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Gibson County Health Department |
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PERMIT NUMBER: _______________________________________________ DATE OF APPLICATION: _________________________________________ NAME: _________________________________________________________ ADDRESS: ______________________________________________________ _______________________________________________________________ Phone: _________________________________________________________ Location & Directions: ______________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ All sand soil: YES or NO Lot Size: ____________________ Water Source: Public__________ Private Well____________ Proposed Well__________________________ Number of Bedrooms: ______________________________________________ Repair or New: ___________________________________________________ OFFICE USE ONLY Receipt Number:____________________Amount Paid:____________________ Person Requesting Permit :___________________________________________ Staff: ___________________________________________________________ |
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