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GENERAL INFORMATION <br /> ��yy ff� /I �. nrko u� <br /> .PPLICANT: fVj17t±/� �c OO+CY ��/'���"r PROPERTY WI ER: r^"i'ss�Keri Q�1>+ j� 1I�iKei �eSf . <br /> .DD SS 3t-12, 4,q di 6e&e 4Qu6 ADDRESS Po. 60 1 <br /> yc- 274'1�, K,2 i C 27603 <br /> HONE NUMBER( PHONE NUMBER cl0 y 3 c101(J <br /> AT SIZE SUBDMSION/LOT# DATE LOT RECORDED "6 <br /> 'ARCEL ADDMS: 43DC7 f )e, 0 D"IRECTIO S/LOCATION: <br /> C f <br /> Is this application for a: ❑NEW SYSTEM ❑REPAIR ❑EXPANSION ❑RENEWAL ❑SUBDIVISIONIRECOMB <br /> Fora [-]SINGLE FAMILY DWELLING Size Number of Bedrooms Number of occupants <br /> ❑APARTMENT/EFFICIENCY/GUEST HOUSE <br /> ❑BUSPU SSIOTHER <br /> Please describe the business,n mber of employees,square footage,etc. Use attachments if necessary. <br /> TYPE OF WATER SUPPLY PLEASE CHECK IF APPLICABLE: RE UESTED 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 ❑ FACILITY WILL HAVE A GARBAGE DISPOSAL OR WATER SOFTENER <br /> F-11 WELL PERMIT SECTION <br /> ❑WELL PERMIT-NEW S 230 <br /> ❑WELL PERMIT-RENEWAL 1 ALTERATIONS 1 REVISIT $ 100 <br /> CHT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT: <br /> O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER ROPROV>EMENTS;AND PROPERTY LINES. <br /> O THE EXISTING AND PROPOSED PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. <br /> INSPECTIONEXISTING WELL I WASTEWATER SECTION # <br /> f <br /> TING SEPTIC SYSTEM INSPECTION / S 100 <br /> DESCRIPTION OF PROPOSED CHANGES 1 ON FO INSPECTION: OGt i "Af f .C/ygl f- <br /> �' <br /> ORIGINAL OWNER AtW a eduCA;go h9TEM IS: CaIN USE or ❑VACANT since (date) <br /> CHAT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:TIIE LOCATION OF ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER VdPROVEMENTS;AND PROPERTY LINES. j <br /> 0 FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. i <br /> 0 EXISTING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY j <br /> MARKED ON THE-SITE. <br /> FILE HOME PARK RECONNECTIONSECTION <br /> ❑MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE S 50 <br /> CHECK MT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING.THE DM ENSIONS AND LOCATION OF THE PROPOSED <br /> MOBILE HOME. <br /> O THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON THE SITE. <br /> O A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> s <br /> 5 <br /> OCHD 09/02 <br /> 239 <br />