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Septic and Well Application Check List <br /> (Complete prior to accepting application) <br /> NOV 1 6 2017 <br /> Date PIN Q13 ' !8•! 3(12Z Permit# 77044L.(23300c)1 <br /> 1---7o1 3 'Z <br /> General Information AOSE/PE Plans Abbreviated R_?view <br /> Type of application is indicated Q Certification Statement n rovided & signed <br /> ged <br /> Applicant and owner information complete ri System Specifications provided <br /> /Directions indicated Ea Construction Drawingirovided <br /> /r' <br /> Site address indicated { Soils Work Provided (New and Old) <br /> Name of subdivision (if applicable) l Surveye Plat o Waiver provided <br /> iii PIN #indicated Required N' en Reduction <br /> tton <br /> �yof sewage disposal indicated <br /> g p Y or N n Review FeeR�uired <br /> Type of water indicated Comments: <br /> 1) Type of construction- 7a--1 <br /> -- $—Mdition check information indicated (if applicable) �-).,txb •7nrt <br /> "onstruction information indicated <br /> 1111' Legal owner's name, signature and date signed ** <br /> M P ease ask for owners contact# Plan Reviewer Date <br /> rrect Fees paid, receipt given and recorded ** <br /> g7 <br /> Application marked with receive date <br /> "15--Survey including all property lines (Required for septic application only) ** <br /> ` —Waiver Form 11 (If applicable) ** <br /> ** If needed ask for EHS help! <br /> *Remind applicant to mark property lines and house. <br /> Front Cou ter Application Reviewer <br /> Signature 1; 1 4241ff <br /> Revised 9/26/2017 <br />