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Receipt#: Amount:$ (./~, ~ J 1. JOB DESCRIFFION J ( ) Site Evaluation ~F~w I~, tallation ()Alteration Use of Stmcture~ ~ O. No. Employees: 3. APPLICANT INFORMATION (~tho PROPERTY OWNER and own, r~side in, or wilt reside in tbe oomplete~l sttu~m'~ ~ will be my own g~nend contractor. ( ) 1 amth~ AuTHoRIZED.REPRESENTATIVE OF THE PROPERTY OWNER: Business Narae (please prim): Mailing Address: Street City: Zip: Phone: ( ) I am a DEQ LICENSED INSTA Ll~J~t' ~n t Mailing Address: City: Zip: ]~lone: ~_ ~9~s~ 4. FEES (Circle the Appropri~e Fee) A. SITE EVALUATIONS~ AUTHORIZATION NOTICE ~ .... IL COMMERCIAL PLAN REVIEW (cost of Site Evaluation, Residential, fa'st lot ~ 3.~35.~) Field Visit Eequi~cd ~ Plan Review is included in permit for systems up Site Evaluation, Residential, ea addnl lot$--2~.00 I No Field Visit Required $~90.00 to 600 gallons) Site Evaluation, Commercial, first 1000 gal $ 335.00 600 gallons - 100O gallons $135.00 Site Evaluation, Commercial, 1000-5000 gal $ 335.00 ALTERATION PERMIT $ 400.00 1000 gallons - 2500 gallons $135.00 + $90/500 gal or pa~ tbereof above 1000 gal thereof above 1000 gal '" PERMIT RENEWAL Site Evaluation, Rural Area Variance $ 335.00 Field Visit Required $ 200.00 PUMPER TRUCK INSFECTION First Vehicle, each inspection $ 80.00 CONSTRUCTION PERMITS, for the first 1000 gallons No Field Visit Required $ 85.00 Each Additional Vehicle, projected DSF; each inspection $ 45.00 Standard On-Site System $ 400.00 NOTE: R~al of a permit may be jrJl~d to l~ ori~ pemlitt~ ff a~ apl~cafl~m for per~lt EXISTIN~ SYSTEM EVAI~ $250.00 Name of Applicant IP~ase_ ~ri~l: ~X ~ si~mture Of Appl4cant: ~'~ -- -- l)~f~: __ ?dallln!Addr~s: ~ & . ~ Test Holes Ready: (date) Ta~kPamped? Date:__ Certification attached? y / N [circle one]