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El: IMPROVEMENT PERMIT- <br /> p SITE EVALUATION/IMPROVEMENT PERMIT FOR AN INDIVIDUAL LOT(Up to 600 GPD) $310 PER SITE <br /> ❑SITE EVALUATION 1 IMPROVEMENT PERMIT FOR A SUBDIVISION I RECOMBINATION OF PROPERTY <br /> (Up to 600 GPD): <br /> NUMBER OF SITES IN SUBDIVISION 1 RECOMBINATION: $310 PER SITE <br /> fjCNSITE EVALUATION CONSISTS OF UP TO Z ACRE& FLOWS OVER 600 GPD REQUIRE ADDITIONAL FEES. <br /> CHEMOT _ _ _ THE FOLLOWING ARE REQUIRED_BEFORE PROCESSING THIS APPLICATION FOR AN, <br /> IMPROVEMENT PERMIT: <br /> vi <br /> 0 A SITE PLAN OR PLAT SHOWING THE EXISTING AND PROPOSED PROPERTY LINES WITH DIMENSIONS AND $ <br /> THE LOCATION OF ALL PROPOSED STRUCTURES,ADDITIONS,OR IMPROVEMENTS WITH LABELED <br /> SETBACKS. <br /> N <br /> 0 E30 T NG AND ANY PROPOSED PROPERTY LINES/CORNERS MUST BE CLEARLY MARKED ON SITE. C'y <br /> 0 THE APPLICANT IS RESPONSIBLE FOR MAKING THE SITE ACCESSIBLE FOR THE EVALUATION. ., <br /> 0 FOR NON SINGLE-FAMILY DWELLING APPLICATIONS,ADDITIONAL INFORMATION TO DETERMINE WASTE <br /> FLOW AND CHARACTERISTICS WILL BE REQUIRED.F] CONSTRUCTION AUTHORIZATION SECTION <br /> ' <br /> x <br /> s <br /> ❑AVI HORIZATION TO CONSTRUCT FOR NEW CONSTRUCTION S 160(Up to 600 GPD) <br /> ❑SITE REVISIT TO RENEW OR MODIFY A VALID CONSTRUCTION AUTHORIZATION S 100(Up to 600 GPD) <br /> THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A <br /> CONSTRUCTION AUTHORIZATION: <br /> 0 A FLOOR PLAN OF THE STRUCTURE MUST BE SUBMITTED. <br /> O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION OF THE PROPOSED STRUCTURES, <br /> DRIVEWAYS,ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS,PROPERTY LINES;DIMENSIONS;AND <br /> SETBACKS TO REFERENCE POEVM <br /> 0 THE EXISTING AND ANY PROPOSED PROPERTY LINES 1 CORNERS MUST BE CLEARLY MARKED ON SITE. <br /> O THE LOCATION OF PROPOSED STRUCTURES AND IMPROVEMENTS MUST BE STAKED ON Srra <br /> THE CONSTRUC770N AUTHORIL4TI0N MUST BE ISSUED PRIOR TO ANY CONSTRUCTION. SUBSE [LENT CHANGES c� <br /> TO-THE SITE PLAN, FLOOR PLAN, OR APPLICATION WILL REQUIRE A NEW APPLICA770M AND ADDITIONAL FEES. . <br /> FLOWS OVER 600 GPD REQUIRE ADDITIONAL FEES. <br /> SIGNATUREs <br /> ❑ TOTAL AMOUNT DUE $ too , RECEIPT# rN l� <br /> ADDITI N—LL FEES MAY BE REQUIRED IF THE RESULTING FLOW IS>600 GPD.FOR NON-DOMESTIC WASME ATER. <br /> SYSTEMS. OR IF ADDITIONAL.PERMITS ARE NECESSARY <br /> THIS APPLICATION MUST BE SIGNED BY THE CURRENT OWNER OF THE PROPERTY OR THE OWNER'S LEGAL <br /> REPRESENTATIVE(eg. SPOUSE, POWER OF ATTORNEY,EXECUTOR, OR PERSON WHO HAS ENTERED INTO A <br /> CONTRACT OR LEASE IA4774 THE PROPERTY OWNER) <br /> ONLY ORIGINAL SIGNATURES CAN BE ACCEPTED. <br /> I AM THE PROPERTY OWNER OR THE PROPERTY OWNER'S LEGAL REPRESENTATWE <br /> I HAVE READ THIS APPLICATION AND AUTHORIZE THE OCHD TO ENTER THE PROPERTY AND PERFORM THE <br /> SERVICE(S)REQUESTED. <br /> r <br /> OWNER:. DATE: 'F 6 <br /> 192 <br /> I. <br /> I <br />