HomeMy WebLinkAboutWALTER G PIPPEL ADDITION BLK 6 LT 6B6loclc
(~ ,~NT
,- · APPLI FILLS OUT UPPER HAP '~ ONLY
Property Owner -.[p/'~,%~ ,..3 .~ i ~-l' ~ ~ 1~ O/kJ ~'~'~l Phone
Address Zip Code
Lending Institution ~/. ~5~/~ ~ F~N~ O~ ~"Cg~ ~d ~ Phone
Address r ~ 'e'~.b '~'" ' ~(~C 1~ ~J~/ . ~ Ki. Zip Code
Rea[tyCo.&A~nt-~[~ ~3~ ~ ~!~_~ /~.LI~ ~[)~(G~f6~/~ Phone
Address Zip Code
Legal Description ~ . ~, . ~ ~ ~'~ ~ ~.1~ ~ ~-~ ~ ~
Type of Resi~nce
~ Single ~mily
~ Multiple Famgy No. of Bedroo~
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A well log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal
~ Individual Year Individual Installed:
Public Utility When Connected to Public Utility: ~ /~ 1
Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time ~~...,~
Time
Inspector Inspsctor Inspirer Insp~ctor
( ~OVEO BEDROOM8 ~ 'OONDITION80~tal Prot~otion'
( ) DISAPPROVED
( ) OONDITIONAL APPROVAL*
72-023 (3182}
OPERATION C
MENT OF ENVIRONMENTAL .CONSE
, pUBLic WATER :SYs-FEM: ,
:Ondition
s :(~f the ~PPi~;
'FO OPERATE" section must be completed before any Water, is mede available to
:)n
public
(date),,The system is hereby
proval to operate for 90 days following the cpmpletion date.
TITLE DATE~'
du¥ing the,interim appr~)val perio(~, or an inspection by the Department has
constructed according to the approved plans. The system is her0by granted
SUBJECT
DATE
SIGNED
SIGNED
Lr~ · ,¥,j~'~EDTFoRr'~ 4S 472 SEND PARTS I AND 3 WITH CARBON INTACT'.
PART 3 WILL BE RETURNED WITH REPLY
DETACH AND FILE FOR FOLLOW-UP