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FOR OFFICE USE ONLY <br /> <br /> 220 High Street NE I J ~ -- ' <br />Code-A-Phone ~8-7904 <br /> <br />FAX 5**-7~48 MARION <br />DWELLING/STRUCTURAL AND/OR SEPTI~L~J'~[~Ili3~TION <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job...Description <br /> <br />~ICE USE ONLY <br /> <br />RESIDEN'IIAI, ~' COMMERCIAl, <br /> <br /> New SFD w/o g~tragc [ ] Rel~atc [ ] Addition [ ] Demo <br /> I Addition ] I Demo [ ] Alteration [ I Olher <br /> hlteralion { ] ~er [ ] ~atlge/~cupan~ <br /> <br />2, Location of Installation <br /> <br />Section ,~5~ ' Town~htp ~ S Range ~ ~) ~nc ~ ~, Map Water <br /> <br />3. Contractor Information <br /> <br />Mailing Address & Phone No <br />Mail~g Addre~ &/~honeAN'o <br /> <br /> fac or }insme~s Name & Number Mailm~ Addrc~ & Phone No <br /> <br />4. Septic Information (Check where applicable} <br /> <br />'re~t IIoles Ready [] Will Call When 'l~l Ilolc~ Ready [] <br /> <br />[Dlue Trak ta~l Pumped:: <br /> <br />Tank Size. <br /> <br />[ !~m peHomdng work cmn property I own or occupy <br /> <br />5. Fee Schedules <br /> <br />(includes EI,i Me, PI) <br /> <br />(l)Sq Ft____x 28 <br />(2) 5% Stat= Surohatg¢ ( 05 x Al) <br />(3) Ba~ Fee tot Plan Rc'~mw <br />(4) Zoning Surcharge 0.ir Apphcable) <br /> <br />(1) Permit <br />(2) 5% State Sumhargc (05 x ~1) <br /> <br />(4) Plans Cheek (65 x I11) <br /> <br />Septic Fees (Includes DEQ Surcharge) <br />(1) Site E~aluation <br />(2) Nca Septic; Installatk-.l permit <br />O) Authorization Nolice <br />(4) Ex~sting System Report <br />(5) Major Repair <br /> Minor Repair (tank only) <br /> <br />Subtotal;; <br /> <br />Miscellaneous Fecs <br />(1) Drive,~ay w/curb @ S? 50 <br />(2) Dnve,~ay w)o curb @ $1700 <br />(3) Site Plan Revle~ (commercial 01115) <br />O) Invc~tigattm Fee <br />(5) Rein~p~tim Fee ~ $25 (g) <br />(6) O~er ms~mJons not Ii,md able <br /> <br />____x$40= <br /> <br /> <br />