A23 92Application Date: _3/1/2010 Tax Map: ��
Amount Paid: Parcel #: �
Receipt#:
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Application for Services (Septic Systems and Wells)
1) Services Requested by:
Name: Charlotte Edens
Address: 550 Oak Point Dr
Semora, NC 27343
Phone # (home): 336599-0456_
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Properly Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: _Take left into Oak Pointe Dr from McGee's Mill Rd and the house is at
the end of Oak Pointe Dr
4) Proposed Use and Type of Structure:
Residential x Business/Type: Other
Number of bedrooms 4 / Number of people served (seats/employees):
Basement: Yes x No (with plumbing: Yes No �
Garbage disposal: Yes x No
5) Water Supply:
Private Well x (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No 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 Preparation' form ver�ing that the properry is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): Charlotte Edens Date : 3/1/2010
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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