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for <br /> be au'vm/~te~ with <br />building per.it o: ~btle hom~ place- <br />~nt pe~C. <br /> <br />for a Petit to ..Ccustr ,uct a New or ',~ep~ir <br />a Subsurface $~/age DtapoSa! S),atem <br /> <br />Pe~C Fete: ~e~__ - $75.00 ($37.50 with site evalvatien) <br /> <br />Eepa~r. ~eplaee~...A/te~ation - $25.00 <br /> <br />}~fltngA~dre$$ <br /> <br />City, $~aCe, Zip ~o~e '" <br /> <br />Serial Number <br /> <br />House, , <br /> <br />. _. l(obile Home ~ Nobile Hc~e Park <br /> <br />(explain} <br /> <br />Number of Bedrooms <br /> <br />,. ~rlvate~Garbase Disposal? <br /> <br />Pzopoaed Subsurface Ze~ase Disposal System PlotPl~n <br />Planaimg gvaluation -- ~uildinE Per~t <br /> <br />Permit No. <br />Issued <br /> <br /> hereby cextity aha: rh~ !~foxmatiOn contained in this application is teue and cozrec~ <br />to the best of ~ k~l~ie ~d belief. <br /> <br /> s~guat~ <br /> 7 <br /> <br />~-57 rev. 12/75 <br /> <br /> <br />