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Private Sewage System Plan Index/Checklist <br /> All plan sets should be legible and permanent copies, organized into sets,bound with staples and covered <br /> by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each <br /> set is signed. Your cooperation expedites your plan review and shortens plan entry time. <br /> Plan ID# Owner's Name o <br /> Lesai Description Address <br /> CiRyVillag wn C X1 ;�27 T221 County my to J /C'� <br /> Contents Comments/SpecialInst:actions <br /> Page# Included Two copies needed for all <br /> ( dans <br /> i 'I Plot Ptan <br /> _ F7Return by Maii <br /> Cross Section Tgnr! <br /> Pw Fax Letter to (County) (Submitter) <br /> Circle One and Provide Fax <br /> 0 Call for Pick-Up: ( ) <br /> Q Other <br /> L. the undersigned, hereby certify that the Seal(if applicable) <br /> plans and specifications submitted <br /> herewith were prepared under my <br /> nd control. <br /> PlumberiDesiener, License,,Registration <br /> LPI 1-1 3a <br /> Address Citv State <br /> � (4ce <br /> Siettature <br /> MEMO <br /> Attachments: / PIMVA'I�r <br /> Application e� <br /> Soil&site evaluation <br /> Fee 1.._� <br /> Needed for Holding Tank Submittal: APPROVED <br /> One copy of notarized holding tank <br /> agreement.(Originals to County) BE". OF MMM9 ,4M 6 <br /> Needed for At-Grade Submittal: MMMN W MW me swim <br /> Original signed and not.rzed <br /> Application for"Use of an At- <br /> Grade" SEE COROSPONDEWX <br /> County on-site <br /> One additional set of plays IM-10268(N.01!96) <br />