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~_onL.<,actor ]l'nform~ttion Mailing Addr*$$1 ..... phone No.
<br /> .... ~Oa~
<br />, ' ...... ~'~o. ."~7- -
<br />
<br /> · " iil .... Residential Single: Family $
<br /> ~SF - Daffy Sewage ow) $
<br />Sit~ ~vaiuation fit~( [~0 8al. DSF 245.~ 20~0 . ,,
<br />'" Site ~vadqatlon. ca[ addL 500~. D~ . 7~.~ 20.~/m ~to ~vg~on, ~ addl. b 205-00 ~0.~
<br />
<br /> S nda~S em ess than I~0 ~1. DSF "' 24~,~ ' 10.~ ' ~ndaM System 24~,00 t0.~ ~/~,~,,,
<br /> ~fiJaed ~at~m mo~ ihan i'000 ~ D~: ..... ~p~ag Fill ,,, 415.00 ,J0.00
<br /> ~ 5 00' ~$1 ~ each addl. 500 ~,1. D$F ..... 10.00 Di~o~ ~h in Sap~lite 24~.Q0 J 0.,~
<br /> .... ~ ' ~ Gray Wat~ ~i~o~) SumP 120.00 10.00
<br />
<br /> Plan Review ~ep~t. ~nor (~nk) 7S,00 10.00
<br />
<br />> 60Q,,,p~ DSF,< 1001 gal. DSF ...... 1~.~ .00 , Cp~,~on Pe~t ~ea~w~ (~e~ V(*~t) 150.00 10.00
<br />(~x~)~ Conslmctlo~,~q~it ~ewa/~o Field Visit) 8L0~ 10,00
<br />[ (For e~k addi6o~a] ,~,,~DSF
<br />A/terM{ohS 245_00 lO.OO ~tho~tion
<br />Rvpair) Minor 7~.~ 10.~ ..... Au~o~afion Notioe ~o Field V{~}{) ~5.00 10.O0
<br />.,~ ,a s mc on Pcn~;i ~g~'gwa/, {,Flexo Violin}
<br />Coos.~¢ io ~ pe~(I Rqggw~ ~o ~etd Vl~ha) 85-~ IO.~ ~aual ~ValUatiodAltem~ve
<br />~ls ,n~s(em Evalt~o~ 150.00 10.~ Aan~ ~Muatio~, O~ Ha~ship MH 90,00 .0O
<br />a etkq~r4e~o, Nodc~ (Fi~ld Visit} 150-00 10.~ ~ A~a V~ce Site E~ua~ou 245,~ 20.00
<br />
<br /> Annua~ ~y.~M.~,,[pn of AItcm~ivc Sy~e~ 1~0~
<br />,,.~nnualEvalunt~onof~eSy*tem ~,00 [ ,,,,,,l~,.~0
<br />
<br /> Pumoct 'f'm¢~ In~eCfi0n, e~. MdL ~mck 3S.O0
<br />
<br />) I w~ll ¢a[I when Test l-Iolea Dug
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<br />NAME OF APPLICANT (please print):
<br />SIGNATURE OF APPLICANT:
<br />
<br />DATE*,
<br />
<br />MC 15-.<:;[ REV 2/93
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