A25 128Appiication Date: �" 1 �� iaz MaQ #:
Amount Raid� ��. �b
Receipt �: Parcci #:
�'n� o�� -____.`1--..`� �.,,�'M �'-�'I�����
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APPLICAiION FOR SERVICES
� THE iNFDRMATI
ij Permit requested by: (OwnerlagenUprospective ownet'}: Steven �onner/Roxbora $t�arn Etectric Plan#
Noms �hone: �336) 597-6292 Address: 1704 DunnawaY Road
Business Phone: ,(336,Zb97-6292 Semora NC 273�3
2) Name and address of current owner. CeciE � Row��nd P4ant Managerl Raxboro Steam Eieclric Piant
�700 Dunnaway Road
Semara NC 27343
3j Property Descripiion: Lot size: Township: Subdivision: Lat #
Oirections to the �rope�ty (including road namns and numb�rs): Narth on �VC 57 iurn riaht onto Concord Cefio
Road Turn left o�to McG�ees Miii Road Left onto Dunnaway Ro2d. Plant is at the end o# [7unnawav Road.
4) Proposed Use and Structure Description: answer eact� af th� following questians:
aj �'roposed X, Existing �, Type oE Structure:Wastewater Treatment Facility tNid�h: Depti+:
b) H�mber of Bedreams: NA Numbe� of occupants or peopie tfl be served; 2
c) Basement: Yes , No X Will there be plumbing in the basement? iVA
d) Garbage Disposal: Yes _, No X
5) Wat�r Supply iype: PrivatE X(n�w X ar existing____), Public,, Corrtmunity_, Spring _
Are any tiveils on 2djoining property? Yes_, No _ lf yes, piease indicate approximate Iocation on the
site pian. There are no nearby �r�eJls.
�j Does your property contain previously identified jurisdictional wgtlands7 Yes^ No K Nat in the area of
this f8crtity
PLEAS� NOiE TNE FaLL�WtNG:
:� A PLAT O� T3�E PROi'�RTY OF2 SlTE PLAN MUS7 �E SUS3UiiTi'�i! Wl�`H TNIS APPLICAi1pIV.
y�'ROP�RTY LlNES At�1D CORNERS MUST 8E C�EARLY MARK�O.
v TH� PROA05ED LOCATION (7F ALL S7RUCTUR�B MUST 8E STAitED OR FLACG�D.
r 1'HE SCTE 1VIRJST BE R�ADlLY ACCESSIBl.E FOR AiU EVALUATEOH 8Y T�iE WEALTH DEPAFtTMENT
S7AFF.
t hereby make application tn the Person Caunty Health Department for a site ev�ivation for the on-site sevrage cisposal
system for thA above-described property. t agres that the contents of tnis appiica#ion are true and �epresEnt the maximum
faci3itses io b� piaced or� the praperty. I unde�stand if the site is altered or the intended use cfi�ang�s, the pennit sha13
bacame invalid. , ,
G� � �( �'"G�� -� ,�% _��,,.r��
Ow er or Legai Representative Daie
PZ�it?. rev. Oo127102
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uth rize taie 1�gent � Date .
° sys�. �� �:�r �p����un �ry. r� ��r �� r�.�.��. w
aeg�g ihe instarlation to insra� thar,ti,o�,ergrade u n,�nt�,e�:
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��uia�ao.ents:
Site Appraved bp
Grout�ng .Approve� bp .
iYJe�l Log
�ell Tag
Air Ven.t � �
Hase B� ' '
Concrete Sla� �
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Weils must be 14 frxt from propertp' liues.
We�s must be 140' fee�tt from s�.ptic systems. oiZ c��,e- v1���r��-z-''L2 -�cs�_� �r
Wells must be at least 25 f�t from atip bu�diag fouadation. '�u�-�c-to ►s ���.ts
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