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A26 212Application Date: � � %"�•Z Amount Paid: � �0 . U O Receipt #: I a I!� 7 d � 3��i% � ❑ 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: .._..,."� � Parcel#: �_ � � ���� �t",,�rn-i nn-�nsa.v.xn�:2nd.s..Il 1HI�r.,s�..Il.yiL-n. tion for Services Services ❑ Construction Authorization (Fee is dependent on the type of system permitted) 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: (,�j r� �(, ►�,.,,.. (�J 1+n. n: � v tM. n c r Address: B3 3n � �p�w�iriclG (L�, �', o oL �.� r-a �f�. '�'t S Z 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: �c, Subdivision: Address and/or directions to Property: Phone (home): 3 3 � S� � o��3 (work/cell): 3 3 6 5 v� o t 4 q Phone: Lot #: ❑ yes � no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � 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 � 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 I� New Single Family Residence Maximum number of bedrooms: �- ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes I� no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square 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? 0 yes ❑ no If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other 0 Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequer�ly altered, or the intended use changes, all permits and approvals shall be invalid. ��� Signatur'e (�'wner/ Leg�dlRepresentative*) '� Supporting documentation required. /- � 3 �� Date 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. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � H O � � W U � a ' APPLICATION FOR SERVICE.S Improvements Permit. (EstablishedJRecorded Lot) ImpFovements Permit (Unrecorded Lot) Iinprovements Permit (Mobile Home Replace) Improvements Permit (Addition) � of Existing System (Loan Closing) ace existing Septic System for New Well _, Replace Existing Well 1. Permit requested by: . /� 7. Dimensions�or Proposed Structure: I owner/prospective owner/a� get�t: �l" �► Width: . , , --- �/_.�,,1- �-,,,��,/��.1�. _. Depth: ZS�S,�� 8. Whatrype (if any, additions, expansions, or replacement is anticipated to the structure or facility ��� tha� this sewage disposal system is intended to serve? ome Phone #:/�,�1• .r�/"/1 usiness Phone #: Na e and addreSs of �urr nt owner: 9. Water supply t}�pe: / privatei'�public ❑ community ❑ springp �-� � ,�1 � Are any wells on adjoinin prope y? es`.� No �. � -� ^ �� �, ; - _ _ , f! � �i,�—/ / _ If so, identify location:� 7 � ^ ��- . Property l5escription: Lot size: . Tax Map#: � Parcel#: - Township: �� �� - �. Directions to property: State Road #& Road �a Numbec of occupants or people to be served: Z 10. Type of structure/facility: Proposed: g,Existing: Q Type of dwelling: House: C� Mobile Home: �Business: ❑ Type of bus' e&s: � .�— Number o Number of bedrooms: Garbage Disposal? Yes�.,,'.� o Basement? Yes ❑ No�i 1f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES• I hereby make application to the Pei'SOn COunty Health Depat'tmeni for a site evaluali� tion ahe �e ite sewage disposal system for the above described property. I agree that the contents of this app and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that nderstand hat in the ev nt have note issued, I must present a survey plat of the property to the Health Dept. I delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. � tij - , . - � � Z Signe� O ner or Authorized Agent permit Issued � permit Denied �❑,/ Plat Observed L`� Signature � Date i2.�o-��. , RECOMMENDATI ONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, Fill areas, wells, water bodies, slope patterns� C�C.� C:IAMIPRO�DOCSIAPPSEC.S�1 FINANCE.PC .. .. v � �� � f . . « ,. i �- . ,;, �� �� �� , , - �, •�; ... 4 5 � � _ L ` �.. " - � �� , t � y n' , _ ^ � I � - . , �.� � \\' l � , . �. r: j' �, 1 I �!`N ' ���r ' . ► �6„ �. �3p9,..� , � � ��-- c '°;1 . . - - � S R' L h%i o � ' '� � - I '/. 'rn O . - .E •�� �, < 1'n �-- 2a - � � '^ � 1 , 5. �5 Q9 � �6 ''� i�'. � � ='��/ . N 0 _ � � � S 1 � -� N .iD � • U �, N w ; w O .I L �o �, Y) N � � � •� 1 M� y I c ''v �' 0 � _. �. ~I � 1� � D c) � ,b6 B6b 3�90'9b-10-N m d � 7 � N �oa o`' , v v �� MqGNETIC .� NORTM >x J . .. G � � � � � �� � --� 1 � ��� � � �a1A�' ; �. .....�s�*�! ` � � ��J �J� � �l � � J:l.�:.-�:R''�'�.n'"Tt7i"<[D:!�i,.T1:�7L�S';��]i�.EL.II �.4..!!.<L':.c`A.11C�� �un�����a� �c��a��a��/ PVg���fice ���a� ��������n�an�5 Tax Map #:�_ Approval Requested for: Parcel#: {� Mobile Home Replacement Building Adtlition Applicant Name: J� I; �� i� w� � orvt a 5 �c� m rt e r Address: o G 2 Phone #'s: �q 7— R' Z3 Sa �— D/� Pernut Located: V Yes No Instailation Date: `% - �$- q 7 Desi� flo�,v: l.�D (gpd) Current Contract with Certified Operator on file (if required): Water Supply: �/ Well Public or Community Wastewater system shows no visual evidence of failure on: 2`�` I 2 (riate) (Applicant's signature if site visit is not required) I��W ���fl�aoa������a���� ����°�d�� Z /'/Z Enviro ental Health Specialist Date � 11/15/OS � �1��J� / " �l1LJ�+Y �l.�l/ \J �� . ��_ ' l j� �\ T ^^ � � `�J 1 V �� �l '..J171,Y il]L•�lrn lr'RT �L'727L��.� ��L�.tfl.11lC�YD. �I'TE ��'TC�-I Name ��a � I I a nn �u w� n�' �' Ta,g Ma.p # ZL� Pa�cel # 1 G� Subdi � ' n Section/Lot# � Z- Z'�j� Autho�ized State Agent Date System cvmponents re�resent iappr�xirtaate �contours only. 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