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MAP/PARCEL
CONSTRUCTION APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? < YES NO
PLAN APPROVAL: DATE A7APP. BY
DESIGNER: �Lu e- PLAN DATE 4 �'
CONDITIONS
WATER SUPPLY:
WELL PERMIT
WELL TESTS:
PLUMBING SIGNOFF
COMMENTS:
imwo-J
DRILLER
CHEMICAL DATE APPROVED
ERIA I DATE APPROVED
BACTERIA -LI DATE APPROVED
WIRING SIGNOFF
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
DATE ISSUED-JBY ��CJ
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
62&�)
NO
WELL CONSTRUCTION APPROVAL
YES
NO
SEPTIC SYSTEM CONSTRUCTION
APPROVAL YE
NO
OTHER
ES
NO
ANY VARIANCE NEEDED
YES
NO
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FINAL BOARD OF HEALTH APPROVAL:
DATE:
f'r'BY :
.