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4 <br /> Orange County Health Department-Environmental Health Division PIN, 01 S f'3)3 7130 <br /> APPLICATION FOR PERMITS <br /> Please mail yr bring in the tins rwo pages or this cnmpktrd form,with payment i net oding the sign alive of t r owner',a limes plan(where <br /> applicable)and a site plan as iadieatcd. A site plan assessment is requi rid from the local pi annin0 jurisdiction for your pxrccl. Ptease c01 our <br /> I11rcr ir"t,havr arty 9 uealinn.ahnul filli 11Z ou[Ih6 for m or[he amaun[rd'DNV Mtn[nredEd,Please Is• a or rint[r>:iWr. <br /> GENERAL <br /> rr i_ INFORMATION <br /> APPLICANT,:` .L.�'7 SST Vt �• �I PROPERTY nR'hT.i{: ��i� U.'1 �,y.r�► it P.c LA <br /> AI7ISRk5S T ADDRE-_% 7c� �.t..�k44w e) _ n'-EI a- joty`L'e <br /> Ca±■. __ Iti fu:F r 4 r�1Alr __ Fi d � __"Cum Ce�,..s PS•d Yn <br /> MTO&,,7,UMBER 1 (.2-25�— PHONL•NUMBF•.R q 1 a 1jS 7. 1715& <br /> LOT S7-E SURDf4TSION 1 LOT'R � DATE T.OTRkC0RDI;n <br /> LOCATION APDRFSS: - ]7TRF�LTIONS I U)CAIION. - <br /> PROJECT INFORMATiON <br /> ❑NEW BUILDING []EXPANSION i'O EJCISTM FACIL.TTY �SF.YTIC SYSTEM OR WELL RE LPAIR <br /> ❑1VEI.T,OR SF.YTTC Prxurrf REMWAL 0 PERMIT RFV ISIO\' r <br /> ❑ARANDONMENT OF WFl.l.OR SEPTIC SYS•1T3M OSMOPIIS1OVIRFCONE1INATION OF PROPERTY <br /> PROJECT DESCRIPTION., <br /> OcUNGLI:F A tiIT1.1'1I0ME Sve Number prSedrem". Number of occupants; <br /> D—,fT-T_.TI F•IYTfi.1I:APA.RT1l F:NT 1 FFF.I.C{E\f'Y G[IF C7H(3I'•SF <br /> �w Ri SfIti P:4S/f1'fNF;R �_ <br /> Please describe the business,number of employees,vilrarle foalage,etc G'se arladfulews if neeessar{. T <br /> -DYE OF WA TElt SLIPP),I- PL PASE CITE CK IF All Pl[CA01-E: "F ID SY 1T %1111PEI <br /> []Pumw ❑SASFME7:r µTill PL['Wi LNG ❑Aeerplcd Trench(25°:rcd.)- <br /> 0 PR'VATF WELL ❑WASTEWATFR OTHER T1IAN SEWAGri GEh'FRATf-T7 ❑C.onvwtiamal grariq <br /> O CO,/fMUNITY RT:I.L ❑PROPERTY CONTAINS DESIGNATCD µ'E"rLANDS [,]Inlnrvalivc <br /> 0 C)TIIER 0 Sflw IS SUBTECTTOAf'PROVALL BY OTIIERAGk.NCY ❑Odsir, _ <br /> ❑WILL HAVE A GARRAOF f)TSPOSAL OR WATER SOFTT•.'NER ❑Pump to: <br /> IMPORTANT:ALL APPLICATIONS MUST CONTAIN THE FOLLOWING 1NFORPAATION IN ORDER TO BE PROCESSE>J <br /> -A SITE PLAN OR PLAT SHOWING: •EXISTING AND ANY PROPOSED PROPERTY LINES EEA EMENTS,RIGHTS-OF• <br /> WAY.,AND BUFFERS WITH DIMENSIONS;SITE PLAN ASSESSMENT FROM LOCAL <br /> PLANNING DEPARTMENT WITH JURISDICTION FOR THIS PROPERTY <br /> •LOCATION OF ALL PROPOSED STRUCTURES,DRIVEWAYS,ADDITIONS,OR <br /> OTHER IMPROVEMENTS LABELED WITH SETBACK$INDICATED. <br /> -A FLOOR PLAN OF THE STRUCTLIRE- (NOT REQUIRED FOR WELL OR IIAPROVEMENT PERMIT APPLICATIONS <br /> FOR AUDIT)ONS, A FLOOR PLAN SHOWING BOTH CURRENT AND PROPOSED <br /> STRP'FVRES IS REQUIRED <br /> THE FOLLOWING MUSS DE_STA_VIED ON SITE: LOCATIONS OF PROPOSED STRUCTURES; XISTING AND PROPOSED <br /> PROPERTY LINESICO•RNERSIEASEMENTS;STREAM BUFFERS <br /> Check A11 Sections That Apply: <br /> EVALUATION ■ SECTION <br /> (T MS IS AN EVALUATION OF TTTE SOIL.FOR A S£PTTC SYSTEM) <br /> 0 LVTROVEMF.NT PERXIA-(Up to 600 GP D) NUMBER UP SI71=5 a ..$435 PER SITE <br /> ❑ INDIVIDUAL LOT ❑ SUBDA'ISIOY• ❑ RECOMBWAT-IoN" L]EXISTING SYSTEM 0 FXP,LXSK74 <br /> O SITE REVISIT TO REISSUE OR K40DIFY A LIAI,•TL)1MPRUV-MF, PFRief[T{with no wcreasc rW-) ............................S 155 PER S= <br /> £AC11 SITE EVALUATION C0141STS OF UP TO 1 ACRF,S EVALTIAT I:n, <br /> PROJECTS GREATER THAN 5 BEDROOALS AND NUN-RESIDENTIAL PROJELTS(>600 gpdy RFOUIRE ADDITIONAL FEES <br /> PLEASE SFF.RYALTH DEPARTMENT FOR SPECIFIC I,N'FORNIATION. <br /> PROJECTS GREATER THAN 5 BEDROOMS,NON-AL51P£.4TIAL PROJF.C'TS(>600 gpol A,N➢SVIIDWIS[ONS REQUIRE TTIAT'IIIE <br /> APPLICANT PRG►WE.A RACKHOE AND OPERATOR❑N SITE TO DIG PITS. <br /> "FOR SUBDIVISIONS&RE-COMMATIONS,A CONCEPT PLAN APPROVA[,OR A FLAT PREPARFl)BY A SURVEYOR MUST BE <br /> SUB?v rrff-D R'1TII THY.U'PLIC:ATTON, <br /> S-1FiNV[RONME\'TAL IIIIALT11 SERVIC'T•«S�Ji MANAGERS`•Rudget end Finunccl9udgcl 16-1711IAMTC APPLICATION july70.'6.ducx 0CM) <br /> f17JIS <br /> 125 <br />