (Required for Building Permit)
-�See site plan and additional attachments (�. .
,- .
Proposed Wastewater System: ,� P�- ,'fr, /�,h, o ype �� Wastewater Flow fomo g.p.d.
New �/ Repair_ Expansion Soil LTAR: . 3 g.p.d./ ft 2
Type of Facility: � S;' � .�� s�,� Basement _ Yes �/No
Wastewater System Requirements
Tank Size: Septic Tank: l� � gal Pump Tank: %�Sb gal Grease Trap: --- gal
Drainfield: Total Area: Do sq ft Total Length �� ft Magimum Trench Depth ��_ in
Trench Width 3 ft Minimum Soil Cover: E'a in
Distribution: Distribution Box 5erial Distribution
� Specifications:
Minimum Trench Separation: % ft
✓Pressure Manifold
c� �c-
Authorized State Agent: � �S . Date: �"'�- ��
Pertnit Expiration Date: �' -�? / - D � _ __
The type of system permitted is ✓Conventional
the permit. � _
Owner/Legal Representative:
Innovative Alternative. I accept the specifications of
� ' Date: �
• ��-
Operation Permit
System Type (in accordance with Table Va) �,� .
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this permit does not guarantee that the
wastewater aystem will function properly for any given period of time.
Authorized State Agent: Date: %/-�2CM ���
PCHD rev. O1/23/02
���;5� ������
' �C � �JI�T��
�' aa�na �,�,+,�*�*�na.�.m.� ��m�.�tE:�a
Name ��� k %�'
Subdivisi n� '
Authorized Sta.te Agent
SITE SKETCH
� J� 1��:. �
Tax Map #� a 3 Parcel #�
Sectio ot g
5'. � - o �
Date
System components represent a�bproxi�nate contours only. The contractor mustflag the systemprior to
beginning the installation to insure that propergrade is maintained
� It�fl'� Ql l�-erm �� �en�",'�`,o�'LS
!. �,',�es a�e �'l��-9��� a»' s.' � , F�lDu1
` `
�� D �-7� a.s S /�-D cJr� . � ��� Rr� � `
flil �SS:� , a �'J�cJ �Q�ow�r.J����/'29GciY.�� \
�r�'o�, fo .iirs�//��,
oZ, �e� aTT'Gi,c`.e_q��C�-9e.5 � s 3 �r �OC'w�TJ�On �/
�F� J / �
'aw �a�s'^�U � �,n-�, c.
3. ��,����� f� �.. � .�,.
I �`J
%�a- sfs�e•�� �res�,5u�e ry�:� !`���
�cc��n-T/'v�f� a�� S P-c�r"r���iyr,
( � �
� ..
u
IS
,�ra; ;eld f��
� �- g �&�)
�
�
�/ J � �
��i _ J
�AP
i
-� �� V �
��
� � /
�
.,o ,
5
t �
� ^
� O� I I
� �
� , � �� ' �\\ I
, ; ��
, ' ,'
�S
��� ��w ���
23 . � � � �, 8
7 NS ,
_ _ -- I
. _ -- - -- �
�
Scale: � f �� � ��
�!S
�
�j�ssu /�
,���,;�'/�
' Ga.�e ✓a/v2
w� 1l, a6o✓e �ro�..��
CLC�°�c c
l �n e � � af -36 `��o �,�,
un�'e✓' /'oc�� 2/�lif�l%a y
✓
-- - �;5. E�
�-- - -
t 7o Lo � g �r
! sec a�cc��e��aJ �
MP
��'�� �f D
"sc'1�����
o���l�l;N.�
- �-�: �
PCHD, tev. 09/12 f Ol
0
NEMA �iX SlmpilX COltt201pM1B1
� �� Duct Seal Hoth
4" % 4" Pze�stue Tz�ated Post i Endi Of Tba Co� ' Cosicrata Rsser
.• Sloped To Shed Wate= 12" Separatioa 2�• Idffistaut`G• *
� � IIectrical Condmt •. . � . -• , . • . 5" Separati,ox
T�¢eaded Gate Yalve
. • � � QIOD21 r
,� � � � ' • . ' ifi���'
S" Coaer •� ' . Accese Covez• � • . ; 1 ' ' , Postla:od Cotrcrete Gmnt •
i . , ` � � • e. , r . . • . ~ . � , l , - • ;� �7St1C - � . . ,
. :' t f �' �•., • i • � '• �
� � •� _ • - Zip Coxd ' Ope�g Filled With '
• �.• �P�+6 F�71ed With �{i Siphon Hole Ties SnPPiY ��. Portlutd Caraettt Crmnt
Inl�et From Septie Tank Paztlaad Cemeat Gsoat �p� � � � �•'
4at1e;t To D�ntioa
d" SCH 40 PPt.'. Pipe ''� Check .�..Np1oa Z" $CH40P�C Pipe
Valve � float Wires ' �
Higk WatQr Alazm Lav�l ; ;
(6° Separati�on� •
;, . , Hish Level - Pam� Oa ; .
