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.. .. .. Inspector Robert DuVall, Building .. Web Site: missaukee.org/buildept.htm . 105 S. Canal St., P.O. Box 800 Lake City, MI 49651 Phone Fax (231) 839-7264 (231) 839-7001 e-mail: [email protected] Missaukee County Building Department Missaukee County Construction Code requires written acceptance from District Health Department #10 for any increase in septic load or well use related to bedroom additions or change of use of existing systems. Applicant – Please complete the following: Date:_____________ Property Owner’s Name:_______________________________________________ Property Tax #:57-_______-_______-_______-_______ Twp:__________________ Site Address:________________________________________________________ City: ______________________Zip Code:_____________ Home Phone #: ( )________________ Wk Phone #: ( )________________ Well and Septic Permit #: ___________________ Date of Issuance: ____________ Number of Existing Bedrooms: ______ Number of Bedrooms after Addition: ______ Occupancy Change of Use (From): _______________________________________ Occupancy Change of Use (To): _________________________________________ Applicant’s Signature: _________________________________________________ Signature by the Health Department Official indicates acceptance of the existing well and septic size and function for the above indicated bedroom addition(s) and/or occupancy change of use. Health Department Official Signature: _____________________________________ Date: _________________________ District Health Department #10 Missaukee County Health Dept. 6180 W. Sanborn Rd. Lake City, MI 49651 (231) 839-7167 Fax (231) 839-7908
