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DATE: OCT 6 2016 �3 . <br /> tcU H v (-1 .°(_)o) 0' Number of pedrooms <br /> PERMIT NUMBER: <br /> (:(c) �` `�°v c,°( . Basement?(Yes dr No) <br /> 5 A8 <br /> PIN NUMBER: CS 1 a kS,. 0 65 L <br /> TAX MAP NUMBER: 'c6,1 C_ CaD / Water Supply��( or Public) <br /> ���.�-- D Survey(CAD) (if no survey— <br /> CHECK LIST FO SEpTI£-R Attachment A) <br /> SEPTIC AND WELL APPLICATIONS <br /> **used to ensure the application is complete at <br /> the time of submission** ❑ Waiver Attachment A <br /> GENERAL INFORMATION: REMIND APPLICANT (IF BARE <br /> Er Applicant Name • APPLICATION) . <br /> Agent's Name(if applicable) ❑ Are the prop_erty lines market? <br /> ❑ Is the house site marked? <br /> • . Cl Current Mailing Address <br /> A0/51fi PACKET <br /> a Phone Numbers (daytime/cell) <br /> • ❑ ust submit one co y <br /> 0' Site Address • ( set if Cejtifica n letter) <br /> • ❑ pages of pa et numbered& <br /> •C1 GPIN Number/Tax Map Number 'cluded <br /> ❑ Ce i I catio Statement included <br /> Subdivision Name ❑ Plat ; ' ' .per <br /> ❑ Site& . Evaluation <br /> 0 Directions to property are clear ❑ Sys spec ations <br /> ❑ Required Nitroge I Reduction <br /> Ely Site plan,plat or sketch attached? /(Chesapeake Bay) <br /> Signature of Owner or Agent <br /> II> Current Date when applied for <br /> application <br /> Cl Fees paid and receipt given and recorded <br /> Application marked/date received <br /> ❑- Health Department ID number recorded <br /> SYSTEM INFORMATION OCT 6 2016 <br /> Checked By JJ=\ Date <br /> [1 Type of approval (Certification Letter, <br /> Construction, pair,Expansion Permit, <br /> etc.) ' <br /> SIGNATURE ,,t �SC,�, <br /> 0/ Proposed usage-(Sliigle Family,Multi- . (Revis 12/5/2013) <br /> Family Dwellint Noa e�-sidential/ <br /> Commercial <br />