.' „ �. '�9aposLock F7cats .
.� '
. • (�„f Drawdawn Hok • • •�
.�
� R,emovable '. • '
, � ,� ( p � �i7oaf Txea , ;
. Low Level-P� Ofi . �
�. ' . � � —
..• �
: ,,
�: ' Precast Cornsete Tank 4" Cox�c:eta • Yt1MP RA?ING �
�•; MatexulStxe p350dP Black � i ' �
, ,.. • , , • . . , . - , � -; ''' Pump Hnst Be Rated To Deliner
'�`�� ' ' • ' • - •' ' • �` ' �� t Gallons Per Hinute
. � ' Against 1�2 Feet Of Tota
Iaso ��•T•a],1j'g(rj� T�,[{ Dyctamic Head tTDH) .
liiacul�au�.uuu a� w W w.t1GiL�I1T.5ic'iL�.IIC.US
fitting�to allowforaannacling�
alear pressure monitoring tube
Qezve tuba in bottom af vadt)
.4luminum dr steel
shoebox-typa cavers with i�andles
(150 lbs. ea�h, max.j
�� �
Support straps ��I
or bars � �
� Ball valve \
�� � � � �
Dead level manifold instaltation
�
Grivel Pit for internal .drain dischuSa
Pag�.�ofg
� � �i � .
��� � �� � re u�r� � . .
� � �
Proi�e Vie�v of Pressure Manifold for Siopaa�� Site Installation �
� (not to scale) � .
'- • TeP - diract thnead or sacldle .
Clemwu2 (it't�pPedwitkmaTe adsntor� tsim
P� liead droo]c ��with ia:ide wal�l ��
9H41�
Oi�se�e�i�t port (�ee wBk e�
�rnagtd ta g�de; wlth xsmovable eap)
�--
� ��atemalvauh drelu
o n n n o •Pxue��►ballyelvo
(�18u VAIVO W�i �00 �SCO�d 1�ARIi�
i
1 1 1 1 1�°�iy�
� co a��: �e�n. �.o�:�,a �
Plan V�ev� of Pressure Manifold for Slopi.n� Site Installation
(not to scale)
http://www.deh.enr.state.nc.us/oww/LOSW W/manifolds.htrn
10/18/00
Simplex Control %�a�� ����
Panel With
Built In Alarm
#g1 p.'E381:: :I8dL24 .•.••+
�768t ?: ?QC'_Y3iZd: �
Hate: fhis is
� •�• nat a Qiring
� �g � "� � . 3iaqrai! Coasnit
�nclasure an glectrieian! " ,
idater tiqht � Duct Seal
+
corraeian "�""�
stall 2 circuit resistant � • � � �
sconaecL svitch •
panel does nat � �
re a dead front :" ..:�._::3 � � � ,
�S �anna! discoanect. �a: ::-�� �
ote: A breaker d�es �:�c:•: '— _
t constitate a � . ` � _
�canuectl > 1 " ta
�
. Eiaish qrade
�nap �upglp �i:cai� � -
31ara.Circnit ;ackiaq 5�=3�s .
3ater iiqht Saal � '� .
flqdranlic ceaent� • .
Schedale �e ?7C — � �araess Si��ss :a.is
S�pply � _._ •--
�
,._____ ._.--..._,_...��.---_�,_,�1_�.,�-�nt-a�±.l_P__.__.___ �.__._____._----. _...___._._.____ _,._,--- .....___,_._______-.__._____...--..._ .._.,.._____.
