ApplicationTO'. OF QUEENSOU1:Y
TnT7N Or nTTENSBTT2y ID E tJ E u V FLBUILDI"Tr AIM ?.MMM T)FrA^T'*F.i"fl ;
/ ( BAY A*In ITATrTLAND TI OADS , P..J,l
lP r LFNS FALT ^ , NE'l YOrP' 128n1 A.M. S 'Fee iq7 p.m.
7�8�9,10�11�12�1�2�3�4�5�6
APPLICATION FOT A PERTTTT TO CONSTRUCT, ALTER OR ENLARrE A SETTArE !
nTSTInSAL SYS M"T TTITIITN THE TOTM nF OTTEFNSBURY
nCCUPA"TT' S IiA"a: -i ,r6 �f_iAT)nT SS—Z_ZelOe-ol
TFLFT'ITnTT..
ADDRESS
OT"IrTZIS TIPTE
IMBER OF BEDROnTlS
rARBArE rR:_NDER? (YES OR Tin) TOPnrPAPIIv: FLAT, ROLLINr, STEEP,
SLOPE, rFIr-LE SLOPE, OTHER
NATIMT. OF SnIL
PERCOLATIOTT TEST
1
MAY, SANT)Y, LOAI, (-RAVEL, ROCKS, ETC.
TTATER SUPPLY: MUNICTPAL, TTFLL, OTiIER_ _
DIArTWT OF PRn"SED SEPTIC SYSTEM
n"IER PERT7:NFNT TNFnRTTATInpT pL`�� _ ? h
TT TS Ii>::P.FBY ArTMED THAT T' TIIIS APPLICATION AND PLATS AP.F APPROVED,
TNSTALLATION OF SE'TArE DISPOSAL FACILTTTES BILL BE T%T)E III ArMPT)ATICE
TTITIi DFTATI.S BIOTIN.
DATE_---' C-STrNATURE OF AT'PLICANT-
LAKE rr.nRrE PARK rO*IIRSS'rON ArnPnVAL:
s s*,nature
VA
--
Do„ c o., w
/tid 1hSPpe,Ti0 n