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Mn _ Afp,4-723 r couNrY <br /> ®ILH R TRANSF RENEWAL UNIFORM PERMIT +'k <br /> U <br /> �— (PLB 67-T) <br /> PERMIT RENIS=L DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D.NUMBER: <br /> - -0 2-Z2 -oZ 4 z <br /> 'ROPERTY LOCATION: CITY: <br /> GE <br /> —� <br /> %< ' ,S 5 T N,R � E (or TOWN OO <br /> /+ F- X101 <br /> OT NUMBER: IBLOCK NUMBER: DIVISION NAME: NEARES ROAD LAKE OR LANDMARK: <br /> � S3-341 vrroER ,m, Aac v <br /> pwFMl4111AI&SANITARY PERMIT HOLDER OPOM XMPW. SANITARY PERMIT TRANSFERRED TO: <br /> :AMIE: m"TIZIf -1 NAME: PHONE NUMBER: <br /> R t4ALA 5C � EYC <br /> 1CDRES,V_d,1�� 357 P 5--?SS- ADDRESS: <br /> _0SCEOLA. X11 !�q nzc <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this <br /> property. I <br /> 'LUMB'R'S IGNATUR� PREVIOUS PLUMBER'S NAME (IF CHANGED): <br /> 'Ll l�CRS A�GpF;S�iS�VV hci( J�OY-i PREVIOUS PLUMBER'S ADDRESS: <br /> y/769 ri7LW ) I <br /> 'IP/MPFSW NUMBER PHONE NUMBER. MP{MPP.SW NUMBER: PHONE NUMBER: <br /> 25851 _ <br /> -sp E ISSUI SENT: DATE/q PPROVED:1 DISTRIBUTION: Criginoi -County <br /> 1/ A' O3 <br /> Cory -Bureau of Plumbing <br /> tG / J _—.—_ Copy -Owner <br /> -VIR 53 (;. 5r.2i � --_ � Cnpy -Plumber <br />