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FOR OFFICE USE ONLY
<br />Received By:
<br />Zoning Validation
<br />Date:
<br />
<br /> SITE ]EVALUATION AND/OR SEPTIC PERMIT AFPLICATION
<br />. Location of In$t~!!~t}on
<br />
<br />Contractor Information
<br />
<br />Auth. Agcntfl.~asee ~iling Add.ss: Phone No,
<br />~nt~r Business Ns~ & Number ~ilin~ Add.ss: Phone l~o,
<br />D~ L~n~d Cout~t & NO. ~g Add~: Phone No.
<br />
<br /> Commercial (DgP - Daily S~w~e Flow) I
<br /> Site F, valua~ioq~, fleet 1000 ~al. DSF 245,~ 2~,00
<br /> ~le Evaluatlo~r, ~a. ~dL 500 ~al. D~
<br /> Cons/ruction & ~pai~.Pe~its
<br /> S~ndatd System Jess than 1~00 rial DSF 245.06' ~0.00
<br /> S~nda~ Sys~m mo~ {h~ 1000 ~1,
<br /> $245,00 + $15 m~h Mdl, 500 ~. DSF 10.00
<br /> C~ping F{[},,, , ~15.00 }0,00
<br /> Omy Wa~r Wast~ D sgosal SR~ 120.00 ,10,00 "YII
<br /> HOI~n~ Tank 245.~ i0,00
<br /> Y~u~ Distgbuflon , ~50.00 10.00 I
<br />.... Reduudant Sy~ ' 245.00 19,00 ·
<br />
<br /> Si~p $]opo , 245,00 I0,00
<br />Tile D~ate~ng System ~0,00 10,90.,,,
<br />Plan Rgyi~w
<br />(For, pach Mditional, 500 gal DSF .... 2~,00 ,00
<br />Constmction,~e~it RenewaJ, (gie{d Visits) ,, I 150,00 { 10,00
<br />~onst~otion Pe~j/Renewal ~o,,~e{d Yisi~) { ~ 85,00 10.~
<br />Authg~ti~ H~ce (~cld ~islt} ; ~ 150,~ I0.~
<br />..~?ho~afion Notige ~o Fiald Vial0 ~ 85.00 '10.00
<br />Annual ~valuation orAl,motive Sys~m
<br />~mo~r Track In~e~tion, ea. MdL
<br />
<br />(Mark if Applicable to this Application) ) Test Holes are Dug
<br /> ) I will call when Test Holes Dug
<br />
<br />) ! am pcffonntag work on a pmpeay I own or occupy
<br />) l am a ~$i~d builder dr ( ) the authotlz~d t~puuacutative
<br />) 7be work will bc performed by a DEQ Liceus~d Installer
<br />) Odlcr
<br />
<br />.....l;t. esidenfial ginnie Fam'ilv "
<br />Site ~valuation~ fi~t lot I,245,00 20.00
<br /> Slt~ Rva u~ou~ ~, ~dt,,,~t~ 205,00 20,00
<br /> ~n~mc/i~u pe~t ,,, m
<br />.... 8~da~ $ys~mI. 245..00 I ~'00
<br /> C~oing Fill ,,, m 4I 5,00 10.00
<br /> Di~o~l ~nch i~S~mllte[ ~4~.00 10.00
<br />G~y,,W~r Di~o~ $~mp 120.09 10.00
<br />Ho]ding T~k.,, 245.00 10.00
<br />~nd Filter , ~45.00 1~.00
<br />,, ~eg~ge Teach ' ~45,00 I0.00
<br />~tecp ~ ope ~45.00 10.00
<br />Al}~tion 24~,.00 10.00
<br />~palr~ ~ior (d~;~eld) I15,00 .10.00
<br />- ~p~t, ~nor (~R) ,, 75.00 10.00
<br />
<br />..... Co~amctlon ~e~it ~newal ~o ~eld Visit). 85.00 .... 19,00
<br />~in~¢tio~ F~ ' ,25,00
<br />Authofi~ioa No6~c (~ield Visit) 150,00 10.~
<br />Au~2fi~ion Nofic. (No Fidd Vislt),, ~0 10.00
<br />: ~stlng Sys~m ~aluatbn · 150.00 10.00
<br />~n~U~ ~lu~o~Al~m~ve S~ ~ ~ l, 1~0.00 .00
<br />Annual Ev~uatio~mp. or He,ship ~ 90.00 .00
<br />
<br /> otal
<br />
<br /> It~ipt No.
<br />I agile to install a~¢ording to the sub~t~d plans and spcclflc~ions, thc laws
<br />of the S~ of O~8oa and ~c
<br />
<br />MC l$-Sl REV 2/93
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