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A <br /> DEPA}iTMIiNT 2- 76 ~ 27 <br /> - <br />$TA~IF~MENT OF F~A$%b%LI~ FOR PROPOgF, D ~UB:~ORFACE SLWAGE DISPOSA~ <br /> <br /> ~%ETURN TO: FE~; SCMEDULE: <br /> ,~arion County Health Department Non-refundable $37,50 per lot <br /> <br />Pi, OPO~A~ ~S~ O~ PARCEL ~N~ER OF HO~SI~S) ~D LOT S~ZE(S): <br /> <br /> or Ct~ ~a~i-g capacity: <br />~%LY DgSAGN~TB~ L~ ZONING, ~ N~ OF"DESi~ATI~ A~ENCY: <br />...... i ................. -- <br />i'EST HOLE 'RBQUI~N%S: <br />one Romesite: You will ~ot ~e~d to dig ~est hole~ unle~ notified. <br />'~o or Mome Ho~esites: ~ tem~ h~le~ ~u~t be prepared on each parcel, 2 ft. by ~ {t. wide <br /> aud 4 ft, d~p, :'~ed 75 ft. ap~rt lm the proposad area~. <br /> lest holes ( ) have been prepared ~ will be prepared by <br /> <br />'I /13 ~___REPORT IS NOT A~)~, It do~ no~ elimA~m~c ~he need for required planning <br /> <br />% IIP,RE8Y REQUEST FROM THE DEPARTMENT OF ENVIRONMENTAL QUALIT~ A STATEMENT OF FEASIBILITY 0] <br />Na)~e of Applicant ~'P~;; __ Signature of Applicant <br /> <br />***************************************----************************************************ <br /> (for DgQ or Agent useonly) t .q - ~ '~ h <br /> <br />baamee~s a~fl recommeadatlona based On Sub~rfa~i Site investigation by DEQ or Contract <br /> <br />Pleaae 8e¢ a~tached report. <br /> <br />Agent Marion County Signature ~ ~-C~ Date 1-5-77 <br /> <br /> <br />