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D~te: <br /> <br />ROUTE SLIP <br /> <br /> (circle one) owner <br /> <br />Applicant <br /> <br /> Activity #:. <br /> <br />Agent <br /> <br />SITE ADDREBS= <br /> <br />TAX ACCOUNT: <br /> <br />WORK DESCRIPTION: <br /> <br />BUILD JMUCH ' ~PLBG - <br />DWELL MANF DEMO <br /> <br />ELEC SEPTIC <br />PREFAB AGEX <br /> <br />ZONING' Initial: _~_~ <br />/~OK to Taka Application OK to ISSUE PERMIT <br /> <br />Additional Information Required: <br /> <br />__ DO NOT Take Application <br /> <br />__ Street Name Required <br /> <br />__ Site Plan Review Required <br /> <br />Parcel : <br /> <br />Map : <br /> <br />Subdivision <br /> <br />Height <br /> <br />~ AC or SF <br />~"__,~_ Zone: <br /> <br /> __ Driveway Permit Required <br />Land Use Case No: - ~ <br /> <br />Lot: Block: <br /> <br />Setbacks: FR: LS: RS: Rear: SP: <br /> <br />Setback Text <br /> <br />Conditions <br /> <br />~ OK to Take Application // ~ ~ '~ __ OK to lSSUE PERMIT <br />v ~e~LN ~ ~~ D~ ~T Take ~p~lication <br /> Assign SEPTIC <br /> Histor~ <br /> Additiona~ Information ~equire~:~ , <br /> <br />Application Type: <br /> <br />Site Evaluation No. Lots: Subdivision: <br /> <br />__ New Installation __ Minor Repair <br /> d g System Eval __Auth w/Fie,d <br /> Review <br /> __Auth/Minor Rpr __ <br />__ Other __ Pumper Truck <br /> <br />System Type: STDS: CAPF: BOSF: SAPR: <br /> PRES: __ RDUN:__. SAND:__ SPTR:__ <br /> <br /> __ Major Repair (Tank <br />Auth w/o Field <br />Auth/Major Rpr <br />Auth/Alteration <br /> <br /> ; DF ; Both <br />Auth/Hardshi } Renewal <br />Alteration <br /> <br />GRAY: <br />SSLP: TILE: <br /> <br />Site Evaluation # : <br />Test Holes Required? : <br />Stakeout Required? : <br />Tank Pumping RequiredT: <br /> <br /> Date: <br />__Y __N Test Holes Ready? __Y <br />__Y __N Stakeout Ready? Y <br />__Y __N Pumper Form Ready? Y <br /> <br />N <br />N <br />N <br /> <br /> Installer/Pumper Name DEQ #: <br /> Water Service ~vate Well) CW (Community Well) <br /> # Existing Bedrooms # Proposed Bedrooms: <br /> # Existing Employees/Seating: __ # Proposed Employees/Seating: __ <br />THIS PRELIMINARY REVIEW IS VALID ONLY WHEN IN CONJUNCTION WITH A SUBMITTED PERMIT <br /> <br />__CI (City Water) <br /> <br /> <br />