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Apalication Date: % Tax Ma #: � `' �
Amount Paid: �-�0
Rec�ipt #: � � SZ��> Parca! #; � Q
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APPL1CA110N FOR SERVICIES
Lot) - $Zfl0.U0
❑ Improvements Pertnit-$15D.00
(Mobile Home ReplacemarrtlAddition)
❑ RepaidReplace Ezisting System Permit
- �225.00
Canstruction Author¢ation for Septic Systems-
$150.00!$200.00
Pertnit Revision Fee - $75.00
IF THE INFORMATION Ild 'i'F9E APPLlCATIOfV FOR AN IIIAPROVEMENT PERMIT IS iNCORRECT,_FA1LSiFaED,
CNe4lVGED OR THE SiTE iS ALTERED. THEN THE IMPR01/EfVIEAIT_PEit14A1T AND AUTHORIZATIOM TO .
CONSTRUCT SHALL B�COAflE INVALID. •
. ) � �
1) Permi� requesied b:(Owner/ gent/pros�ective owner): p
Home Phone: - � Address: � C� �� �
Business Phone: — � � � � �� �
2) 1Vame and address of carrerrt owne� �' � 1` e�
. � . - �
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3) Properly Description: Lot size: �_
Directions to the propQrty qn�luding roaji i
#.�
4) proposed Use� u�e#ure Description: answer each of the following questions:
a) Proposed . Existing Type of Structure: Width:�_ Depth: 3� ';
b) Number of BedFooms:�-� . Number of occupants or people to be served: ,�_ _
c) Basement Ye�� No �IViliihere be plumbing in the basement? � �
d) 6arbage Disposal: Yes _, No [� . �
5) Water Supply� Type: Private w_ ar existing�. Public_, Community , Spring _
Are any wells o�n adjoining property? Yes_ No _ If yes, please indicate approximate location on the
'site plan. � . �
6) Does your property cantain previously identified jurisdictional wetlands? Yes_ No �
�
PLEASE NOTE THE fOLLOWING:
9 A PLAT OF THE PROPE�TY OR SITE PLAN MUST BE SUBMITTED WITH'�'IiIS APP�9CAT10[d.
➢ PROPEi�T`f L1NES AND CORNERS MUST BE CLEARLY MARKED., ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAt�D OR FiAGGED.
�'PHE SITE NiU$T BE READILY ACCESS1Bt� FOR AN EVALUA710Pf 8Y THE HEALTH DEPARTMEiVT
STAF�: �
I hereby make plication to the Person County Health Department for a site evaluation for the on-site sewage disposal
sysiem for-th ove-described property. I agree that the cantents of this appiication are true and represent the maximum
faciiities to plac�d on the property. I understand if the siie is altered or the intended use changes, the permit shall
became i lid. ------.-_.._._.
2
Ow r or Lsgal Representative .� Date
PCND, cev. Ofil27/02
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���n�^�n��n.c�na��.� �c��.���n.
:(anuary 4, 2009
Janie Clayton
424 Roy Carver Rd.
Semora, NC 27343
RE: Site Evaluatioi2 Application Dated 3/30/2007
Tax Map: A24 Parcel# 30 & 117
Dear Mrs. Clayton:
nsuring a healthy environment
The Person County Environmental Health De�artment has a policy that states a��y
application, which has not been acted upar. for 3 months becomes void, and ;�ly fees paid
are then forfeited. Our records indicate tliat an application was filed on 3/30/2007 for an
onsite wastewater (septic) permit. Our Department conducted a site evaluation on
4/16/2007 and with Kevin Neal(Regional LSS) on b/6/2007. We have not yet received a
surveyed plat showing the off site/supply line ease»zent areus connecting the building
lots. No other communication has been received from you concerning this property. If
action is not talcen by 4/4/2009, the application will become void and all fees forfeited.
If you have any questions concerning your applications, please contact Adam Sarver of
the Person Colinty Environmental Health Departnient at 336-597-1790.
Sincerely,
� �'
Adam Sarver, REHS
Envirorunental Health Program Specialist
Person County Health Department
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 275�3