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FOR CITY USE ONLY -IReceiv~d By: ~ IZoning ValiOati?~' ~ MARION COUNTY BUILDING 285 Chureh St NE - R ~ t 24 hr. lnspectmn Li~:~9~ ~ srr~z EVALUATION AND/OR 1. LOCATION OV INSTALLATION -- ~' '~a/~T')~J~ ~ ' Phone No. Private Well ( ) spgng ,. ] ...... In'cp. ~t Curner ~mmunity Well ( ) City 2. CONTRACTOR INFORMATION 8~Z¢ ~valuation, gingle FamU7 Dwelling, first lot ................................... ~,,3 ...................... [...._...7 ................. L.~C;...g:~.00 Sim Evalua~oa, Single Pamil7 Dwelling. ea addl lot ...................................................................................................... ~0.00 Si~ gvaluafion, Commerdal. fi~t 10~ gallons ................................................. ~ ................................................. 32fi 00 Site Evaluation Commemi~ 1~ - 5000 ga OhS .......................................................................... 32S,00 + $I 00/500 gallons Site gvaluafion, Rural ~a V~=c¢ .............................................................................................................................. 3~.00 Construction P¢~it or Core,iai Major Repair. f~st 1~0 gallons: Aerob{¢ System ...................................................................... T ........................................................... 223.00 Capping Fill Systm ................................................................................................... 598 00 Cess~ol .............................................................................................. 387.00 Disposal Trench in 8apmlite ............................................................................................................. 387.00 Evap0transpimtion-Abso~tion Sys~m .......... l..; ............................................... 223 00 ~a7 Wat~ Disposal Sump ............. 1 .......................... ' ........ 195'00 P~ssum Dis~bu~on S s~m S~d FI er Sys em ............................................................................................................................ 708,00 Seep~e Pit ..... , ................................................................................................. 317.~ Tile Dewate g Sys e n .................................................................................................................... ~mm~a[ PI~ Review . . . ' ' · ....... ~ ~1~* - lO~ g~lona ' 10~ ga on~ - 5~0 ~a lous ' ' ....................................................... ....................................................................................................... 133.00 + $25/500 gallons Co~ial Minor Repair ............................................................................................................................................... I78.00 gingle Family Dwelling. Minor Rep~}r Single Fmily Dwelling, Major Repair (~alnfie d ........................................................................................................ 215.00 Residential or Co~emlal: Altera~ons .......................................................................................................................................... 383,00 Pe~it Rengwal Field Visit. · ........................ [ - 232 00 Pe~t Ran*wa No F Au~ofization, Field Visit ................................................................................................................ 252.00 ~isfing System Evaluation ....................................... , ............................................... ~2.00 - ' ............................................................................. 252.00 Annual Ev~uation, D~ge $ysmm ..................................................................................................... 128.00 Pump or Dos ng Si hun P ............................................................................................... 25.00 Pumper Track InspecOon. First Vehlole ..................................... [ 1~2 Septic Re~nspeetlon F~ ................................. , ......................... , ................... ~,00 Septic Inspeetlon t~r which no t~o s s~ fieally indicateg ...................... 1 .................................................................... 40 ~&r Nameot ~ i ~ ~ . 'Applicant (Please ~nt)~ ~ t(twY Tank Pumped: Pumping Certification Attached: (Y) (N)