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To be submitted with application for <br />bu/ldin$ permit er mobile bo~e place- <br />merit permit. <br /> <br />Application to the Department of Enviroamental Quality <br /> <br /> a Subsurface sewage Disposal System <br /> <br />Permit Feet: Ne~ - $75.O0 ($37.50 x~ith slte evaluation) <br /> <br />R~pair, "Repl~c~, Alteration- $25.00 <br /> <br />Section 25 Twp 8 Rge ~ <br /> <br />288 <br /> <br />Tax Lot or Account # <br /> <br />LOt Size 2 acre~ <br /> <br /> 7?43 Shaw ~!ighwny-,ac, &umsville <br /> " <br /> <br /> ......... he= .............. <br />Site Evaluation ·Serial N In,failer's Name <br /> <br />~. G~N~L D~SCRZpT ION <br /> <br />Repair <br /> <br />Installation will serve: House x ~obile Ho~e Mobile Home Park <br /> <br />Co~rcial Building .... Other (explain) <br /> <br />Number of Living Units <br /> <br />hou:e has burned ~ buil:Jing ne:~ hou,~e to <br /> ~l;lace Chat <br /> Number Of Bed~ 3 bedroom <br /> <br />~ete~ Supply: Public ._ Co~unity~Private , <br /> <br />Garbage Disposal? no <br /> <br />Proposed Subsurface Sewage Disposal Sy~te~ PlO~ Plan <br /> <br />2. Planning Evaluation -- B~/Iding Permit <br /> <br />3. gullding pla~ <br /> <br />I hereby certify that Zhe iufol~ation contained i~$ epplicattou is true and correct <br /> <br /> Date - <br />~-52 rev. 12/76 <br /> <br /> <br />