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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 <br /> ::56REI pA LtLLi 5 <br /> Leg Descri tion Address <br /> L. pL 5. 14 . EAU CL.A1 <br /> City[VillageqoCounty <br /> IJoa � <br /> Contents Comments/Special Instructions <br /> Page# Included Two copies needed for all <br /> plans <br /> 2 PLOT' PLgNS nReturnbyMail' <br /> 3 PLAN VIEW C90S Me. <br /> 4JRTE'R14L LAYOUT F-1 Fax Letter to(County)(Submitter) <br /> Circle One and Provide Fax#: ( ) <br /> 5 fi rlk CRo c <br /> 6 PUMP uRY Call for Pick-Up: ( ), <br /> 7 <br /> 0 Other <br /> I,the undersigned,hereby certify that the Seal(if applicable) <br /> plans and specifications submitted P.o.W,T.S. <br /> herewith were prepared under my Conditionally <br /> direction and control. <br /> Plumber/Designer License/Registration# /� D OVE D <br /> c l n wgmiS gZ6, ~E A OP COMMS <br /> Address City State �rylS10M ANS10,01101111 <br /> 2-7760 w 3.S' I�E85`!✓:'R�tJl.5`1693 <br /> signature <br /> SEE CORRE ENCE <br /> For Office Use Only <br /> Attachments: <br /> Application <br /> Soil&site evaluation <br /> Fee S97 = 21058 <br /> Needed for Holding Tank Submittal: p <br /> One copy of notarized holding tank 1 <br /> agreement.(Originals to County) <br /> Needed for At-Grade Submittal: AUG 2 9 C07 <br /> Original signed and notarized <br /> Application for"Use of an At- SAF > ^I^^^ •1 <br /> Grade" �7 <br /> County on-site <br /> One additional set of plans SBD-10268(N.01/96) <br />