����' ; ��� ���� ��
�, ��--�' � � �� � �l.
IE��a-�� � ��.�.�.71 ZE��.�.]L�I�.
WELL I'ERMIT
1'I.EASE SEE A'i'T'ACHED PLAN FOR WELL SI'I'E LAYOUT
Tax Map #: �'�3 Parcel # 1�_ Township (�-hrI /`� �Y--
Applican�
Subdivision: ,,.� . r.� .�-� h� /J�ar' Section: '— Lo� � �
. _ _ . ._ � .
T�e Of WatCT S11DD1V:
Rec�uireffients•
Site Approved bp ;/ 3�-F (� - 3 0�
Grouting A proved bp ✓� �t (0�4-�
Well Log 3 N- C� -�
Well Ta.g; i'"-c`-� ll--?/ -a
Air Vent �' / ' /�z
Hose Bib !� /� - a/- o
Concrete Slab /1-"
Well Driller.
Communitp Public
Well Approved Bp: � � Date: / / 'a/- � �
'�°5ee Attached Site Sketch**
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other
PCF-ID, rev. 09/07/01
��
���� )� Ji ��� ��
�� * � � � ����
IE����-�-„ ,t-,Y„ ���.�.11 �3L3L��.]L�11�
Applican
Location
T��x M�p ! P�rc�el :
S�ubd�ivi�s�ioii - � -
Fih��s�e tS�ec:t�i o n L,olt �
Operation Permit
System Type (In Accordance With Table Va): .
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF T}iE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
.�� /%- �4 � ��
Authorized State Agent ' � Date
Installed By:_,�. ��r���,��'
Date: / / - � � T- � �—
,
/ ��
c��'a�,, ,s
�
PCHD, rev. 07/29/02
0
Tax
Ow�
Add
SE�TIC YANK 1NSPE�CTION CHE�9CLlSZ (Type il - I�j
# Parcel # System Type (Tabie Va) �
�piicant Subdivision
�ocation Sec/Phase Lot # _
State ID/date
Capaciiy.
Tee and Filter
BafFle
Sealant
Riser (if applicable)
Tank Outlet.Seal
Permanent Marker
Pump Tank
tate ate
Trench Width ft.
Trench. Depth in.
Trench Length ft.
Trench Grade
Trench S a ' g
Rock Dep and Quality
Dams/ pdowns etc.
Pres re Laterals
Capac�ty gal. � ipe Sleeve
Waterproof lSealant ' Tum-ups/Protectors
Riser Required Setbacks
Water Tight From Wells :
Pump From Property lines
Check Valve/Gate Valve . StructuresBasements
nti-sip on o e itc es ramage ays
Floats/Switches � _ . _ . . ._ . Surface Waters .
Alarm visable and audible ublic Water Supplies
Etectrical Components V'cal Cuts >2 ft.
Rate (gpm) Wat r Lines
Approved Pump Model Vehic Traffic
Blocic Under Pump Adjace Systems
Pump Removal Ro /Chain Easemen /Right of Wa�
Distributio System er
Serial Distributi n ' Easements R orded .
ressure a' o rt e erat ontr
Low Press Pipe • Tri-Partate Agree nt
Appr. Pip Material and Grade �
Comments
pcf�d rev. 3/13/01
°e[GY �'%e- �''� �� �
���; r� Y'- /_ �
���r, 7��-��` '�er
\
���
�
�;
�
_
!
0
� �
� - � �
�, - ;
� I�� N / l
% %/
i__ _ ..�-` � /� 1� � 1
11
- � � (%' l!
`I �
0
• ,
. `` • '
_ `
:
Ti:
v�
\U �. �- % '
� `L
� \ ...:�
d
:i : � -
�"� �% �� �. ��Je
�.�
� l ,.� � L{ ':'r;.�' . Y
l ': � J '`'' , "., ^%
� '.1 .✓. � y �r.
�P...� LtNG
'6'� se�} c��
�„ � .• p
��'P
�-�-e z.
� � - _'v 'i/��
�
. �
,,� - . .
� � .
