|
~OR OFFIC~E ~A$~ ,O~LY
<br />Received By: r ff~, {/$:~;l~e-- _
<br />Zoning Validation
<br />Date:
<br />
<br /> Code-A-Phone 58S-7904--
<br /> OUNrv
<br /> SITE EV~UATION ~/OR SEP~C PE~IT A~PLICA~
<br />1. Location of Installation
<br />
<br />2. Contraqt0r Informa0~ql ,,
<br />
<br />PrOpeay Owner Mailing Addte~: Phone NO.
<br />Aoth. Ageat/Lea~e Mailing Add~ss: Phone No.
<br />
<br />~nt~ctor Bu~essN~&~umb~ . ~, ~ , ~ ~~a~ ~" .~ ~, ~
<br />DEQLicen~dCoat~r&No. ~i~ ~. ~'Lk~_ ~t ~ilingAdd~ss: ~ phoneNo, ~
<br />
<br />'"C~mmereial ms~ -Dailv Sewage Flow) r
<br /> Site EvMaationr ~& Md[, 5Q0 ~1, DSF 75,00 20,00/m
<br /> Standard System less than 1000 ~. D~ 245.00 ~0,00
<br /> S~adyd System mo~ ~han 1000~al. D~:
<br /> $245.00 + ~ 15 a~h addL $09 ~M, DaF, 10,,00
<br /> ~apping Fill .... '"' 415.0~'" 10,00
<br /> Gray Wate~ Was~is~osal gum~ I~0,00 10 00
<br /> Holding Tank 24~,00 10.00
<br />
<br /> ,,, P~ssu~ DJstfibutiqa 350.00 10.00
<br /> Redund~n SyStem 245,00 10,00
<br />
<br />., Seepage T~nch 245.00 Ip.00
<br />Steep Slope ,
<br />Plan Rcvie~
<br />>6~ gal DSF,<I~I gal DS
<br />
<br /> ARc,liana 245.00 10.00
<br /> Repalq Minor ..... ~5.00 , 10.00
<br /> Cqpst~etion Pe~it ~newal ~o Field ~Jsits) 85.00 I0.00
<br /> ~istlag System Evaluation ~po~ 150.00 I0.00
<br /> .,, Autho~fio~ Notive (~ieM VisiQ I'~0.06 10.00
<br /> Authofizado~ Nofi~ ~o Fi~M Visit) SS.00 10,00
<br /> Annq~l Evaluat{o~ ~fA~mati~e Sys~m , 150.~ ~0.~
<br />...Annum Evaluatlon..ofLa~e gys~m 90.00 ,. 10.00
<br /> Pumper T~¢R Inspection, Fi~t track ~ 00 .00
<br /> ~per T~¢k Inspections ¢s. addl. )~¢k ~5.00 .00
<br />
<br />) ()that
<br />
<br />Residential Single F~mily .... $
<br />.. Site Evaluatio% flint tot 24~,00 ,20100
<br />S te Eva.lu~ on~ e~,, ~dl. lot ..... 205 00 20.00.,
<br />
<br /> S~ndard System , I 245,00
<br /> Capplng FilL 415.00 10¢,~0
<br />Disoosal TrenCh ia S~lito 245~Q0, 10.00
<br />G~y W~cr Disposal Sump 120.00 10.00
<br />Holding Tank ~45,~
<br />P~ssu~ Distribution 350.00 10.00
<br />.. Redundant I 245.00 10.00
<br />Sand Filter 445.00 10.00
<br />~epagc ~a~h I 245,~'0 10~00
<br />.,,Steep Slope 245.00 lO.00
<br />Til~ .~wateOag 350.00 10.00
<br />_Abe~ion. ' ~4~.00 10.00
<br />~pair. ~ior (~infield) 115.00
<br />Repair, ~no.r (~ak) ,. 73.00 i0.00
<br />Cq~mctloa Pe~it Renewal {Field Visit) 150,~ 10.~
<br />~r,st~¢tion~¢~it ~,nawal ~o E~*!4 Visit) ~5 00 10,00 .,I
<br />,, Rains~*~tlon F¢~ ,, 25.90
<br />Authofi~tioa Notice (Fi*Id V~sit) 150.00 10.00
<br />Authorization Notice (No Field Vlsi0 85.00
<br />~iaiag Sy~m gvaluat~n 150.~
<br />Annual RvM~atio~Al~mative S~s~m : 150.00 .00
<br />Annual Evaluatio~omp. or ~aMship .~ 90.00 .00
<br />~ A~a ~afi~ee Si~ Evalu~on 245.00 20,00
<br />
<br />J
<br />
<br />to' e /
<br />
<br />MC IS-SI REV 2/93
<br />
<br />
<br />
|