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CONSTRUCTION AUTHORIZATION . # <br /> I A CONS 1RUCTION ALRIIORI"LATEON IS NEEDED 171 OB TAIN A RVILDLNG VEIL►HT AND INSTALL A NEVI IC NYSTEMI <br /> ❑CONSTRUCTION Ai1T11ORTLATION FOR NEW C CONSTRUCTION OR rXPANSICIN ... . .. ..S 325(lip to A06 GPD) <br /> ❑SHE REVISIT TO REw uE OR MODIFY A VALID CONSTRI)CT1ON A[MMRIEATTON S I S$(Ilp to 00 GPI]) <br /> • CHANGF_S TOTE[E 1;1TE PLAN,FLOOR PLAN,OR APPLICATION REQUIRE.A NF.W APPLICATION AND ADDITIONAL F'Ef—k <br /> • SYSTEMS WTTH A DESIGN FLOW OVER 090 GALLONS PER DAY►►TLL REQIJME ADOMONAL M.S. <br /> SYSTEM TYPE MUST lik RE U691 ED FOR CONSTMVC1TON AL`111ORMATION <br /> WELL PERMIT SECTION <br /> [] NEW ❑REVLACEML I" Q tRRIGAT1OY• <br /> ❑MONITORING WFLI.(PER WELL.FIFLI]) ❑CTROTHERINAL WELL(PER WELL FIELD)..........S535 <br /> "•Wei permit fee includes inihol treScr nmpics Enr water mpply-cils. <br /> If The wd will scar more then one Purpwc(ucump lc-do nling wafer supply AND gcuTlKnini),kndtate ui rm page I under-Ikscnbc your pfojc&'. <br /> ❑PFRMTT 11ENE►1'AI,AI.TEkAT1ON,OR SITE REVISIT....--...- ... .. .. ... ..... $155 <br /> ❑►i'TLL REPAIR PERmrr CLNNTR INSTALLATION.DEEPENING OF Fx1STTtiG LVFI-1 HYDRO-FRACT URTNO) -. NO FEE <br /> ❑WELL AHANDONAErNT .. . .. . ........... ....- .. .. - - .. ...ND FF.E. <br /> CIIECIi THE RO7i AND SHOW ON THE SITE Pi.r►N IF ANY OF 77iF:FOI.I.O►5'[NG ARE.ON OR ADJAC E TT TO THIS PROPERTV: <br /> ❑EXISTING SEPTIC 5YsmmS OR SEWER L.IRZS ❑CHEMICAL OR PETROL-rU-M STORAGE T&NKS <br /> f- ■ ■- ■ ■ <br /> ❑T:XTSTTNG SEPTIC SYSTEM I WELL AUTHORIZATION WSPECTION WITH NO LNCRCASF TN►VAST]•:FLOW-.-..S 155 <br /> ❑MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE....... .. ................... ........ . S 95 <br /> ❑rN-OFFICE REV IEW FOR Ai,-THIORtzA'I'ION ....... ..........................................................-................... <br /> ORIGINAL OWNER 51"STICIII IS: ❑IN USE or ❑VACANT since {dski <br /> SECTIONSIGNATURE <br /> TOTALAMOUNTDIIE S KE:CFIPT+r <br /> Make checks payable to:Orange Counry Health Department <br /> 11T.F.ASF ['HECK ►YtI-Ti F-L,'►TRONM FN-TA[_R F:AI'I'(I STA FT TO DISCI_SS_11W .AAfOt 1tir Q V APDITTONAT.FEES FOR >v ON'• <br /> HURDEM1[TAT-PROJETTS ANTI F[Q IFS T.ARr:FR T I,8N i RFTIRnQj1C, <br /> 'LIFTS APPLICATION MUST BE: SIGNED RY THE. CURRENT O►VNER OF THE PROPERTY OR 7111E OWNER'S LEGAL. <br /> REPRESENTATIVE: M.p.,SPOITSF KAVER OE ATTORNEY,EXECiiTOR,OR OTHER L[C}NS£D PRoFESSTONAL(ATTORNEY, <br /> REc.ALTOR,BUILDER.e1L)► HO BAS I:%i'ERED INTO:►CONE'iCAC'i'QR[JASE WFTH TIiF:OV^'ER.%N0 WSO CAN LEGALLY <br /> REPRESENT'tTTF PRC7PEWrV OWtiI::IC LN TRANSAC'11ON"SREGAR111NG'rIIE PROPER'1'1') <br /> ONLY ORIGINAL STGNA C(,'RES(NOT FAN ER)CAN BE ACCEPTED. <br /> I AM THE PROPERTY O►VH'ER OR TEIF.PROPERTY OWNER'S LEGAL REPRE.SEN'TATINT—I HAVE READ TEAS APPIACATTON AND <br /> AIA'HOR[7F THE MID TO ENTER TIrE PROPERTY ANND PERFORM THE.SIER►1M,,I REOTIE.SEED. <br /> I UNDERSTAND THAT 1 AIN RF—SPOtiSIAL.0 FOR NIA KING T11E SETS ACCESSIBLE FOR THE EYALUATIONMERINH L 111 C <br /> APPLICATION a; QUO CONFlRME07 <br /> DATE RECENED: REVIEWED■Y: ASSIOTJED TO; <br /> NOTES: <br /> SAPNVIRDNMEN'PALIMALTH SERVICI:S\MI MANAGEHS\Budget yid FwmccSudge,I6-l'2 k.►[r APPLEC:ATIONjuly 20151ocz OCItD <br /> a7n a <br /> Lem P <br /> 126 <br />