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'� � _ .' �� �� � � �` � �� �`�� � :.. \ � �� �� � . . „ � , �, � �. � � � . , � ,.. � �'�; �, : �� � a.�::: � . � �� ��� , � '� ` � : � �u�A"�� � �} .,.> t �\\ . �.. �m..�� � � , , ���� �' , ��,��� .,���� \� � � � \ tti o � � \� � , ' . \� \\ �� �� ii7 \����\\ \�� i . c, ,�: . . . \� .�.� �.. \\\� \ ��\o�� �`.� �\\����a�� �� � ..,�\:��.,.: ... � ��\��\�\ � \ . � , �\o ��� :\������ �� \\ :.�, ����� + r ' Application Date: O 3 ( � Amount Paid: Receipt #: _ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 1) Applicant Information: Name: Edward & Michele Wyant ��,� 9� I��I�.��� �` ... �}� � ���g}���y��?1� ;�"534'H:iC1CYY3"8'kT.�L.3IIA��tAY. A 31C74iil'd:.�1 tion for Services Services Address: 8�6 Pinesborough Estate Rd Semora, NC 27343 Construction Authorization (Fee is dependent on the type Permit Revision $75.00 Tax Map: A24A i3 Parcel#: 1 � 5 � 9070-04-70-6604.000 � �ac t N ''�'J l,�Y'� V Ou ho�c e of Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 Phone (home): (work/cell): 336-583 -9668 2) Name and address of current owner (if different than applicant): Name: Alternate address : Phone: Address: 876 Sam Caulder Rd (previous owner: Sam & Christirie Caulder) 3) Property Description: Lot Size: • 88 Subdivisio�inesborugh Estategot #: 13 Address and/or directions to Property: Highway 57 North from Roxboro. Cross over Hyco. Turn Right on Zion Level Church Rd. Turn Left on Pines] ❑ yes � no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes � no Is the site subject to approval by any other public agency? g] yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) three bridges �roucth Estate Rd 4) Proposed Use and Type of Structure: �Residential Home lost to fire. � New Single Family Residence Maximum number of bedrooms: 2 ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? � yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? � yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): � Conventional ❑ Accepted ❑ Innov ive ❑ Alternative ❑ Other ❑ Any I certify that th infor tion provided ab � is complete and correct. I also understand that if the information provided is inaccurate�i�'the �i�is�subse�ue�rttly �red, or the intended use changes, all permits and approvals shall be invalid. Si�nature (Owner/ Legal R�� * Supporting documentation req Date 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 evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� � �, � . � � �.►. ,� �-_� �../ `�.� � � � � ���7rn-�v-n�x�ucD�t�n..lr�rnce'�tn��n.� ������.���n.. Building Additions/ Mobile Home Replacements Tax Map #:_�� Parcel#:�_ Address: r�('v ���1� r.,`�,�� ,� . ��t -�.�G� 1'E'-?7� � Approval Requested for: Mobile Home Replacem ent _� Building Addition �E��.g�r�t� }�j� Applicant Name: ���,�,�� �- ���,��% L��t��n/'f-' Address: Phone #'s: ��� — q(� Permit Located: Yes ✓ No Installation Date: Design flow: � (gpd) Current Contract with Certified Operator on file (if required): Water Supply: V Well Public or Community Wastewater system shows no visual evidence of failure on: 5,� � �� e) (Applicant's signature if site visit is not required) Addition/Replacement Approved Environmental Heal Specialist ���/,� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount �.