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EnTi~or~ol:tal Ik;ai~h S~[wices Division <br />~[~rion Co~ty D9t~m'~tmamt of ~blic Health <br />Salad, (~on ~Y301 (~}g~s~4~), a~ent for: <br />De~s~v~:nt of Enviro~ental <br /> <br />To be submittedwith application for <br />buildiDg permit or.bile hc~e place- <br />ment permit. <br /> <br />~plication to the Department of Enviror~r~ntal Quality <br />for a Permz[t to C~nstruct a New or Repair <br />a Sub--face S~ge Disposal System <br /> <br /> Permit Fces: <br /> <br /> Repair, Alterati9~- <br />[~TFATJ~CE INFORMATION <br /> <br />Ea~!i~g A~ess <br /> <br />New - $50.00 ($25.00 with site evaluation) <br /> <br />City, State, Zip Code <br /> <br />Tax Lot or Account # ~4,A'- <br />Lot Size <br /> <br />Property Bjdress <br /> <br /> £gg/r <br /> <br />Installer's Nsme <br /> <br />B. C.%~P~ DESCRIPTION <br /> <br />Nc~vConstruction <br /> <br />Repair <br /> <br />Installation will serve: ~uso 5~bile Home Mobile Home Pe~k <br /> <br />Co~m£rcial Building/__~Other (expls_in) ...... ~ <br />Number of Living Units Number of Bedroorrkq <br /> <br />Water ~%pply~ Public ~ Cc~munity__ Private ... G0_rba~e Disposal? <br /> <br />REQUIRED I~HIB!TS <br /> <br />1. PropwJsed Subsurfs~e Sewage Disposal Systa~n Plot Plan <br /> <br />2, planning Evaluation -- Building Permit <br /> <br />3, Building Plans <br /> <br />I hereby certify tk~t the information contained in 'this application is true and correct <br />to thc b~st of my knowledge and belief. <br /> <br />Permit No. <br /> <br />Issued <br /> <br />EH-57 7/74 <br /> <br />Signature (~er/installer),/' ' <br />Date " <br /> <br /> <br />