A40 65Application Date: 1 � �i ���+5� � -�°q ����
Amount Paid: __�l �_ /,,. _ �: � ����
Receipt #: � j�
]�:uawfia•�TM���n.sad�m.� u�m�si..��.
Services
0 Improvement Permit (Site Evaluation)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
Tax Map: /4 � �
Parcet#: �-
Cal I �6� 0 µo �
-1�o M � ��
❑ Construction Authorization •
(Fea is dependent on the type of system permitted)
❑ Permit Revision
$75.00
Repair of Existing Septic System
Applicatioa: Na Chazge/ CA $150.00 or $300.00
�) Applicant Inf rmation:
Name• �',.�.� ��s � r e c� 1�s
Address: 3 0 lo V ou ro, C�.�, n� �� ti ur<h t2a.
�a s[ Lc�orfl , nl �C . � -z � � y .
2) l�Tame and address of current owner if different than applicant):
Name• Fa� e �oo�k S
Address: o o� Q t
�n,� l�d�D � • C iS 7 LI
a��`'
3) Property Description: Lot Size: ��l`-( Subdivision:
Address and/or directions to Property:
Phone (home): 3 3 ta -�� z- I 3 4�
(work/cell): 3 3 6- S a W-�� ti, �,
Phone: ��, �- 3 ZZ - l 3� �
Lot #:
❑ yes no Does the site contain any jurisclictional wetlands?
❑ yes �o Does the site contain any existing wastewater systems?
❑ yes Cl"no Is any wastewater going to be generated on the site other than domestic sewage?
O yes C��no is the site subject to approval by any other public agency?
❑ yes L��no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
C � , �-o. �3 �dks }
A1 a rt-� S J
4) Proposed Use and Type of Structure:
OResidential �
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expaasion of Existing System If expansion: Current number of bedrooms:
L�Repair to Malfunctioning System Will there be a basement7 ❑ yes ❑ no With ptumbing fixtures? ❑ yes ❑ no
�Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well L7 Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
�
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative 0 Altemative 0 Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the infoYmation provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shadl be invalid.
1� .
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
!�� v 5 , Z���
Date
Permits are vatid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
llfl/111 Parcnn rnnntv RnvirnnmPntal Nealth '��5 4 MnrQan St.. Sllite�'. Rnxhnrn Nf �757'2 (�'tF_SQ7_17on1
���.sf ���.���
—= ������
I -�nav�na-��nna��n�.�:�,]1 IF� � �.Il�I�n.
SITE PLAN
Name (�t+tt lJ�or!�S TaxMap# A�i6 Parcel# �0�
�Subdi 'sion Section/Lot#
,�_ l I- 2 0- I�f
A thorized State Agent Date
System components represent approximate contours on/y. The contractor mustJlag the systemprior to beginning the
installation to insure t/:at propergrade is maintaine�L
���
o`�
\^' `i �Q`' t��,�k
, �b
�C V1 `(�
��pQ�-Y � �Qi
\ A�,
�a �� ���
��
�
�s��z.
f
.— ,. — bi� I�h�e nd lo� � �r,
u S�
b �d ��� e� t�- I�a K i h
use.
��
167$3•
�l�Pw.•�,. � �� ��r i�r�
►c�sf�+lfe�
— �U�e�� o uf �� Ul� s � re� � c�u �e.
�f-a 0 Ic� on� I�b�" ��e � �q acc�sS� I���,
3'� ►oas�er �l�ah `.i �e�'
�� � IU�w �iSeY 1,��5 Pja ec� on
�
�,� � a n �
\�1� � ti
.�� _ ��,
.�r
�
7�c�i
1 : 50 Fee#