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I <br />• • III IIIIIIIIIIIII III <br />7~~r ~~~~pV~.m®~p~r~/~17L~~!-+rJ~~/~~TU~./71nV7~lpl ~ll7[~r~}~/7~~7~ <br />~~~'rr~~1L71L~aY1~~1rVT1V~ll~1rV Ala mY~~lL] [®~ (1/V^allTy1~V ~~1rD}~7LrU17L~7l~f [11(1~1U[ll~1TVll1G1V ll ~rr~ 7y~T <br />ll1 V llJill ~7 1LL~ W LillLe ~~ V V t11VIItL JAJ~ll~1C ®0.yL'il1L ~~~ ll ~lyll <br />- ;- ~ -+ (Attar meat 4o F/In®or 1Levelapment Appticat9oa) <br />RECE <br />Application No. Application Fee: new = $250.00 reAa'tr = $50.00 <br />~POIDP s~ ri®109WB~Pto0P0® Q.`®Ptg17M~fm®e9, ~rtlJ p~r~®PB Vif~-® N1N~O9C'~S (bID uet~R,~IV, aOfl~P ®P PC" fOJa'IDP ~QD <br />~ena$6vii~ma0 B~t~~~ ®u~~~~t S?p9sbE°son Bsn ~®situPfiat ~®msn4g/, ~®0®P~@l® g@n~0d ®C~t~fiw a ~PwflaQ <br />6P®ew 4'tD~ C-0~~O(dJo ~~~. a~wdl $Pu~00 Sr>IPPUB~Ov dug G~rnVO®¢sww~ ieo~PUtaat4u~uo. <br />AIPIiD]LII(CAR1'II': ;~ ;-1 ';. ,,~ -- ,, ooa~ev:~q-~- <br />AImImIiP.IE~~: ~'~, ';. " < ~ta¢e zd~e®c7e ' <br />Pl®T1E: (!f aEppdecarae is woE eke ordwer of'eke properly, ekece ®copy oj® cosetrrsee fov s® ov Aer~rsrse <br />beltweera oppBdcratrl seed ow~rrev, op ®w®B~vized Be~tet? fvowr eke ooe~baea coFCSeoePltsm e® lkis r~p6ac®edoea saaats8 <br />be saebvvrdtdead <br />H.ITAoA6. HD)"r.S~IfH®FI ®1F E,ARI-D: Attach a of deed and/or curve let <br />~IEL@RdIl'Q H81E~NII1BIEIID <br />Type of Installation: :,. \ New Installation _ Alteration Repair <br />Corrtrador Name: ;,. i t Lic# ; ; ~ . ~ .<... <br />Address: % " ~ . ~i ~ _ :Telephone: <br />Estimated Cost of Fro'ed;'•;~` . / C%C/J, C'i Size: Orals. ' <br />Service 12ata: -Private Residence _ Seasonal Use -Other. Descri6a_' Commercia6_Tnstitutional <br />Hs system designed t'or B,1)[tD gallons pre day or 6ess? `•. Y N <br />Number of Bedrooms: Number of persons: <br />_Bath -Kitchen _ Garbage grinder _ Washer _ Dishwasher <br />Source and Type off C]Yat¢r Suppty: ~, Well _ Sprirrg Cistern _SurfaFe Creek <br />Well Permit No. Well Depth ft <br />Yf Sn lied by Communi Blame o6 Stn tier: <br />®]E7F~~IE Y7S~ ®Rl1i.~I <br />Type of soil or soil classification; ~ ` ' a ~ ~:. ~. _ ~ ::. ~_ . ~.,_ <br />Depth of Bedrock ft Depth of Ground Water Table: ft <br />Percent Ground Slopw: c :' ' ~ % Distance to nearest Community Sewer S tem: <br />Type oG Hndnvidtral Sewage HDesposal Syseem Praposed: (t) "Septic ( )Aeration ( ) Vau14 <br />( ) Silt Trench ( ) Sand Fiher Trenches () Subsurface Sand Filter <br />Proposed IIpsigm of System: < ~ -. , ~ ~' - - ~ 1- ~ _ ,- . <br />Is effiuent to b: discharged into water of the State? _ Y~+yN_ , ~ d ; . , ~ _ ', , _ _ . <br />Was system designed by a Registered Professional Enginee~7 Y ; ~1`I' <br />Tf yes, Adach copy of Engineer's Design Report Attach Site Plan SheeK , Y <br />~ -- ~ Soil Percolation Test II3esalts <br />ffio7e No. l . ! r M~autes pea inrL ISote PIa2 ,i :.; "% NGautes par inch l8[n1re FIo. ~ ...! ~. Mnutes pa inch <br />j :~i , <br />lIlealth Yn ettor Su atur'e: ;' ( t-' BDate: - ' - _ ' <br />Jjthis permit granted , I rmdersfimd that I will b¢ responsible jot the op¢r~ion, maintenanc¢, ohd p¢rformanc¢ <br />Applicant Sigaatrrre• ; I a "' : ~.~ - ' -Da~• - - <br />_ i <br />CostilBa Coai'aty (Land LJ'se Admiois4rator <br />>~e~irod rJdareh H~sn <br />Division of Minerals & Geology <br />