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UseofStractore: Ne. Employees: ~ SeafingCapacity: /~ T0tal#ExistingBedrooms: ~- <br />2. LOCATION OF INSTil.I ATION <br /> <br />Total # Proposed Bedrooms: <br /> <br />Subdivision: Lot: Block: <br />Map: Zone: parcelSize: ~, $~ () SF .~ AC OOB:~I~Y () N <br /> WaterS,p.,,ly: i> v eWe,, omm.nityWal, Ei,, <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 />( ) I am the AUTHORIZED REPRESENTATIVE OF THE PROPERTY OWNER: <br /> Business Name (please print): <br /> <br />Mailing Address: <br /> <br /> Street <br /> <br />( ) I am a DEQ LICENSED INSTALLER: <br /> Busioezs Name (~le~e p~nt): <br /> <br /> Mailing Address: <br /> <br />CiVy: Zip: <br /> <br />License #: <br /> <br />4. FEES (Circle the Apln.q,rlate Fee) <br /> <br />City: Zip: Phone: <br /> <br />A. SITE EVALUATIONS <br />Site Evaluation, Residential, first lot $ 335.00 <br />Site Evaluation, Residential, ea addnl lot $ 205~00 <br />Site Evaluation, Commercial, first 1000 gal $ 335.00 <br />Site Evaluation, Commercial, 1000-5000 gal $ 335.00 <br /> + $90/500 gal or part thereof above 1000 gal <br /> <br />Site Evaluation, Rural Area V~iance $ 335.00 <br /> <br />CONSTRUCTION PERMITS, for the first 1000 gallons <br />projected DSF; <br />Standard On-Site System $ 40~!00 <br /> <br />Alternative System: <br /> Aerobic $ 400.00 <br /> Ceppihg Fill $ 600160 <br /> Cesspool $ 400.00 <br /> Disposal Trench in Saprolite $ 400.00 <br /> Evepolranspiration- Absoq~tion $ 400.00 <br /> Gray Water Sump $ 200.00 <br /> P~sure 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 Dewatering $ 600.00 <br /> Pmnp or Dosing Siphon $ 25.00 <br /> <br />For more than 1000 gallons: $ 400.00 <br />+ $40/500 gal or part thereof above 1000 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required $ 250.00 <br />No Field Visit Required $ 90.00 <br /> <br />ALTERATION PERMIT <br /> <br />$ 400.00 <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 200.00 <br /> <br />No FieM Visit Required $ 85.00 <br /> <br />Single Fam0y Dwelling Major Repair ~'"'-~ <br />~eld or ~ld ~y) $ 200.~ <br /> <br /> ~, Major ~p~: See ~NS~UC~ON <br /> PE~ for f~ <br /> <br />ANNUAL EVALUATION <br /> Of an ALTERNATIVE SYSTEM $ 235.00 <br /> <br />B. COMMERCIAL PLAN REVIEW (cost of <br />Hah Review is included in permit for s~ems up <br />to 600 gallons) <br />600 gallons - 1000 gallons $135.00 <br />1000 gallons - 2500 gallons $135.00 <br />thereof above 1000 gal <br /> <br />PUMPER TRUCK INSPECTION <br />First Vehicle. each inspection $ 80.00 <br />Each Additional Vehicle, <br />each inspection $ 45.00 <br /> <br />EXISTING SYSTEM EVAL $ 250.00 <br /> <br />~FEETOTALS: <br /> <br />Al. Enter Total Fees from Section 4A $ <br />.4.2. Add DEQ Surcharge($'30:00) $ <br /> for each item marked in <br /> Section "A" $ <br /> ~bto~h $ <br />B. Enter Total from Section 4B $ <br />C. Reinspection Fee, $50.O/hour $ <br />D. Hourly Inspection Rate, $50.O0/hour $ <br /> Total Amount Due: $ <br /> <br />Tank Pmnped? Dale: <br /> <br />Name of Applicant [Please Pr/ut]: <br />Malll~ Address: Teat HoL~ Ready: <br />Phone: Certiflc~ion attached? y / N <br /> <br /> <br />