G�: !1
t��.i;'
�� ,� �
�• ��.
.�, ,,y ,..
�r ,
;�, ,._
r.
'�/ f.4'
' �:� rC %9
'�(t
'!
::
�'R,
�;'
t
• � � • •.. .. ., ,�
� �„ � � � ' �
, ��. �;
`� ~ ���yy"�"x �•�-���' •-..� .�
• ` �i
�, :
, ��
i
/�
• jrt ,!
�N �
i� �� �`
:_ r t
.:
� M
S �• �
,; c �.
; s.
!,.-:
;y .�.r
r �•p
1', /'.
: -. ,',
� r �v
i, �
���J �� �JiCJ �� V �
� ������Y
��a.��i �z-o aas.xn �c arn� tG-..� �l 1E�L �� II t�Ila
� 3, "�
�a�r a� � �o_� �
��a�o�u� S w� rl �r,�1/: ns
Do �O' DD [r�0(lOd __ � � �a �
�-- �Vell Lo
Owner: �l d � �
�' N Tax Map , � parcel # ��
Location. �
Subdivision: Lot #
�
Distance From nearest Property Line (Minimum 1 p fll jonstruction
Distance fr o m Sep tic System (Minimum 60 feet) ,�. �
� ✓
Total Depth: o ft Yield: ��'j ft
�_ � GPM Static Water Level: ___�__
Water Bearing Zones: Depth �$��} ft �
Casing: . .
Depth: Frorn �_ to $. Diameter: 6� �
Type: Galva.nized Steel � �—
Weight: �_ '1'����5; f�� Height above Ground:
Drive Shoe: ✓`Yes No An roblems encountered while settin_ in
If "yes" give reason: y p � �' —YeS `—iV°
Grout:
Neat: SandJCement `�� Concrete GraveUCement
Annular Space Width ____ 3 inches Water in Atuiular Space Yes �No
Method of Grout: Pumped Pressure Poured c� Depth to Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag � Pounds
If mixture (sand, gravel, cuttings) – Ratio � to �_
ID plates: c�'es No 4 x 4 slab �es No
Drilling Log T ,,,.�.�__ „__ .
I hereby certify that the above information is correct and that this well was constructed in aceordance with regulations
set forth by the Person County Health Depart�nent.
Signature of Contractor
. ID # d 3 Datc ('�— 6 7—'
PCHD rev O1/16/02
Application Date: 3/3fl 1 l-������,—��) ��`.� f�.�q �D �(�}�T
�� ,? ��.e�.��. �.��� �
Aitnoant Paid: � � � ��•��
Receipt #: � 3 Z
r� �! 7� � ���.A�-���.��.�.1 �m�.a�.
Auolicafion for Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
VVeli Permit (New/Replacement/Repatr)
$30Q.OQ/$200.04/$75.00
Tax Map: Z `J
Parcel#: i � �
Services Re uested
Construction Authorization
Fee is de endent on the e of s tem armitted
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150,00 or $300.00
1) Applicant Information: /� (
Name; ►� i G�-G) c� Wic."'t"Q J��
Address: 1f�l1Q �n�� Lvwe1( oat
�✓ 2- b
2) Name and address of current o ner (if different than applicant):
Name:
Address:
�o �l�
Phone (��j: �/P' �/$�'� 1 Z Z O
(v�ce11): �'l9��/$-'O�Stf
Phone:
3) Property Description: Lot Size: Subdivision: �c�-�: �oO�Lot #: �
Addzess and/or directions to Property: '7 �(� Gr r e«. � l�ct r��� r'
o i` o�. G
��yes no Does the site contain any jurisdictional wetlands
� yes ❑ n Does the site contain any existing wastewater systems7
❑ yes ��o Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes L�L_J"� Is the site subject to approval by any other public agenc}�?
C7 yes Q"no Are there any easements or right of ways on this propert}�T
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: ,r ��,� ,��r �-AC �¢ � 1.�� (��"" � "` �'
❑Residential
❑ New Single Family Residence Ma�cimum number of bedrooms:
❑�%pansion of Existing System If expansion: Current number of bedrooms:
C�'Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fuctures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square f'ootage of Building;
Maximum number of seats:
5) Wuter Supply: ❑ New well L'J Existing We11 ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this propert}�? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ �y
.I certify that the informatian providecl above ts complete and correct. I also understand that if the informatron provided is
i�aaccurate, r th stt is s bse ue tly tered, or the intended use changes, allpermits and approvals hall be invalid.
