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1 <br /> GENERAL ■RUATI <br /> ■ <br /> APPLICANT: �►vGr4s �+�+ R.'Le PROPERTY OWNER: 6b ken an aatcloor 4r.�a .� �l.�3>Irr`cs�►c <br /> ADDRESS q3 a 0 C/&S t-4-t L �►� ADDRESS PO OOX 10 55 13 0 '? Ave <br /> � d IUc_ 27 zq3 9,z e6 4, Air- Z76o5 <br /> PHONE NUMBER 1I g 3 O 1 3q e o PHONE NUMBER too jj Y _qq33 LJC,, �-� <br /> LOT SIZE 161-05 SUBDIVISION/LOT# DATE LOT RECORDED <br /> PARCEL ADDRESS: c�j 1y' DIRECTIONS/LOCATION: <br /> [� <br /> cf Is this application for a: ❑NEW SYSTEM ❑ REPAIR ❑ EXPANSION ❑RENEWAL ❑SUBDIVISION <br /> For a: ❑SINGLE FAMILY DWELLING Size Number of Bedrooms Number of occupants <br /> ❑APARTMENTlEFFICIENCY/GUEST HOUSE <br /> GRBUSINESS/OTHER c 1,�'11►.rrn/,►� ctrrwY �,c"+r1 --- _ <br /> Please describe the business,number of employees,square footage, etc. Use attachments necemo y. <br /> TYPE OF WATER SUPPLY PLEASE CHECK IF APPLICABLE: REQUESTED SYSTEM TYPE: <br /> ❑PUBLIC ❑BASEMENT WITH PLUMBING ❑CONVENTIONAL <br /> PRIVATE WELL ❑WASTEWATER OTHER THAN SEWAGE GENERATED ❑OTHER(SPECIFY) <br /> ❑ COMMUNITY WELL ❑PROPERTY CONTAINS DESIGNATED WETLANDS <br /> ❑ OTHER ❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY <br /> Check All Sections That Apply <br /> ❑ WELLPERMIT <br /> _ SECTIOU # <br /> ❑ WELL PERMIT-NEW $230 <br /> ❑ WELL PERMIT-RENEWAL/ALTERATIONS/REVISIT S Ipp <br /> CHECKU13T THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT: <br /> Q A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES. <br /> Q THE EXISTING AND PROPOSED PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. <br /> ® JIM171114Z • # �3 <br /> EXISTING SEPTIC SYSTEM INSPECTION $ too <br /> ESCRIPTION OF PROPOSED CHANGES/REASON FOR INSPECTION: Ve-(-i , Imo°+�a►�� ,'o. s o <br /> b1n 4 w err -t <br /> NAME OF ORIGINAL OWNER Ca- ��5 f b Qyyy� <br /> 1 Ts 1 <br /> CHECT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> Q A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION OF ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES, <br /> Q FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMTrrED FOR REVIEW. <br /> Q EXISTING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY <br /> MARKED ON THE•STTE. <br /> ❑ MOBILE HOME • ■ • # <br /> ❑ MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE $50 <br /> CHECT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> Q A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE DIMENSIONS AND LOCATION OF THE PROPOSED <br /> MOBILE HOME. <br /> Q THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON THE SITE. <br /> Q A COPY OF THE FLOOR PLAN MUST BE SUBMIMII FOR REVIEW. <br /> 191 <br /> OCHD 8/01 - ' — <br />