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FOR OFFICE USE ONLY <br />Date; / I.C~, C~. <br /> <br /> JUL <br /> $~0 a.~ - 4;30 pm ?~ 58~147 <br /> <br /> gI~ EVALUA~0N ~/OR ~C PE~ ~PLICATION <br />L Location of lns~lla~on ~ · ~ ~ <br /> <br />3, Fees <br /> <br />~ercM (D~F - D~ilv ~ Flow} <br />~nda~ Sy~ ~,than 1000 ~. DfF~ <br />~my Water Wane Dispo~ Sump ~ 20~0 10,~ <br />~lc De ~atqfigg,,$y~em ,,j~,00 10.~ <br />,,,,,,g,~b~t?, mi~r · .. ,... ,, i · 7~.~. ...m.~, ':":':' <br />Au{h0d~tJ6~ No~oe (~cJd VisiQ 1 ~.~ 10,~ <br />Annual Ev~uatioe of Al~m~vc Sy~g~ 1~,~ 10,~ <br /> <br />(Iv~tk iiAppli¢~bk: to flfia Appllcalion) ) Test H~les a~ Dag <br /> ) 1 will e. all when Test Holes Dug <br /> <br />) <br /> <br /> Residential Sin~tle Family , $ <br /> Site Evaluation, ficsl lot 245,00 20.00 <br /> <br /> smdatd s~m : 24s,~ ~'""i'b.~ <br /> <br />Gray W~r ~1 Sump 120.~ I0,~ <br />~1* ~w~edu$ 350.~ I0.~ <br />RepMr, ~aor(mk} 75,~ 10,~ <br />~na~c~n Pc~t ~,n~[ (~cld Visit) 150.~ 10~ <br />.... iu~o~ ~ ~o~ ce (No ~aM X~,, , 85.~ 10.oo '. ....... <br />~~iR ~. 90.~ .~'":' <br />i~ . :' ' .~45.~ 20.~ .... <br /> <br />NAME 01~ APPLICANT (please print): <br />SIGNATURE OF APPLICANT: DATE: <br /> <br />MC 15-$I REV 2/93 <br /> <br /> <br />