A25 4Application Date: � 1�
Amount Paid: L
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)
$3 00.00/$200.00/$75.00
�� S � ���� �� Tax Map: S
�, � • - � Parcel#: �
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Services
1) Applicant I�rmatio •
Name: ..�,G. `1 .� V � �
Address: � C% � �� `c� •
for Services
Construction Authorization
(Fee is dependent on th�e t� pe of
Permit Revision
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size:
Address and/or directions to Property:
Phone (home): ��o " ��1�' 4�i��
(work/cell): �-; („ — �C) �-1 — � 1 � �
Phone:
#:
��}'es C�no Does the site contain any jurisdictional wetlands?
C3yes ❑ no Does the site contain any existing wastewater systems?
❑ yes C�'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?
❑ yes m no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
�Repair to Malfunctioning System Will there be a basement7 ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze 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 property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If pplying for `Authorization to Construct', please indicate preferred system type(s):
�Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 cert' that the information provided above is complete and correct. I also understand that if the information provided is
inac + rate, the sit s su equently altered, or the intended use changes, all permits and approvals shall be invalid.
� � 1 I�
�\Signature (Owner/ Legal Representative*) at
'� Supporting documentation required.
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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)