� � 3a �S"
5ig ature ( wner/ I.egal Represenfative*) D te
* 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 evaIuAtion.
(10/11} Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
����,s� ���.���
- — ., � � ����
ICs�-Yn�-��:�����.]L I�IL��.11�I�
Taz Map: %I Parcel: �
Subdivision ' � -
Phase/Section/Lot #
Applicant: /Vl l ���e � W��YS
Address/Location: _�___
-------_—���- � _�. � �� --_------- -_ ---_
Permit Va •: Five Years
Type of Facility:
Number of: Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Autherized State Age .
(X) Owncr or al Representative:
Improvement P�rmii
Non-expirina
New Addition _
/ Employees / Seats:
VVater Supply:
gallons/day
Type:
T}�pe:
The issuan�e of this permit by the Health Department does not guazantee the issuance of other required permits. lt is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is not affected
by a change in ownership of the property. This permit was issued in campliance with the provisions of the North Carolina �Luws
nnd Rules for Sewa�� Trealment and Disnnsa! Svstems'(15A NCAG i8A .i9U(1). Neither Person County nor the Environmental
Health Specialist w�rrants that :he septie system will continue to f�nciion satisfa�torily in the future, or ihat t�e water supply wiil
remair poia5le.
Authorization to Construct Wast�water System
See site plan and additioszal attachments �_).
x
Proposed Wastewater System: u�?n�c�vta V�lt/� (*)Type �� Design Flow �d �_ gal./day
Nev� Repair � Expansion _ Soil L"Cf�R: ►`3 a gal./day/ft2
Type of Facifit-,�: S� �{Q�PS. Basement: � Yes _ No
("•`) System Typ�s Illb, Illbg, IY, and V, require periodic system inspections by the Ferson County Health Department.
Wastewater System Requirements
Tank Size: S�ptic Tank � gal.
Drainfield: Total Area ��O sq. ft.
Trench Width � ft.
Distribution: Distribution Box / Serial
Specifications: ��
fluthoriz.,d State �►gent:
Pump Tank _� gal. Grease Trap ^ gal.
Total Length �_ ft. Max. Trench Depth � in.
Mic►.Soil Cuver � in. Min:Trench Separation � ft.
ribution / Pressure Manifold �
�•�
S�'i� f'?'��.
issue Date: �--�5 l S
Permit Expiration Date: ��S —2 c�
7'he system permitted is: Conventional `� /Accapted / Alternative / Innovative . I accept the co»ditions
and specifcations of this permit.
{X) O��ner or Legal Representative: Date:
Person Counry Environmental Health, 32.i S. Morgan St, Suite C, Roxboro, NC'37573/ph: 336-597-1790 (rev 5/12)
0
�� �L � �LJ 1' �J JL �
]Ena^�i�ro„�*,•,•,, a�aa.�m.11 7H[��.Il�a
Natne i (`�tOt � Qc�
Sub ' ' 'on +�' L�
�
Authorszed State .Agent
s
�
�o
�iTE ��7CC�I'
p,�essare n.�ah;-�o�
�
Tag.Map # �3 � P � cel # �a�
Section/Lot# � �
� 5�1s��� .
�.
Date .
rP�lacc.e
da��
,�Qr( vc►l�k
l �� �Z�
► �!-�.��
�LJ
Y V8�
�
�
� � Dinub� �►►�K
��a,� s / r�� w� a���
���e �i-�✓otv� � fi r��,lo�
�✓� C�..�►n c�Gv,
�
� �-Q�1,�`ae (���c��.`y`
.e,� ��s-�,-� I�a � ( �a (v�e
a� a-o,p ��
� t1
� ,� S-� f� vi�� �2
�l-Q vJ ✓av� ( ���"� � � �•
�
� �'7✓Livad-1� �1 our�
QY� d �- dYa;,��-e(�
w ��� -�ro.�K-�.� �u�pf•
So �'� w� l� sl�.��
�„f a �4-e,,�.