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A27 34Application Date: � -��i -I 3 `��.5� ������T Amount Paid: j O,� �' v Receipt #: �3 7�1� � �' � ���� �':�mv+aa•aaTM��+�+�e�d,m.l� �c�mIl�. Application for Services Services Requested ❑ Improvement Permit (Site Evaluation) $600.00/$300.00 (if> 600 gpd) CJ Mobile I�ome Reptacement or Building Addition $150.U0 (if site visit required) ❑ We11 Permit (New/Replace�ent/Repair) $300.Q0/$200.Q0/$75.00 0 Constructiott Authorization (Fes is dependent or. the type of 0 Permit Revision Tax Map: � � 7 Parcel#i 3� Na Pern� � f � �oUud - ❑ Repair of Existing Septic System Application: No �hargc/ CA $150.00 or $300.00 ,r' � : �1) Applicant In rmation: Name: �o�.�es ��15�{�,r c�"i'�n_, �,� _ Address: laSb`� N.�((., �i?; n(�. � I u��ac�ri �-� (�� i � a- 2) Name and address of current owner (if different than applicant): Name: ,✓� � 17 l i�� o... w�. Address• S o�¢.,r��nc�,.._ �.0. � �2�x h� �� rver a�� � � Phone (home): � )g - `�3a - (0 0 3 S� (work/cell): Q 19 - 01 �c� - 3� o S' � Phone: 3) Property Description: Lot Size: �� Subdivision: � Lot #: Address andlor directions to Property: 3 S� e�a r� ��— ❑ yes o Does the site contain any jurisdictional wedands? �s 0 nn Does the site contain any exisdng wastewater systems? ❑ yes Q.aa' Is any wastzwater going to be gei:erated on the site other than domestic sewage? ❑ yes ❑ no Ts the site subject to approval by any other public agency? ❑ yes �-sr� Are there any easaments or right of ways an this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed ilse and Type of Structure: ❑Residential ❑ New Single I'amily Residence Mar.iarum numEer flf bedrooms: 3_ ❑ Expansion of Existing System If expansion: Current number of bedroems: ❑ Repair to Malfunctioning System �ViII there be a basement? CI yes ❑ ne With plmnbing fixiures? ❑ yes ❑ no ❑Noa-Residential Type of basiness: tvlaximum number of employees: Total Square footage of Buildin�: ol ��C o�� �jQ��� Maximum nur�be: of seats: �; 5) Water Supply: ❑ New welt �ting Well � Community Well ❑ Fublic Water ❑ Spring �� rlre there any existing wells, springs, or exysting waterlines on ihis properry7 ❑ yes ❑ no If a 1 in for �Authorization to Construct', pleas� indicate preferred system typg(s): � PP Y g ❑ Conventional ❑ Accepted ❑ Innovative C1 Alternative ❑ Othzr __�� ❑ l�ny 1 cerl� fhat tre ir fnr.ntaiion��rovia'ed abnve is complete ancicc�rt�cl. I also c�ttd�rst�xnd that i{the informatio•rc provided is inar.r.urate, o,r, �the site is subsequently altere�, or the intende� r.�se chunges, all pErmits and crpproi�als shall be ir.vali�? S�nature (O�vner/ Legal Representative*) * Supporting documentation required. �� Date o Permits are valid for either 60 months or are non-eapiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. � � � � �,�� ., ,: �- 1 )= i i � `� I� � �, t � . �.� 1 , �� .� �� �� � �� y � , a .-r .9"" �.�'� � �� � ' �1� � �1 � �,:�.z-�-s����_��.�.�A�.�i<� .',l '�-����.�.11�::� �a�a�d��� r�����m��/ I���bfl�� ��a�� ���nfl�a���a��n�5 � Ta.� IVIap #: q a�1 Parcel#: 3�i Address: 3�' �� s�c�a� Ro Appraval Requested for: Mobile Home Fceplacement �( Building Addition Applicant Name: ��hEs �a.-�-�x�cz►a�.� '�v�. p�wt�► b' o�ivc� l�i�ar►s Address: - Phone ,#'s: 919-`13�- b�35 y�q• �80 � 3qaS Permit Located: Yes )(, No Installaiion Bate: 11t�K►�a�..