9.13.23 BOA Agenda Packet - Laserfiche WebLink

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GENERAL INFORMATION APPLICANT: James O OWNER O tN►��yG ADDRESS 66 /9 ba !a.,PROPERTY DRESS PHONE NUMBER 56 3 " 3 PHONE NUMBER LOT SIZE _ft.SUBDMSION/LOT# DATE LOT RECORDED PARCEL ADDRESS: r_ DIRECTIONS/LOCATION- Po— Y wr iG Ile 1CY' �'W►i Ge-tr. Is this application for a:)9 NEW SYSTEM ❑REPAIR ❑EX§ANSIGN ❑RENEWAL ❑SUBDIVISIONIRECOMB For a INGLE FAMILY DWELLING Size Number of Bedrooms Number of ocaipants APARTMENT/EFF UNE /GUEST HOUSE ❑BUSINESS/OTHER Please describe the business,number ofemploy+ees,square footage,etc. Use attachments ifnecessary. TYPE OF WATER SUPPLY PLEASE CHECK IF APPLICABLE: RE UESTED SYSTEM TYPE: ❑PUBLIC ❑BASEMENT WITH PLUMBING ❑CONVENTIONAL PRIVATE WELL ❑WASTEWATER OTHER THAN SEWAGE GENERATED ❑OTHER(SPECIFY) ❑COMMUNITY WELL ❑PROPERTY CONTAINS DESIGNATED WETLANDS ❑OTHER ❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY Check All Sections That Apply ❑FACILITY WILL HAVE A GARBAGE DISPOSAL OR WATER SOFTENER F-1WELL PERMIT SECTION # ❑WELL PERMIT-NEW $230 ❑WELL PERMIT-RENEWAL/ALTERATIONS/REVISIT $I00 CHEC T THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT- 0 A STTE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION ANY STRUCTURES,PROPOSED ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES. O THE EXISTING AND PROPOSED PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. IMF• • # ❑EXISTING SEPTIC SYSTEM INSPECTION S IM DESCRIPTION OF PROPOSED CHANGES/REASON FOR INSPECTION: ORIGINAL OWNER SYSTEM IS: ❑IN USE or ❑VACANT since (date) CHECKLIST THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION OF ANY STRUCTURES,PROPOSED ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES. O FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW, O EXITING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY MARKED ON THE SITE. ` RMOBILE HOME PARK RECONNECTION SECTION ❑MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE S 50 CHECT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE DIMENSIONS AND LOCATION OF PROPOSED . MOBILE HOME. melala 046 O THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON SITE. O A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. sy OCHD 09/02 7�)