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'~ ~7:---' -: .......................... ] ' ~oN cotr~rY smLo~¢ I~Sr~CTION <br /> <br /> ( ) S~ Evalminn ( ) New Im~l~ ( ) ~afion ( ) Repair ( ) ~om~on ( ) E~a~g Sys~m Repo~ (for 1o~ p~oaes) ( ) ~ <br /> U~of~c~e: ~i No:Employee~:~ S~gCap~i*: ~ To~,Ex~g~m,: To~sed~om,: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision: 't ~]~}ff)~H Lot: /]t~ Block: / <br /> <br />Property Locater: , Water Supply: ( ) Private Well ( ) Community Well J~City <br /> <br />3. APPLICANT INFORMATION <br /> <br /> ( ) I am the PROPERTY OWNER and own. reside in. or will reside in the completed structure and will be my own general contractor. <br /> <br /> Business Name (please p~int): ~ ~.~ "~-~ I~ . <br /> Street City: <br /> <br />( ) I am a DEQ LICENSED INSTALLER: Business Name (please print): <br /> <br />City: Zip: Phone: <br /> <br />4. FEES (Ch'cle the Appropriate Fee) <br /> <br /> A. SITE EVALUATIONS <br /> Site Evaluation. Residential. first lot $ 335.00 <br /> Site Evaluatiom Residential ea addnl lot $ 205.00 <br /> Site Evalualion, Commercial. first 1000 gal $ 335.00 <br /> Site Evaluation, Commercial 1000-5000 gal $ 335.00 <br /> - $90/500 gal or pa~t thereof above 1000 gal <br /> <br /> Site Evaluation. Rural Area Variance $ 335.00 <br /> <br /> CONSTRUCTION PERMITS. for the ftrst I000 gallons <br /> <br />Alternative System <br /> Aerobic S 400.00 <br /> Capping Fill $ 600.00 <br /> Cesspool $ 400.00 <br /> Disposal Trench in Saprolde $ 400.00 <br /> Evapotranspira~ion- Absoft ~on $ 400.00 <br /> Gray Water Sump $ 200.00 <br /> Pressure Distribution $ 600.00 <br /> Redundant $ 400.00 <br /> Sand Filter $ 750.00 <br /> Seepage Pit $ 400.00 <br /> Seepage Trench $ 400.00 <br /> Steep Slope $ 400.00 <br /> Tile D~watering $ 600.00 <br /> Pump or Dosing Siphon $ 25.00 <br /> <br />For more than 1000 gallons: $ 400.00 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required ('"~'2¢~-0~.7 <br />No Field Visit Required .... ~' ~)~(~ <br /> <br />ALTERATION PERMIT <br /> <br />400.00 <br /> <br />PERMIT RENEWAL <br />Field Visil Required $ 200.00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br />REPAIR PERMIT <br />Single Fmnily Dwelling, Major Repair <br /> (TankfDrainfield or Drainfield only) <br /> <br />$ 200.00 <br /> <br />Single Family Dwelling, Minor Repair <br />(Tank only) <br /> <br />$ 100.00 <br /> <br />Commemial. Major Repatr: See CONSTRUCTION <br />PER,MITS for fee <br />Conunercial Minor Repan~ $150.00 <br /> <br />ANNUAL EVALUATION <br /> Of an ALTERNATIVE SYSTEM $ 235.00 <br /> <br /> + $40/500 gal or part thereof above 1000 <br />N~me ofApplleant ll~ea~ P4qlttl: '~ ~.~l .~...~: --., 1~ <br />r~: D~q - ~l~2 ...... Celeron ~ed? Y / N <br /> <br />PUMPER TRUCK INSPECTION <br />First Vehicle. each inspection $ 80.00 <br />Each Additional Vehicle. <br />e~h inspection $ 45~0 <br /> <br />EXISTING SYSTEM EVAL $ 250.00 <br /> <br />RECORDS REVIEW $ 40.00 <br /> <br />FEE TOTALS: <br /> <br />Al. Enter Total Fees from Section 4A $~_ <br />A2. Add DEQ Surcharge(S30.00) $ <br />for each item ma6ced in <br />Section "A" $ <br /> Sul~olaL: <br />B. Enter Total from Section 4B <br />C. Reinspection Fee. $50.0&our $ <br />D. Hourly Inspection Rate, $50.00/hour $ Total Amount Due: <br /> <br />MC 15~11 Rev 9~ <br /> <br /> <br />