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GENERAL <br /> INFORMATION <br /> APPLICANT: ! PROPERTY OWNER: <br /> C� ' 8 <br /> ADDRESS C ";v, �kr ADDRESS F V <br /> PHONE NUMB PHONE NUMBER <br /> LOT SIZE SUBDIVISION 1 LOT# DATE LOT RECORDED <br /> PARCEL ADDRESS: C P DIRECTIONS 1 LOCATION: <br /> mg6g.,�4 qg6� _ <br /> Is this application for a: ❑NEW SYSTEM 2ftPAIR ❑EXPANSION ❑RENEWAL ❑SUBDIVISION/RECOMB <br /> For a: ❑SINGLE FAMILY DWELLING Size Number of Bedrooms Number of occupants <br /> APARTMENTIEFFICIENCYIGUEST HOUSE <br /> C3BUSINESSroTHER C k l Z e. / 4J It -x <br /> Please describe the business, number of employees,squ re footage,etc, Use attachments if necessary. <br /> TYPE OF WATER SUPPLY PLEASE CHECK IF APPLICABLE: REQUESTED SYSTEM TYPE <br /> ❑ttmuc ❑BASEMENT WITH PLUMBING ❑CONVENTIONAL <br /> RIVATE WELL ❑ WASTEWATER OTHER THAN SEWAGE GENERATED ❑OTHER(SPECIFY) <br /> COMMUNn Y WELL(cz+y&-rj) ❑ PROPERTY CONTAINS DESIGNATED WETLANDS <br /> ❑OTHER ❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY <br /> Check All Sections That Apply ❑ FACILITY WILL HAVE A GARBAGE DISPOSAL OR WATER SOFTENER <br /> ❑ ------- <br /> WELL PERMIT SECTION # <br /> ❑WELL PERMIT-NEW $230 <br /> ❑WELL PERMIT-RENEWAL/ALTERATIONS/REVISIT $ 100 <br /> CHECK UST THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT: <br /> D A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER I1AFROVEMENTS;AND PROPERTY LINES. <br /> O THE EXISTING AND PROPOSED PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. <br /> EI ` ■ ■ <br /> ❑EXISTING SEPTIC SYSTEM INSPECTION $ 100 <br /> DESCRIPTION OF PROPOSED CHANGES I REASON FOR INSPECTION: <br /> ORIGINAL OWNER SYSTEM IS: ❑IN USE or ❑VACANT since (date) <br /> CHE-CDOMT 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 /> O FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW- <br /> 0 EXISTING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY <br /> MARKED ON THE SITE. <br /> MOBILE • ME PARK RECONNECTIONSECTION <br /> ❑MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE $50 <br /> Y 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 PROPOSED <br /> MOBILE HOME, <br /> O THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON THE STIE. <br /> O A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> 228 <br /> OCHD 09/02 <br />