A25 211Application Date: � Z� K� I D Tax Map: �
Amount Paid: ��� Parcel #: �'=�-2 � j
Receipt#:
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Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted)
Mobile Home Replacement or Building Addition � Permit Revision
$150.00 (if site visit re uired $75.00
❑ Well Permit (New/Replacement/Itepair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Services Requested by:
Name: ' � c�/ 2
Address:.3�� ��'7h�s /��c
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Phone # (home): 334 5��� S7�z
(work/cell): '�Z(;�-S�',j -���!
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description:
Address and/or directions to
l�� 57,c1 �� C�e�z/-C
Lot Size: 8� SsU Subdivision:
�ertv: �nSR n9 �P� �,.p� r�l; l
4) Proposed Use and Type of Structure:
Residential ✓ Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes ✓ No (with plumbing: Yes ✓ No _�
Garbage disposal: Yes No ✓
5) Water Supply:
Private Well ✓(Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No ,/ Yes
Lot #:
(please show location on site plan)
Note: A comnleted annlication must also inc[ude:
➢ A plat/site plan of the property that shows property dimensions and the size and [ocation of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the property 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): ����,t° ,�`-(ilc�., Date : Z �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Application Date: �`� � y�� � Tax Map: ���
Amount Paid: Parcel #: �, I �
Receipt#:
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Application for Services (Septic Systems and Wells)
1) Services Requested by: �r
Name: %��, � �.�.A � Ls \^C. Phone # (home):
Address: (work/cell): _
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Lot #:
4) Proposed Use and Type of Structure: t r� ��-� ���� —( G%�' (�
Residential Business/Type: Other �� _ � � � � �
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No
5) Water Supply:
Private Well (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes (please show location on site plan)
Note: A comn[eted apnlication 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 property 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):
Date : � - /D - Z /7/�
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map #:�
Approval Requested for:
Parcel#: 1 �
✓ Nlobile Home Replacement
Building Additaon
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Permit Located: Yes ✓ �o
Installation Date: —� Design flow: �l� (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: V Well Public oz Community
Wastewater system shows no visual evidence of failure on: f 2–��–/ U _(date)
(Applicant's signature if site visit is not required)
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Envir nmental Health Specialist
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11/15/OS
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Name ��, i, ���� � � � ; "� � %
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Authorized State Agent
Si'�E S�TCI�
Tag Ma.p #�.Pa:tcel # Z�
Section/Lot#
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Date
System components riepresent apprnximate�contours only. The contractor mustflag the syste»a�irior to
begin�ring the iristallation to ansure thart pmpergrr�de is maintaaned
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