|
Received By:
<br />Zoning Vali~dation
<br /> to
<br />
<br /> Sn'~; EYALUATiON .4~D/OR SEPTIC PERMIT APi, LICATioi~UILDING INSPECTION
<br />1. Location of Installation ~
<br />
<br />Subdivision ~ ~hg~W~ ~t ~ Block ~
<br />Mobil~ Hom~ Eark ~ ~
<br />
<br />Contractor Information
<br />
<br />Commercial (DSF - Daily ~ai~e Flow')
<br />Site Evaluation, first 1000/~L DSF 245,00 2A,,~. .......
<br />Sit~ Ewlu~ion, ca. addl. 500 gal, DSF 75,00 20.00/m
<br />Construction &Rcpair Pc~i~
<br />S~nda~ Sy~m lcsg than 1000 gal, DSF 245,00 10.~ ....
<br />Cappin~ Fill 415,00
<br />Dgldi~g Tank 245.00
<br />~dundan/System ............. 245.00 10.00
<br />~%~¢pag¢ T~ch ........ 245,00 10,00
<br />~ ~il¢ ~wat~fiaa System ........ 350,00 10.00
<br />(For ca~,,,~itlona1500 ga DSF 25.00 ,bb"
<br />Autho~ion Notice (Fiel~,~f,iQ 150.00 10.00
<br />Authodzation Notlca ~o FieM Visit) .,~'99 10,00
<br />Annual Evaluation of AIt~jve Syaem 150.00 1%90
<br />
<br />(Mark if Applicable to this Application)
<br />(~ Test Holes am D~g
<br /> ) I will ~all when Test Ho]ca DuS
<br />
<br /> ) I ;~m performins work on a pmpcn¥ Iowa or' occupy
<br /> ) I am a registered builder 0r ( ) thc authorizcd mpmsel~la~ive
<br />(~ The work will be performed by a DEQ Licensed In~ller
<br />( ) Od~cr
<br />
<br />MC 15-SI REV 2/93
<br />
<br /> Residential ginnie Fnmilv
<br /> git~ ]~valuatlonr fir~ lot ...... 245.00 20,00
<br /> Si~ Evaluaion, ca+ ~dl, lot 205.00 20,,9~
<br /> ~nstmction p~Jt
<br /> C~pin~ ~ill,, 41~+00 10,00
<br /> Gray W~r Di~o~ Su~ .......... 120.00 10.00
<br />..... ~pldlnt Tank 245.00 10.00
<br />P~a~ Distdb,~lion ~50.00 I0.00
<br />Redundant 245,00 I0.00
<br />Sand Hl~r ~5.00 10,00
<br />~p~e ~nch ........... 245,00 10,00
<br />~t~ep Slope 245,00 10.00
<br />Tile ~wat~dn~ ,. 350.00 10~
<br />R~alr, Minor (~,~k) 75.00 10,00
<br />CoO~mcfion ~it ~newll (Field Visit) ....... 150,00 10,00
<br />Coa~ction Pe~it ~newnl ~o Field ~sl ) ,~5,00 10,00
<br />Relnspf$l~on Pea 25.00 ,0~
<br />A~lhofi~ilon Notice (Field Visit) , 150.00 10.00
<br />Autho~iqn Not ac (~o F ~ d V a t) SS,00 10.00
<br />
<br /> Annual ~,9~tio~Al~mative S~s~m ........ 150.00 ,00
<br /> Annual ~v~u~io~emp. or H~ship ~, 90,~ .00
<br /> R~I A~ ~ancc Si~ ~y~o~on 245.00 20,00 .....
<br />
<br />[To~al$ ~ """ I
<br />Rcccipt No.
<br />
<br />NAME O~AP~LICANT (pleose print):
<br />
<br />
<br />
|