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A27 341Application Date: g a�' � � Amount Paid: 1� Receipt#: ,�0 5 8 I � _ Tax Map: � � � Parcel #: 3 � c�-�-�— �...,��_s� �I��$�C�� � - � � � ���� 1I-�'-�-N-a.0 .���.-�.-� ���..m.11 IF]I�c�.�.11�lla Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the e of s stem ermitted) obile Home Replacement or Building Addition ❑ Permit Revision $150.00 if site visit re uired) $75.00 O Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 '•� •� � • �' l. /, ���� -� 1 r��'���i��r�s'�lrl � ��t • , . - �.�.�'"'"_�— -- Phone # (ho e): (worWcell): ��<�� �{� 2)Name and address of current ow er (if different than applicant): Name: {y�� Address: l • � _ 3) Property DescripNon: Lot Size: `S �� Subdivision: Address and/or directions to Proper�: __ _��---7 (1 or .i , n . ,_ . � . . ., '� ea 1� � u �l � til � �O �' � t�� -�i ntie �-o M e�.'� ��J�'�1� Lot #� La�a� c 5�#' 7 Q,,,,, �a. C 4 � -d e "S�C. 4) Proposed Use an pe of Structure: Residential Business/Type: Other � Number of bedrooms 3 / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No 5) Water 5upply:� Private Well l (Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the properry that shows property dimensions and the size and location of a[l proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am subrnitting this �pplicaticn tc request services fro�r, t�e Derson County Health Dep�rtr,ient. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): Date : � 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) e��,�� 1�1�' ���11� �� ����7�� �1m�9';Y]['��rn �emm rg971¢1R.11 �C 11iD�.��C�['R 1 �I'I'E ��'I'C�-I Name �ev � � �i � ��n Ta.g Ma.p # I� 2� Pa:�cel # �� � - Subdivis Secrion/Lot# _ y�-2.9-I� Autho�ized State Agent Date Systera co�nponents r+e�resent appr,nacir�aate�contaurs only. The coniractor sq$ust, flag �lae syst�rrz�iraor to begin�ing the instadla�iora to ansure that prnperg�rtde is rnaini�ained �u�. `�!C' � im e F?t % c,,s �� �, i� i,� � r�a v,��t� -t��, w� a � X i s-f�it -�a v� � 7� �° � � S fi � � _� '�' `��--c��`� � � � , �� � s,� r Ey � "� ae �. ��;�,i �„�� � gY `'�^ �' � _ � �fr�� �`'e � �:Ij �� ��x � � �.. ���.���,�fi� � �:�# f����,S��x'�, k} �t��"�`Y.��S�'�� pt'� y��T� i �� �`yd'�a �. �,�`'�„ r-.r s� .9 �. } � °*' � �"'''�'k+a� � F����.Y ,x. �ri�;'�.��a�t�r�`z�;s, F `�,� ',��.a��`�� �T�'Szat`�" � �� � �� :� I �� . 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'' i• '�`� 'k i �.� ' J ( . a �' Y � � � j( �� j �� y,..' a �s f � '�;I;4 � �r �y�:,�'*: ' � u �,t.�.�i ��:. � .... � � �� � �� , s__ _ _ . = . � . -.-1 0 �.u�� ..� � `�� � � , � � � �: �, a ,� �`,��y�- � � � �v-. 7 � , �.J `L..:/ �.J� �5;� � Tli 1�.'.s:R'�t.�`Ii1L� {CD:�'.,1.J13']1.�� �.i.73.t�.�.R.�1 .�� �C:c`iL 11 t�.1�. �uun���aa� r'�&�Q�fl$Il�flfl�I PV��I�D��c� ��Il'�fl� ���D����flH��2�Il�5 Tax 1VIap #:�21 Parcel#: 3 Approval Requested for: �/ �Home Replacement Building Addition Applicant Name: .S r � �. Q c� i' Address: Phone #'s: _ 3 3 i�' SS 3-� 4?� Permit Located: Yes � No Installation l�ate: ? Design flo�,v: 3(.e p(gpd) Current Contract with Certified Operator on file (if required): Water 5upply: ✓ Well i�ublic or Community Wastewater system shows no visual evidence of failure on: �- Z`� -1 � (date) (Applicant's signature if sits visit is not required) >�� �hK� � A��Il�go����a������nt �g��a°�a��r� �'- ZS - // Envir ental Health Specialist Datz 11/15/OS ��� �� l�'J�.l�.� �1.�! — , �_ � � ��°� 1�„��y�,Y,,,,,,,,,,��¢,m.11 ]HL��.11� ; �I'I'E ��'T��-I Name �� v� S o��i�e���n� 1�, /_ e�r��a �m �f� Ta$ Map #� 2� Pa:tcel # 3� 1 Subdivls Section/Lot# 7 r `� �—� . / �.-., — � �Authorized Sta.te Agent Date System cumponents nepresent asppr�xir�aate�contours only. 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