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FOR OF]FI CE~f~NLY <br />Received ByZ ~ <br />Zoning V31idajiOn ~ <br /> <br /> SITE EVALUATION AND/OR SEPTLC I~EI [CATIOI~IIm{i~ t~51,~,~110~q <br />1, Location of Installation <br /> <br />2, ContractorInform,~t,tjOn ~ '~ ~' /~ 1~ ~ ~ ..... <br /> <br />At ih. Ag*n~as~ ~ ~iling Addms*: Phone No, <br />Cc ~t~r Busines~l~ame & Number : Ma n8 Add,ss; Phone No, <br /> <br />DE~ Lic*l~d Cont~tor & No. ~iling Add,ss: ~one <br /> <br />Cdmn~rciaL(DSF l Daily Sewas,e Fl0w) $ Resldential Single Famil~ <br /> <br />Sit,~ Eval.afio., es, addL S00 g$]. DSF 7S,O0 20.00/m' S t~ Evs u~ion, =m ~dl, i~i 1305~0 <br />~stm~tion l~Repair Pe~its I Conatmctiog pe~it <br /> S~dard S~s~m less th~l ~000 6al. DSF 245.00 l lo.o0 S~nda~ $ya*mI 245,00 <br />StapdaM Sy$~ mo~ ~.~ 1000 iai. D$~: Capping Fill . 41,~.~00 10.00 <br /> <br />Capping Fill q[5,00 10.00 ~my Wa~r Disposd Sump 120,00 10,00 <br />Dispo~ Tmn~hea in ~wllt*' ,,, 245.~ 10,00 Holding Tank ...... 245.~ <br /> <br />HoMing Tank , , 24~.00 10.00 R~dundant 245.00 1 q,.,O0 <br /> <br />Tile Dewat~fin8 Sgst~m ~,$0.00 10,00, ~pair, ~jor ~dminfl~Id) 11~,00 10.0q <br />pla6 Review Repair, ~np,t (rank) 75:99 10.00 <br /> <br /> (~.r ;aoh ~dittona1500 gal. DSF 25.00 .. .~0 Rdn.~pection Fe~ .. 2~.00 .00 <br />AIt~fions .... 245.00 10.00 Authorization Noti¢~ (Field Visit) 150.00 10.00 <br />g~yhir, Minor 75.00 10.00 Authorization ~ot c* ~o Field Visit) 8~t00 I0.00 <br />Con,traction Pc~it ~newal (Field Visits) ~ 150.00 10.00 ~isti~g System EvaluationII 150100 <br />Con~ctiOn Pe~it R~nowal ~o Field Visits): 85.00 10.00 Annual Evaluatio~Al~ma6w System 156.00 .00 <br />~i4tins Sys~m Evaluation ~po~ I 150.00 . 10.00 Ann~al Evaluati~*m~. or ~aM~ip ~ 90.00 .00 <br />Aut~ofi~t,~qn Notie~ (Field visit) 150}00 10.00 ~ Ru~l A~a~afian*¢ Si~ ~aluation ~43~00 20.00 <br /> <br />(Mark if Applicable to fills Application) <br />{ ) Test Holes ar~ D~g <br />( )~jJl 0afl when Test Holes Dug <br /> / <br />('") [ ~m p~o~iug work o~ * p~p~fly I own or ~upy <br /> )~amar~sis~mdbuilder0r( )lheauthofi~d~p~nmtiv~ <br /> ) ~l~e work will be p~domed by a DEQ ~¢en~d In$~ll~r <br /> ) 9ther <br /> <br />MC 15:SI REV 2/93 <br /> <br />R~ceipt No, ' <br /> <br />NAME OF APPLICANT(please print): <br /> <br /> <br />