� Design flow: 3�� (gpd) Current Contract with Certified Operator on file (if required}: _�_ ,. Water Supply: x �ell Public or Community Wastewater system shows no visual evidence of failure on: '� as �� (date) (t�pplicant's signature if site visit is not required) Comments: � � y x �$' 6A�. �c�,s � . Ca4�. �GK(J � 33b� S9'1- IhqO ' � � -- �tr1������1��������a�e�at ��pu-��v�e�l o�.�,,x. Q. �.. Environmental Health Speciaiist as' 13 Da e Person Counrr Environm��tai =�eaith; ��� �. ti:orQan St., Suite C; RoYboro, NC 27� � 3 Fhcne: ��6-�97-??9C/ ra;:: ��6-�9�-7�OU � tv�%,^,�i.�,ersoncoun�tv.i,e� ���� � ,�/���j�� / I �\�� W`' `\_ v � �6 V Jl � J�a-a ras�aaaa'n�::zn�-�.]L 1L3i��u.��I�n SITE PLaIV ilame ��5 �r�t�� - twt: A�Al, � V�•-�v,t1 1�x::i4C�,y T�c �?ap #�� Parcel #�� S �� i�n � �ection/LGt# � +i . • `i � �S l3 <: uihorized St;Zte A.gent Date System components represerit approxfm�te corrours only. The contractormnsr llag tbe sy,rem prror ro be�ig the instal/ation to insure thatprnpergradeismaintafned. I �<. � �� ��� � 9�n�....n�n,?�n�n.�;�.11 1I�I��ll�l�n Building Additions/ Mobile Home Replacements Tax Map #: 2�1 Parcel#:_3N Address: 38'ZS ��nfa �, Approval Requested for: Mobile Home Replacement ✓Building Addition Applicant Name: 1.�Gt�g P� �)/ CD M P � o� Address: 4����c��� Pv� � r �,,� �r� ������ �(!. C� �73�13 Phone #'s: �� • �"03 - 33D� Pernut Located: Installation Date: � Yes �o Design flow; 31 a (gpd) Current Contract with Certified Operator on file (if required): Water Supply: �ell Public or Community � Wastewater system shows no visual evidence of failure on: -I a- l _(date) (Applicant's signature if site visit is not required) l� Addition/Replac�ment Approved � � Envir ental Health Specialist Jo - lo�ri Date Person County Environmzntal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty net ��� l f ���.��A � ---' t� � � ���� ' I����-������mIl II�[��Il�ll� . i ' y. f'. '� .. ���'; L�d •a., .�; _ ,I --__.____ Site Piar. Name: � Subdivison: _ Tax Map: �?% I Parcel: � I— ress: 3� 2� ��'►'IOtQ Fd. Lot: I EHS��.,` Date: %D–/D�–(`� r �-. � .k t. ' ��„� �ja"" : ' i $�;, ` ` ;� i �"' ".��' , � � ,� , „�t i �: M } � , � .. . �ti k �{.:. .. . .. ' f ..w✓W Y��,f•_.•r _ . � �r' � , ; `. ,� Si..� ..sf/'.n-� ' . A � � r , ' .' ....;.,.�' f �, .,, � � � ���: � e^" ,,,t• �. � � .�„ �,.�� _ ..,� _ ; � . . • .t. , : ' � �� ' ' i _. __ _ ' �} C; ;;' � -7 ' - r (� e a �� �,J 1,; � � � ; . . � ��, , ; � +�.. ���i �r " � ,�� / / � � .� . - ..a� ��-. . . �` �.� F I z ici � ��';� . . . � - - � � � - e� ( `-� Q.; �`,y � � _ I " ! ��' `� �, � ----% `�'R�..,,� _ � �: � . . �;`-= � � f +� -+� - � �. RS _ �a ,� � � � �� - � � � ., � � ". ___---� ���.�s� - ��l�rf►��, '.:� � � ;��� ��.1 � - . . S- ��. �.�_\ i� . � �� , , �.�- , � o ��� / � �, . �,��:- .. rn rn . ., �«; . �. t , �' �,.'�� " � � �, t � 1�'t ��, _ � tem Type: I - –_ -- — Septi k: _ gallons Pump Tank: gallons Total Linear Feet: Max.Trench Depth: " j I �. � � F ��_: � vrl.r ' . � �� ' �� � � � � � �,..,,. - _ �_ F � �w _�._ � ''� OI Scale: _�1 Note: 1) Drain lines represent approximate contours. Drain line locations must be f�agged prior to installation. �� Coniact PEf5Gi1 .r.:�Uilt`y ���Vi�01'll��:di �E��.�i'vV�ih �^'/ y::e�tions ,?36; SQ?-l��C. t Additional Comments: � s �