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<br /> Nov 15 06 12:06p MILD LOEWENTHAL 808-323-3282 p.4 <br /> <br /> io L4 of <br /> wnarn an avn c,.rinv.r+c..~••REQUEST FOR CESSPOOUSEPTIC TANK PUBLIC RECORD <br /> <br /> To: Department of Health Ph. (808) 322-1` 7L 14 `3 <br /> Kealakekua Health Center (nailing address) Fax (808) 322-1511 <br /> 91-980 Halcldi Street Suite 103 Keakealaai B14 (scow io atioal <br /> Kealakekw, Hawaii 96750 79-1020 ffo* ila Stroet Rm 113 <br /> Attn: Wastewater Branch Keablockug Hawaii 96750 <br /> <br /> The following Department of Health record is hereby requerted. <br /> Identify or describe character of record: Tau Map Key Number/Address MORA 111V 2~ S5 <br /> <br /> Big Island: TMK Zo <br /> <br /> 2( Sts 9 only TMK L3, - - Paired size <br /> Istaod 3 -Ilawaii Island Zone See Plat Parcel <br /> O CESSPOOL IIFO TION 0 SEPTIC SYSTEM INFORMATION <br /> 0 OTHER INFORMATION (SPECIFY) CESSPOOL OR SEPTIC USE REQUMEMENT <br /> <br /> <br /> Name of Re"estor Signature Date <br /> <br /> <br /> Company/Organization Phone Fax <br /> <br /> For Department Use Only <br /> <br /> _ NO CESSPOOLRYIORMATIOfCofff4F <br /> _ CUSPOOLDWORFI T"IN <br /> CESSPOOL DRSXW APPROVEDUTNO <br /> CESSPOOL DvMRMATION APNO STT7tC SYSTEaa DVSEP77C SYSTZaI NOTDSEPTIC SYSPEM N07 APPROCHED LZTTW <br /> <br /> <br /> SEPTIC SYSTEMAPPROVZD OFOR _ BEDROOMS <br /> 0TML. } 1 <br /> <br /> <br /> S i~ IS A UQ~/LC' r r~ ct <br /> NOTE: C es <br /> All sketches are made CL 1 d fec- <br /> front existing records - <br /> only - acwd condition <br /> may diner. Streal <br /> distances/oriess"doo <br /> will be indicated it <br /> available - some records <br /> are incompiew. <br /> FOR REFERENCE <br /> ONLY - VERIFY IN <br /> FIELD <br /> NOT TO SCALE <br /> t t 13 a,6 <br /> Wastewater Branch .a,ew <br />