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FOR O 'mCE
<br />Received By:
<br />Zoning Validation/~/Z_,~_~
<br />Date:
<br />
<br />MARION COUNI'
<br />BUILDING INSPECTION
<br />
<br />1, Location of Installation
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<br />Subdivision "')~}~'~ ~ I ~ ~ ~ ~ o ~ ~" D ~t & ,,.Block "~ No, Em~loT*es
<br />Mobile ~9me ~a~ ,
<br /> ....... I
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<br />2_iContractor Information
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<br /> Commercial (DgF'2'Dailv Sewage Flow~
<br /> $1t~ Evaluati~ first lO0O ~al, DSF 24~,00 20,00
<br /> Sit~ Evaluatlon~ ea. ~d[. 500 ~1. D~ 75,00 20.O0/m ........
<br /> Cohstmetion & ~pair
<br /> standard' System le~s ,{~,gn 1000 8al, ~SF 24S,00 "1,0.00
<br /> S~nda~ S~$~m mo~
<br /> ~245.00 + ~15 each Mdl.,~00 gal DS~ 10:00
<br /> Dijposal T~neheMn Sapmli~ ...... 245.~ 10,00
<br /> He'ding T%k 245.00 I0.00
<br /> P~asum Di*tSbq0on ....... 350.00 1~.00
<br /> Sggpag¢ Trench 245,00 10.00
<br /> St~Sp SIo~ 245,00 10,00
<br /> AIt~mtions 245,~ ~0,~
<br /> R~pair~ Mino~ ....... 7~,00 ~0.00
<br /> Cofistmclion ~e~ii Renewsl (Field Visit) 1 ~1),00 10,00
<br /> Construction P~ t Renewsl ~o Ficl~,V s ts), 85,~ 10,00
<br />
<br /> Authorization Notko (Field Visit) 150.00 10.00
<br /> A~ofigafion No,i,? ~o Fid'a Visit) "85.00 10,00
<br /> Annual Evaluation of Al~mative System : [50.00 10-00
<br />.,Annual BvMuation of~e System ~.00 I~,00
<br />
<br />Mark ifApplleable to this Application)
<br /> ) Test Holes a~ Dug
<br /> ) I will call when Test Holes Dug
<br />
<br />) I am a registered builder or ( ) the authorized r, pgsentative
<br /> The work will be performed by a DEQ Licen*ed Installer
<br />) Oth*t
<br />
<br /> Residential Sinffle Family S,,,
<br /> SiR, Evaluation, first lot 245,00 20,00
<br /> Site F~valuatlon, ea. ~ldl. 1o[, 205,1)0 20.00
<br /> Constmctio~ permit
<br /> Standard System ...... 2~,5.00 10.00 ~ff~ ,,
<br /> Capping Fill ....... 41~,00 I0.00 ....
<br /> Disnosal Trench in Saprolit¢ 245.00 10,00
<br /> Orgy Wats.r_ Disposal Sump 120,00 10.00
<br /> Holding Tank ,,, 245,00 10.00 ,, ,
<br /> P~cssui~ Distnbutlon,, 350,00 10.00 , ,
<br /> Rcdun0,ant 245.00, , 10,00
<br />Sand Filter 445.00 ,, 10.00
<br />Seepage Trencb. 245,00 10,00
<br />__Steep Slope 2~,~,00 10.00
<br />Tile Dewat~l~ng 350,00 10.00
<br /> Altor~tion ,, 245.00 10.00'
<br /> Repairr Maio~ (dm. infield) 115,00 10,00
<br /> P..gpalz, Mincer (tank), 75.00 10,06
<br /> Construction Permit l~newal (Field. Visit) ] 50.00 10,00
<br /> Construction Perm t Renewal CN'o Fiel,d V s t) 85.00 l.Or00
<br /> ReinSlS~etion Fe~ 25-00 .00
<br /> Authodza6on Noti¢~ ~i¢ld ~}sit) ~ ap,oo 10.00
<br /> Autbo,~zation Noti¢{ (No F,ield Visit) 85.00 10,00
<br /> ~sting Sys~m Evaluation 150,00 10.00,
<br /> Annual l~valuatioa/Alt *m ative $~/stom 150.00 .00
<br /> Aurmal l~v al~atio n~Tcmp. Ot Hardship MI'I 90.00 ,00
<br /> Rural Area yafiance si*~ Evaluation i45.00 20.00
<br />
<br />NAME OF APPLICANT (please print);-
<br />
<br /> ' I-I/
<br />
<br />SIGNATURErOF APPLICANt: ff DATE:
<br />
<br />MC 15-SI REV 2193
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