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SITE EVALUATION / IMPROVEMENT PERMIT SECTION <br /> ❑IMPROVEMENT PERMIT(Up to 600 GPD) NUMBER OF SITES ILL $3I0 PER SITE <br /> INDIVIDUAL LOT ❑ SUBDIVISION* ❑ RECOMBINATION* ❑ EXISTING SYSTEM❑ EXPANSION❑ <br /> ❑ SITE REVISIT TO REISSUE OR MODIFY A VALID IMPROVEMENT PERMTT(Up to 600 GPD) S 100 PER SITE <br /> EACH SITE EVALUATION CONSISTS OF UP TO 2 ACRES FLOWS OVER 600 GPD REQUIREADDITIONAL FEES. <br /> c";,"12iLrT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN <br /> IMPROVEMENT PERMIT: <br /> o A SITE PLAN OR PLAT SHOWING THE EXISTING AND PROPOSED PROPERTY LINES WITH DIMENSIONS <br /> AND THE LOCATION OF ALL PROPOSED STRUCTURES,ADDITIONS,OR IMPROVEMENTS WITH LABELED <br /> SETBACKS_ <br /> Q EXISTING AND ANY PROPOSED PROPERTY LINES 1 CORNERS MUST BE CLEARLY MARKED ON SITE. <br /> a THE APPLICANT IS RESPONSIBLE FOR MAKING THE SITE ACCESSIBLE FOR THE EVALUATION. <br /> o FOR NON SINGLE-FAM LY DWELLING APPLICATIONS,ADDITIONAL INFORMATION TO DETERMINE WASTE <br /> FLOW AND CHARACTERISTICS WILL BE REQUIRED. <br /> o FOR SUBDIVISIONS&RECOMBINATIONS,A CONCEPT PLAN APPROVAL OR A PLAT PREPARED BY A <br /> SSURVEYOR <br /> CONSTRUCTION AUT • " ■ ■ #� <br /> X AUTHORIZATION TO CONSTRUCT FOR NEW CONSTRUCTION OR E?PANSION $ 160(Up to 600 GPD) <br /> ❑SITE REVISIT TO REISSUE OR MODIFY A VALID CONSTRUCTION AUTHORIZATION S 100(Up to 600 GPD) <br /> CHEZ THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A <br /> CONSTRUCTION AUTHORIZATION: <br /> /A FLOOR PLAN OF THE STRUCTURE MUST BE SUBMITTED. <br /> 'd A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION OF THE PROPOSED STRUCIT.IRES, <br /> DRIVEWAYS,ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;PROPERTY LINES;DIMENSIONS; <br /> NIA, AND SETBACKS TO REFERENCE POINTS. <br /> a THE EXISTING AND ANY PROPOSED PROPERTY LINES 1 CORNERS MUST BE CLEARLY MARKED ON SITE. <br /> M o THE LOCATION OF PROPOSED STRUCTURES AND IMPROVEMENTS MUST BE STAKED ON SITE. <br /> THE CONSTRUCTION AUTHORIZATION MUST BE ISSUED PRIOR TO ANY CONSTRUCTION_ SUBSEQUENT CHANGES <br /> TO THE SITE PLAN, FLOOR PLAN. OR APPLICATION WILL REQUIRE A NEW APPLICATION AND ADDITIONAL FEES. <br /> FLOWS OVER 600 GPD REQUIRE ADDITIONAL FEES. <br /> SECTIONSIGNATURE <br /> 0 TOTAL AMOUNT DUE $ '" RECEIPT# r 06 r r <br /> IF THE RESULTING FLOW IS>600 GPD FOR NON-DOMESTIC WASTEWATER SYSTEMS OR IF ADDITIONAL PERMITS ARE <br /> NECESSARY, PLEASE CHECK WITH ENYMONMENTAL HEALTH TO DISCUSS THE AMOUNT OF ADDITONAL FEES. <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 WITH THE PROPERTY OWNER) <br /> ONLY ORIGINAL SIGNATURES(NO FAKES) CAN BE ACCEPTED. <br /> 1 AM THE PROPERTY OWNER OR THE PROPERTY OWNER'S LEGAL REPRESENTATIVE <br /> I HAVE READ THIS APPLICATION AND AUTHORIZE THE O CHD TO ENTER THE PROPERTY AND PERFORM THE <br /> SERVICE(S) REQUESTED. <br /> o • � nATE:G� d'7 <br /> 208 <br />