Laserfiche WebLink
l <br /> Plb #67 7/71 <br /> Wiesen,in Department of Health eM Social Services <br /> Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> A. OWNER OF PROPERTY <br /> Hese Address (Street. Citys Zip Code) <br /> 1Q LJCS <br /> B. LOCATION OF PROPERTY WHERE SYSjg WILL BE CONSTRUCTED ALTERED OR EXTENDED Cmm + C <br /> Cheek One, <br /> CITY VILLAGE LEGAL DESCRIPTION dO S Lam/ <br /> TOWNS 'IP (Block. Eat, Seo.) <br /> ! . <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? _YES No PERMIT NUOER <br /> D. SEPTIC TANK CAPACITY r/S—C� GALLONS NEW INSTALU,TION_Z REPLACEMENT_ ADDITION_ <br /> MATERIALS, PREFAB CONCRETE POURED IN PLACE_STEEL YL OTHER_ <br /> NUMBER OF TANKS TO BE INSTALLED, I <br /> E. TYPE OF OCCUPAYCY <br /> Check Ones One or Two ptwi;y Residence, Co®eroial_ Industrial_ Other_(Specify) <br /> Number of persons to be Accomcodated_] Number of Bedroom_ <br /> F. APPLICANCES, ETC. Food West. Grinder YES 41 NO Automatic Clother 'Washer YES �JD <br /> Dishwasher YES �_NO Aut cwtio Potato peeler YES _74O <br /> OTHER (specify) YES VN0 <br /> G. MASTER PL/UIDER MAKING INSTALLATION �r /fit 1 <br /> Namat K<tiit 17 '$"(-i. ✓ k. Address. fiat ,,,y o� (-a ,C��Y -�,• Lj,*S. <br /> SIGNATURE OF APPLICANT avb Y t <br /> J Ucena. Number, MP '7 <br /> ADDRESSt �i[t<—. L J1.n MP RSG <br /> H. (TO BE CONPLETED BY ISSUING ADEM) <br /> Date of Appllesticn Pee Paid <br /> Permit Issued (date) Permit Number <br /> Agent (more) For, <br /> towns village, oltys county, eta. (specify) <br /> NOTE. The Applleetlov cannot be considered for filing until ell of the above gcestlom we answered <br /> and the fee paid. Agents will forward appllcatlms the fee of =1.00 for an septic tso,k soul <br /> the third copy, of the peralt (cattsfy) to the Division of Health. Checks and moray orders should <br /> be toads payable to the Division of Health. <br /> COMPLETE OTHER SIDE <br />