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Amount Paid: ._,: �•� `i ��� " �� Parcel#: �
Receipt #: �' � ����
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0 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 (ATew/Replacement/Repair)
$300.00/$200.00/$.75.00
�lication for Services
Services Re uested
0 Construction Authorization
Fee is de endent on the e of
0 Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: •
Name: /1 N s se II ��me �
Address ll .� Old H� c k ar D�
�oxhwre ; NG ?��73 �
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 'lJ/ �" Z 7 Z" 4�1 � I
(work/cell):
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property:
❑ yes no Does the site contain any jurisdictional wetlands7
❑ yes C�no Does the site contain any existing wastewater systems?
� yes C'1 no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C'f no Is the site subject to approval by any other public agency?
0 yes ❑ no Ar.e 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: 3 I Occupants: y
❑ Expansion of Existing System If expansion: Current numb�e/r of bedrooms:
❑ Repair to Malfuncdoning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? � yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building: /�CL�
Maximum number of seats:
5) Water Supply: C�New well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing wateriines on this property7 ❑ yes C'f no
Please note any known ground water restrictions or sources of contamination:
�
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted � Innovative 0 Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. l also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner! Legal Representative*)
* Supporting documentation required.
lI/Z �/�7
Date
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evatuation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N��27573 (336�97-1790)
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Site Plan
Name: �
Subdivison:
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dress:
. Lot:
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System Type: �g
Septic Tank: �DDD gallons
Pump Tank: � allons
Total Linear Feet: 00
Max.Trench Depth: 2 "
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Tax Map: /-�ZS
Parcel: �
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EHS: �
Date: /��/ � � Scale: / � _ /,� �
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Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additional Comm�nts: �'�/yf�.•t/i h1�L1 �� �D�t/�/��/�Ait/.�rGI2/I✓l�� /.3� ��'��DJ
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