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Envizommemt~l' Bealih Services Division <br />Mafias Coant~ Dep~ o~ ~blic Health <br /> <br />To be su~nui=te2 with application for <br />building perm/t or mobile home place- <br /> <br />APplica~io~ to the Depart~en~ o£ Enviro~ntal <br /> a Subourface Sewage Disposal System <br /> <br />$25.00 <br /> <br /> ~u~ne aelly <br />Name of Applicant <br /> <br /> 5?75 Shaw Hwy. $~ <br />Hailin~ Addre~ <br /> ~I l~sville 9~825 <br /> <br />City, State, Zip Code <br /> <br />Tax Lot or Accoun~ ~ <br /> <br />P~operty Address <br /> <br />Installsr' s Name <br /> <br />B. GENERAL DESCRIPTION <br /> <br /> Instal/at/on will ~erve: <br /> <br /> Co~mercial Buildln~ <br /> <br /> ~ater Supply; P~ltc <br /> <br /> x <br /> <br />Hous~ ' <br /> <br />Other (explain) <br /> <br /> Repair, <br /> <br /> x <br />__Mobile Home __Mobil~ Rome Park <br /> <br />Numbsr of Bed~oo~ <br /> <br />Private x Garbage Disposal? no <br /> <br />I. Proposed Subsurface Sewage Disposal System Plot Plan <br />2. Plannin~ Evaluation -- Bufldin~ Per~i~ <br /> <br />3. ~uiif~n~ Pla~s .... · ..... <br /> <br />I h~roby certify that the t~for~ation contained in this application'is ~=ua end correct <br />to the best of 'my knowl!~ge and belief. <br /> <br /> <br />