A27 254AQalication Date: —�!z'
Amount Paid:
RecEipt #:
Tax Ma #: Z
ParcE! #: �
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�aa�-�.a-am9�a�� .Da:a��31. ��o�.���ia
APPLlCATION FOR SERVICES
COPISTRUCT SHALL BECOIIflE INVALID.
1) Pertnit request�d by: (Ownedagent/pros�aective owner): ..v%�v �� �
Home Phone: ,,��- tY/SF Address: 'z2z. �
Business Phone: �y-��.2- ?�� � ,� tU� . �'rJ'7�
2j Name and address of current owner: .SA�
3) Property Description: Lot size: �� Township:
Directions to the property (including road names�and numbers): _
Lot #
4) P'roposed Us d Structure Description: answer eactt of the foll g questions:
a) Proposed� Existing= Type of Structure: INl�tw >�n ��t._, Width: Depth:. �,
b) Number d Bedrooms: � �. Number of occupants or people to be served: � _
c) Basement Ye�J No _ Will there be piumbing in the basement? �
d) �arbage Disposal: Yes � . No _ �
5) Water Supply. Type: Private (new _ or existing�, Pubiic� Community� , Spring _
Are any wells on djoining property? Yes_ No _ If yes, please indicate approximate location on the
'site plan. � . �
S) Does your property cantain previously identified jurisdlciional wetiands? Yes_ No�
� . _
PLEASE MOTE THE FOLL�IMNG:
➢ A PLAT OF THE PROPEiiN OR SITE PLAiV MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERiY LlNES AND CORNERS MUST BE CLEARLY MARKED. �,.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STia►f�D OR FiAGGED.
➢ THE SITE MUST BE READILY ACCESSiBLE. FOR AN EVALU�►T10N BY THE HEALTH DEPARTME3VT
STAFP: �
( hereby make appEication to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described p operty. I agree that the contents of this application are true and �represent the maximum
faciliti��.s to be piaced on the pra�erty. I�understand if the siie is altered or the intended use cfianges, the permii shail
Owner or Legal
L -/���
Date
PCND. re�. 06127102
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�JL71.�.�'`V+iiillt'1�11 �r�1{.,G4� ���n..�
�ua�c�ag �lddifao��/ l�obile �o�e Rep�ac�ffi�ent�
- T� � #: ��7
Approval Requested for.
Applican� Name:
Address: • �
Phon� #'s:
r��#:�_ � �
Mob�e Home Repla.cement
� Buildi.ng Addition '
, lis'�- X�22 �-72on
es V No
Permrt Located: �'Y
Installation Date: ? Design �flow:. 7 (gpd)
CutTeat Contract with Certifie Operator on file (if requirec�: � �
W�ater Supply: Well Public or Community
Wastewater system shows no visual evidenee of failuc� on: I�� 2�1-n� (date)
� (Applicant's signahue if site visit is not required)
���r�����, . ._ �,. �
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� � Addition/lteplac�an�nt Approved .
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�'ZS 07
Environm tal Heaith Specialist � Date
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SR 1306 60' RJ�iI
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p = 05-9-28
R = 1909.64'
L � 177.4B•
LC � 597•IB'00'W
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SITE PLAN -
N� D�Ui Q Tas Map # Ti7 Parcd #�
Subdid ' L Semon/I.or#
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State Ageat Uau
SYB� �P°a� ��'PP� cmmras ualy. Tlie caaaecrormusrilsg rhe syarem pcar m 6eg�a�g r6elas�aa m
;.,a,,.r �PmPergadeJamsmmrne�
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1. You must su�mit a site plan with your agplication. A sampie site plan arid site pian wori�3�t are
• attache3.- Be sure to reaa what pon need to s3iow.in tbe site �lan. (:hec3t ihem af as yon draw thean on
- thc site plan � � .
Z M[a�t a31 PmP�' ��- � Pr�P�Y iines witi�in 25� �xt aithe proQase+d honse sta must be cieariy
m� and an�readii� identifiable as properiy lines. If yon are propasing to sabdivide your
p�operiy, � yom m�st � tfie pmposcd loca�n af aIl new groperty l'mes:
3. If the lot.is too thic�ly cavered wifh trees,.falien trees, imd�zhra�, ur othe�z mateaal then you w�l
need'to. clear to the exteat that a pesson can get onto ti�e Iot and mnve amnnd freaip. IF YOU
CI:�AS Y�URP�i)�TY, �E �CaR�v NO7C 9'O D� TH� L�ISTING 30�L�
� This cauld adversaly affect.the outcame of paur evaluation. If yon have any questions, Please caIl tha
. Person Gntmty Envisonmental Health Offic$ at (33� 597-1790.
m
_ :. . 4. Mark the proposed house sitt. The pmposed hause sit� camcrs �st be staked out on tfie properiY
.'..' ' and i� mustreasnnablq mat+e3� thc site plan submitted with tho application. • .
5. Post the bright orange sign with yom name an it nezt to the roarl so that we can ideutify your
P�P�9• . . ' .
6. �VVhen you have camplete� these items, sign the statemeIIt belaw and retam it to �on C.annty
� Euvironmentai Healtts at 2fl-E Court 3L, Rnxhom, N'C 27573. This statea�enL w�1l.serve as .
canf�nation that yom loChas been ��ed ecx�ding to.tbese insizuctinns. Onc.-, we �ive this
canfiunatims, w�s w�1i. move it to activ� staxus. Application wiil be porocrssed 'm� the 9rder that ,
canfinnation was recaived. ' �
7. I-� when we amvo to evaluate yaur p�oQerty, we find thai it is nat p�s�ed arxarding to these
�trvciions, we v�71 placa yrna apgiication on mactive stams. _ We wi'il reiurn yom� appli�ation b�
acsiva ssa�s when we have cu�mation that the propesty, is prc�ared propa�p. Yoa w�11 be notified.
if �is ocams. and you w�71 be req�d to notiiy Environme�tai Health Section upon c�anpletion af
site pre}�azation. Yaur applic�tion.� bc handled in t�so a�der that the canfirmation was recaived.
8. If �au have aay.qnesiions about what is axpe�ted, Yon si�oi�ld c�ll � a�cs at poar.ssrIiest
� c�avenievice and aek iat asais±bne=.in ordet to avoid any pos�ille de3ay5 due 6o ia�Capes site p12u2 ot
Iot prcp�eation. An eavironmentai hea�th spe�ialist cau be nac3ned. hetwr,cn 8:30 aad 430 a_m. and
between 4:30 and 5:00 p�. at (33b7 5�'1 17.9Q. � � .
Ma�i or deiivertiris f� to: Pe:soa Canuty Envaonmr�tai Heaith •.
. . 2U-� Comt St�t � � �
. . . Rozb'om. Ne Z75T3 . • .
�� V ! �� ��Y �9 � m9 P�P�S'* ioc�ted at
�2 � Q has heen grepared far s�e �d soii
evatnation in a,cx:�rdanc� wiii� ti�e lot p�azation 'snstr�cxions 3iste� abnve. I undestand that ia�iure tfl �.
prep� mY P�Pcm� in ac�ardaa� with t#use msorncti will msait in p1ac..ment of my application on
ina�tive status uni� t�e ProP�Y � P�� I�P .
Siguat�e of �Ii�an� Dare: �� �