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~uvlrorm~ntal ~l~h Services Division <br />Marion County Departm~ut of ~lic H~th <br />$~l~, ~ 97~1 (~5~6), ~t <br /> <br />TO be submitted w~th application for <br />builddun~ permit or mobile homa place- <br /> <br />Application to the Departmen~ of Eaviror~ental Quality <br />for a Permit to Oonstruct a New or ~ <br /> <br />Permit Fc.s: N~ew - ,T~30.00 ($25.00 witch site evaluation) <br /> <br /> ~Re~air, A~l~ teratio~n- $15.00 <br /> <br />T~ LoS or Account <br /> <br />Lot Size <br /> <br /> Address <br /> <br />lV~%v C~nstruction <br />Installation ~ill serve: <br /> <br />~cial Building ~ <br /> <br />Ho~.~ ~ ~obile ~ ~ Mobile <br /> <br />Other <br /> <br />Namer of Livir~ ~i~s ~/ _ N%z~er of Bedrocm~ 3- <br />Water Supply: Public .- . C~rm~uity ~-__ <br /> <br />Private ~/ C~drbage Dispo~l? <br /> <br />1. Proposed S~bsurface Sew~-~ Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Buildir~ Permit <br /> <br />5. Building <br /> <br />I hereby certify th~ ~he informal;iOn contained in *his -~licaZi~- ~ ~ t ..... --' ....... <br /> <br />L%~ S~ture (~er/in~t~IZjr) .... <br />EH-57 7/7~ <br /> <br /> <br />