A23 170--rr-----_-.,.. �...., OC `�U �Q � 1 ax lvlap: � 3
Amount Paid: p Q, Q d Parcel �:
Receipt#: �'g���3�
�.� a a i 3.��� ��� 1����� ���
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.J.�_ ��:rz�s+ii �r.r:a u-n.::r.,z-n..c�.� sc sa. Q-.e.n..0 ?�"`�� «�.rR 11. i'C. il-a.
��p�ie�tiora for S��-wic��
(Septic Systems and Wellsl
J+� Improvement Permit (Site Evaluation)
� $200.00/�300.00 (if> 600 �pd)
G Mobile lEIome Replacernent or Buiiding �ddition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/S 125.00
�e�aces Requested
❑ Construction Authorization
(Fee is dependent on the type of sy:
L Permit Revision
$75.00
❑ Repair of Existing Septic System
" No Char�e
important: If tl:e infonnation in t1:e applicatia2 for a,n dmpraveme�tt Permit is irtcorreci, falsified, or the site is alfered, tl:en 1{ie
Improvement Permit and theAurl:orizafion to �'nnstruct s1:a11 becvme invalid
Servaces I�equested by:
Name: ,� � , �l�,�, �,
Address: .�'v C ,t� `
_ �.,G>ar•.��— /li _ �2 ;�,���
_ �
Phone # (I�ome}: �' — f� �5
(r�e�dcell): .� v
2)1Vame amd address oieurreni o�va�er (if different than applicant):
Name:
Address:
a
3) Property Description:
Address and/or directions tn
Lot Size: � Subdivision:
Lot #:
4) Proposed Use an pe of Stre�e�ure: `
,
Residential �gusiness/Type: � � �' � "�' Other
Number of bedrooms / Number of people served (seats ployees):
Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes ` No
Approximate si�e off building found�taoa�: I.engtP� �ic➢th
�%) Water Suppl�y:�
Private Well V Pro osed Existin �
i P S _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
{please show location on site plan)
1Vote: ,4 compleied ap�licutioia �acsst radso itaclude•
� ffl plat/site plan of ihe p�operty thrzt �laows property dir�aensio�as antd zhe .size at�d locaiaon �f call
pr�oposed structures.
� A signed copy o.�`'tdae `Lot Pa•eparratio�a' f'opnz verifying tdzat tfie pr���r,�y is �^er�dy td r5� evac'uaied.
� am submitting this application to r�quest �ervi�e� from tbe �er�o� Coa�nig� �1leafltia �e�a�t�nen�. �'Ia� information
provided is accarate. I unde�-stand that ii a�ay ,bt� i,s ltered or t�e intended use s3a�nges, ali pe-r�eats sE�ail �ecocne
invalid. / � �
�igs�a%eare (Owner/Legal Representative}:
����: �-,� s-d �
I I/07 Person Cou;:ty Environmental Health; 32� S. Mergan St., Suite C, RoxUoro, NC 27573 (336-�97-1790}
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.1�L�.?���.'�. °�.�iT'Zi''T'A^',1 �.. '�� .�� JS. 1L�'it�.���
�aai��i�ag ���.fltions/ l�o�i�� �o�ae ���iac�ffie��
Tax Nlap �: ��
Approval Requested for:
Applicant Name:
Address:
Phone #'s:
Pazcel#: ` ` �
� Mobile Home Replacement
Building Addition
- .� �l
Permit Located:
Installation Date:
Yes � No „�
—� Desi� flow: {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: 3! Z �� (date)
� (Applicant's signature if site visit is not reqnired)
: � �r�e��tio�Zep➢ae����t �pp��v�
� � ! o
En ' nmental Health Specialist Date
11/l�/OS
A � ConnectGIS
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