A29 244/�qpiit�,lCy011 �c��8: -0� . ,,,1,�a (,��5(OZD i ax iUtao �:
��,mount :?aid: � �it�s�
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(�er.�' ,t;!_ �,1� "�'�' . Parc...� �•
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j��-•�.:�-.��� m�.�.a,.71. ZE�-3i��.11.�Ik�.
Improvements
7ier1� rBrmic-� iau.uu
�ome Replacemer�Additlon)
;epiace Existing Sys26m Perm
�iPPl.ICATIOId FOR SERVICBS
Permit
$150.001�200,U0
Pertnit Ravision Fee -
�t) Pei�r�iG rea�ta�ste�d by; (Own�rlagenf/prc�spsciive awner): ���
Horr:rt, �hane: � ' Address: 3��r li
Bu�,�:r;ess Phone: �" :^ o S
:�j N�rr«:� and a��trssg rr� curren8 ownnr: � �
3) Pr�c�;a�jr4y i3e�ca�ptaan: Lat size: �r'e- Tawnship: � e ���
Oi�•,�ciions to th�e p�aperty (Inciuding roact names.and numbers)�
�',�rm
s�a; lle, t�ot #i�
4) 1���;�p��s�ad I3s�r ��n Struc�ure �escriptiore: answer ach of the foilowing questions:
a} f�rnposed �'; Existing ,..� Type af Stn�cture: ��s ic���i�j4-7 Width: Depth:
b} i���.�mber of Hedr�ooms: � Number of accupants or peopls to be served:
c} B�sement: .Yes , No Wi11 there be plumbing in the basemer�t?
d J �ar�age aisp+osal: Yes � No ____ :
S) lt��L9or Su�apib Ty�se: Private. �(new ,� or existing___), Pubtic,, Community_, Spring �
Are any wells on adjoining property? Yes� No _„_, If yes, please indicate approximate location on the
"site plan.
6) Duc�s your �ro�ert�/ contatn previously lsler�tifi�d jurisdlctional wetlands? Yes_, fVo v�'
PL�►�SE NO'�E 7NE FOLLC?WING:
��► P1�1T �h� TiiE �ROPERT`f aR SI'i'E PLAPi NiUST SE SUBNIITTE� WITH THIS �►PPI.lCA7�d�N.
� ��'RC3PE32�f'.LINES �1AlD �ORNERS MUST.BIE CLEARLY MARKED. ,
��%iE PR�Pt3SED LOCATiOtd OF,QILL STRUCTURES AAUST 8E STA�ED OR FLAGG��.
�.�'41E S17�� �lIUST BE R�DtL`l ACCESS➢BLE FOR AN EVAL.UATI�M BY THE �iEA�.TBi �EP�4RT1flE�7
:iTAFF.
I herE:l:r� make appiicafiorr to the Person Caunty Health Department for a site evaluatlon for the on-site sewage disposal
systerh fc�r the above�d�escribed properiy. t agree that the contents of tiiis applicatian are true and represent the maximum
facilitiE:.; to be piaced on the �roperry. I understand if the site is aitered or the intended use change:s, the permit shall
oecorri�: =nva�id. I �'
or i:�ga
q, iy os
Date
FCND, rev a6127102