A25 81Application Aa#e: y 3C -� �' / rf� Ta�c Map: !� Z�
i� I C 1 4 l l l l t � S 1 C l: � CJ. � v� �r �iITG�� #: �,
l�eceipt#: �2.1 �31
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� Application for S�rvices {Sept�c S�stems and W�Ils)
Services
Improvement Permit (Site Ev�
, $200.001$340.00 (if � 600
$150.00 (if site visit requi
� '9VelI Permit (New/ReplBcemE
$300.UU!$20U.00/$75.00
1) Services Req �e by:
Name: � / �F Gv�i �S a
Address• � �"
P �
�
is
❑ Repair oP EYisting Septic System
No�
Phone #� (ho ): " � .S ` - G �3
(woric/cell}:� 6� _ � -
2)Name a address rr �tt owner 'f di ferent thau pplicant):
Name; , :Q- � � �
Address: � 3c� / � �
iL, L
3) Properiy Descrrption: Lot Sirx�: �� Subdivision: T.ot #:
Address andlor directions to Prorerty: 3� �� /�lrG fE� ,
4) Proposed r7se and Type of Structure: � G,�t �� �7�'�' c
Residenti�l $usinessfl'ype: l�i'l � %�- Other
Number of bedroocn�� ! Number of people served (se employees)��v��itif.��
Sasement: Yes 1/ Na�o(with plumbing; �fes --- —. °,�_)
Gsrbage disposal: Yes
S� Water Suppl / /
Pri��te Well I/ (pmposed Bxisting �
Community Wel1: Public Water System:
A.re there we11s on the adjoining properties? No "�Yes (please shaw location on site ptan)
1Vnte: A campl�ted tc�nlicrrtio� must nLso rncLuale:
➢ A p!'atlsite pCan of tl�e praperiy tfiat shows property dintensions and the si,ze and locatton of alr
p�oposed structures
D A signed copy of the `Lot Prepa�ration' fornz ver��� tha�t the property is reardy to be evalu�rted
Y am submitting tttis a�piication #o request seeYices from the Person County �Yealth Depsttmen� i underst'ant� that
if the information gravided is incorrect or if the site is bsequeutly altere , or if t�e intended use changes, all
gcrmits �nd approvals sh��l beeome invalid. �
;
.
Signature {Qwner/Legal Representariy : - Date : �
� t
1010$
Person County Environ�mental He�►lth, 325 5_ Morgan St., 5uite C, �iaxboro, NC 27573 (336-597-1790)
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