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E--- . - I R <br /> APPLICANT: 6M6 PROPERTY OWNER.-1W (f <br /> ADDRESS ADDRESS�D lea,/ 7& - <br /> PHONE NUMBER g _ PHONE X ZGS <br /> LOT SIZES c.SUBDIVISION 1 LOT# DATE LOT RECORDED <br /> PARCEL/ADDRESS: ft A DIRECTIONS 1 LOCATION:J] GuA47c/d <br /> r / Lw-le- &d l)?, �n �rn�r�u LT <br /> e - <br /> dp <br /> f or <br /> Is this application for: ❑NEW ❑REPAIR ® EXPANSION ❑ RENEWAL ❑SUBDMSION/RECOMB. <br /> For a: ❑SINGLE FAMILY DWELLING Size X Number of Bedroomk_4 Number of occupants /. <br /> APARTMENTIEFFICIENCYIGUEST HOUSE 01 <br /> ®BUSMESSIOTHER aimmrje 67-V <br /> Please describe the business, mun6er of mployees,squareYootagdeic. Use attachments if nece <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 ❑or see REQUEST FORM <br /> Check All Sections That Apply ❑ FACILITY WILL HAVE A GARBAGE DISPOSAL OR WATER SOFTENER <br /> ❑ WELL PERMIT SECTION # <br /> ❑WELL PERMIT-NEW $230 <br /> ❑WELL PERMIT-RENEWAL 1 ALTERATIONS 1 REVISIT S 100 <br /> CHEC JST THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT: <br /> a A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES. <br /> o THE EXISTING AND PROPOSED PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. <br /> - � - # <br /> ❑ EXISTING SEPTIC SYSTEM INSPECTION WITH NO INCREASE IN WASTEFLOW $100 <br /> DESCRIPTION OF PROPOSED CHANGES 1 REASON FOR INSPECTION: <br /> ORIGINAL OWNER SYSTEM IS: ❑IN USE or ❑ VACANT since Late} <br /> CHEC0=T THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> o 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 /> a FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> o EXISTING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY <br /> MARKED ON THE SITE.. <br /> 1-1 <br /> MOBILE # <br /> ❑ MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE S 50 <br /> CHECKW7 THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> o A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE DIMENSIONS AND LOCATION OF THE <br /> PROPOSED MOBILE HOME. <br /> v THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON THE SITE. <br /> a A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> 207 <br /> OCHD U51U5 <br />