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EHPR-4-11-10696 (2).TIF
Ea�viro�nffiQn�a� �ealtk� Additioa�al Fee Coliectiom Notice The following additional fees as checked below must be collected prior to further action by our department: ❑ Repair Permit Application �/h p� � _(�_.' � -� (� 3 ❑ Permit revision (re-draw) . - y � ❑ Well Permit - � ❑ Authorization to Construct (system upgrades, etc.) � �Other (please explain below) ���� (�, '"� ��L lu'� �v �if1'1 !'�UV.i� �`(!7`lin(� �(� � ��`� C�� �Y/ v . � x , - �- � � . . ;� c � ; �� EHS � � Date S ��