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Deponent of ~v~ro~ntal ~ll~y <br /> <br />To be submitteg w/~h applica£1on for <br />building pe~m/~ or mobile ho~e place- <br /> <br />a Subsurface Sewage Disposal SyStem <br /> <br />Permit ~ee$: N.e~., - $75,00 ($37.50 ~l~h ~ite evtlua~ion) <br /> <br />N~me Ot--Applican~ <br /> <br />City, $ea~, Zip Code <br /> <br />Loc Size ~ ~L~. <br /> <br />Proper ty Agdress <br /> <br />Site ~valuaCion S Nm~er Installer's Na <br /> <br />Co~relal Building___~_Other (e~pZain) ~ ._ <br /> <br />l~t~r Supply: Public <br /> <br />. Co~unt ~y <br /> <br /> H~ex of Bedrooms .. ~,, ... <br />l~ivate L~Garbage Disposal? ~ <br /> <br />1. Propoaed Subsurface Sewage Ikispoa&l System PioC <br /> <br />3. Buildin8 Plans <br /> <br />i hereby certify that ~he i~fo~mation concalued in this applicatio~ is cru~ ~nd correc~ <br />to the bmoc of ~ k~owledge ~d belief. <br /> <br />1~FI-$7 rev. 12/76 <br /> <br /> <br />