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A25 58Amount paid. °21�60 1-13'�a Re::eipt .�� � '[la2 Date • � C�- � �7 � • � APPLICATION �OR SERViCES � � H O � � �-. W U � a 1, permit requested by: . owner/prospective owner/agent:`�ar �, l�'� ( l � r.t.�„s Address:3 �`% �-1. (�' �' C�' �'Q-F � (� � � _ _ _._.. �ti c�' �'73U� - � ., :¢ z ome Phone #: ��� q-� g� Z usiness Phone #: � �� - �-� � `f Name and address of current owner: as�s r��:��.�s �.�� . Lot size: Tax Map#: � � �?-_ s Parcel#: 5 � � . Directions to property: State Road #& Road ames,�tc. � �� � � � ���� ��rr Li'�.0 �-v.�n I�Iumber of occupants or peoplE � to be secved: - 7. Dimensions or Proposed Structure: Width: 1�� Tr �e� roo M 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility . that this sewage disposal system is intended to serve? 9. Water su ply type: " privat public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No j�. If so, identify location: 10. Type of structurelfacility: Proposed: DExistirig: I� Type of dwelling: House:'� Mobile Home: C� Business: � ,� Type of business: � .. .: ._;. _ .. ,_, . Number of Employees: 3 � � ,�d d � �-� �� . � Number of bedrooms: _ : � Garbage Disposal? Yes ❑ No � ..- - Basement? Yes ❑ I`Io� If so, # of basement fixtures: � CLEARLY STAI� ALL CORNERS OF THE PROPERTY AND THE CORNERS OF. 'ALL _ _ _ _ _ PROPOSED STRUG"TURFS, - - --_ _ _ _ _-: I hereby make application to the PerS0I1 COIII1ty_ �ealth Departmeilt for a site evaluation for:the on-sit�: sewage disposal system for the above described property. I agree that the contents of this application�,are true and represent the maximum facilities to be placed on the property.. I understand if the site is.altered or the intended�use changes, the permit shall become invalid. I understand ttiat before an Improvemerits Peiniit can b. issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no�. delivered a survey plat of the property to the-Hea l t h De t. wi t hin 6 0 D A Y S a f t e r t h e d ate of the evaluation of _ _ _ _. _ . the site by the Health Dept., this application shalTliecome void and all fees paid forfeited � . , . . . � . .. . , . ; �: �.. _� _ , „_ _ ..., :.•;; >; ;-.;. - Owner or Authorized Agent � � �� Permit Issued ❑ Permit Denied ❑ Plat Observed D � . � . .::3.... , . . . . Signature Date � •� ._: . �� . .. ! ;:�; - . . • � '.'"' _ -..... ..'..... � � .. .. . .. . . .. . .. . . � . . .. .. .. .,. - - � . � . . . .�.- .. .�._ . . ... . . . _ '. _.. . • . - . _ - '.. . . , " ' . . .. . .. _.. . .. . .. .. _..' _ . ' _' . � . � _.. . ...." _ .. .. ... .. _. . 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RECOMMENDATIONS/CONlIvIENTS`. ''`� . . �; `: � _, . . . - < �.> :.!' ' � . t . STTE CLASSIE�iCATION DIAGRAM (Include: Soi1 azeas, property lines, roads, streams, gullies, wet areas; fill ;.� � areas, wells, water tiodies; s7ope pattems,:�etc �' , '" - C:VIMIPR0IDOCSIAPPSEC.S�IFINANCE.PC ;': . � . _ . .. ..,., •!� �� �7 Yerson County Health Department Existing Sewage System Report For: Mobile Home keplacement �ddition Requestee: Y!� , � W 1 1' ► Q.rYI � Home Phone# ����996 0� �� q MC.�����5 : eusiness# 597- /7y �E'�✓7� o t2A N� �-�Z 34 � 'r a x M a p# /'�'o� J� - J`M � Location/Directions: � �-�1� S �,i �_) �. y� OftSe. ✓� a. 5+- C,Pd� L erz��-c,e .�� �� �7 9� Original Yermit Located �-[�Y� IJ Septic System Uesigned For: Kesidential _�� Business # f3edrooms # Employees Other (speci�y) Other Uate lnstalled Water supply � � 'Pype ot System ��3�i V�i-+ DYLQ� Nitritication Line Tank Size V Certified Operator Required � � On site wasL-ewater disposal system showes no visually apparent malfunction on 1� 1 l I`� 0 Yermission is granted to: �C�,C'� vV i����4-'CYi S According �o the attached site plan.. - Environmental Health � � s< 7 DATE 0 . ��� . � , = �~��`� � 7 _ c � c� o _ _ , � � ��.o �'V.7 . 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