A27 112Application Date: la 3 1�3 ��� �(" ������ Tax Map: �`l
Amount Paid: 1 �,.,,.•'� �� Parcet#i 1�`J-
Receipt#: 1$�3`j� 1 � ���nt�f�7f�1�1�
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Services
� Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
,�Mobile Home Reptacement or Building Addition
$150.Q0 (if site visit reyuired)
❑ Wetl Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
� Repair of Existing Septic System
Application: No Charga/ CA $ I50.00 or $300.00
�Applicant Information:
Name: /' ,sa � a
Address: ��!,J d J�'.� QZ
l�lu r�J�� JY1z/l� �r/r' 2� S�l l
Q�Name and address of current owner Sif different than applicant):
Name: Cs. .s�,Cl u �11'� �'
Address: �a („i + ,v -�,a
o��t Fo s �v �. 2'1 Sy l
� Property Descriptian: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 31G - 3� 4% • j6 7-t
(work/cell): 6 �• 2 �! 2 I
Phone:
Lot #:
❑ yes B'no Does the site contain any jurisdictional wetlands?
❑ yes 8-no Does the site contain any existing wastewater systems?
❑ yes H"no ls any wastewater going to be generated on the site other than domestic sewage?
❑ yes E1no Is the site subject to approval by any other public agency?
❑ yes �' no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fiatures? ❑ yes ❑ no
�Non-Residential
Type of business: ��r��%r'pr/ Total Square footage of Building: �2 S �LZ k'Z-`k �
Maximum number of employees: / Maximum number of seats:
5� Water Supply: ❑ New well C7"Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes L�o
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the informatiott provided abnve is complete a•rtd correct. I also under.stund that. if tlze information provided is
inaccurate, ot- if the site is subsequently alteped, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Z� - �3
Date
Permits are valid for either 60 months or are non-expiring �vhen accouipanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/111 Person Countv Environmental Health. 325 S. Morean St.. Suite C. Rnxh�rc► N[: �757� ���F_547_t �Qm
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Ta.� 11�Iap #: i��`� Parcel#: l la- flddress (olo� �c�� '0. W►►� P�
Approval Requested for: Mobile Home Replacement
X Building ��ddition
Applicant Name: "�ED 5��;0l���►
Address: �`I S W o�.F� '�aA�
N•ic�� tn�v.s . tJ c. :2��
Phone #'s: 33� - 3b`} � 3b�1 �j 3:� - S�� ' 24�-1
Permii Located: Yes �C TIo
Installation Date: �— Design flow: � (gpd)
Cunent CQntract with Certified flperator on file (if required): t.� A
Water Supply: x Well Public or Community
Wastewater system shows no visual evidence af failure on: 1�`� �3 (�ate)
(Applicant's signature if site visit is not required)
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Environmental Health Speciaiist
la � �3
Date
Person Coun�i Env;ronmentai :� eaith; 3�5 S. y�orQan St., Suite C, RoYboro, N� 2 i�73
Fhcne: ��6-�97-??9C1 ra:•:: ���-�9"-iB�U V � �-��:��v.�ersoncoun�t��.i,e�
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SITE PLAN
Name ��� ��M�� Tax Map #�-� Pascel # � lt
Subdivision Secrion/Lo
'U�c3�� /�. Sl'�R'�� 1 � `�__
Authorized State Agent Date
System companeats represeat appmximate cantours on/y. The coatracrormustflag t6e sysrempdor to begianing rhe insta/lation ro
iasure thatpmpergrade is maintained.