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Eu¥iron~n=al H~lnh Services Die,sion <br /> <br />To be submitted with ~pplteatto~ for <br />building p~rmit or mobile home place- <br /> <br />Application to the Depar.~meut of Env/roumental Quality <br /> for a Permit to Cou~t~uct a New <br /> a Subsurface Sewage D~spos~l Sys£em <br /> <br />Permit Feed; New - ~75.00 ($~?,~0 wigh site evaXuation) <br /> <br />~epair, Rep_la,ce~ Alteration - $25.00 <br /> <br /> 996? ' iii ~-r- :xd. ,-umcvi~le <br /> <br />City, State, Zip Code <br /> <br />Lo~ gize I '~cr(' <br /> <br /> 86(!] !{olm,luist I<d. ,-, <br />~foper ty Address <br /> <br /> s-'i' -zvsinacion Seri ................ <br /> <br /> N~ Constructio~ <br /> <br /> N~ber of Llving Units <br /> <br /> Water S~ply~ <br /> <br />c. <br /> <br /> 2. <br /> <br />l~staller' s Na~e <br /> <br />House__Mobile Home ,,~ ~Mobile Home Park <br />Other (explain) <br /> <br /> M%~ber of Bedroom~ <br /> <br />Proposed Subsurface gewage Disposal S~stem Plot Plan <br />Plam~ing Evaluation ~- ~utlding Perm/~ <br /> <br />3. Building Plans <br /> <br /> hereby certify that ~he information contained in this apRlication is true <br /> <br />~-57 rev. 12/76 <br /> <br /> <br />