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FOR OFFICE USE O~LY
<br />Received By:~
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<br /> MAI~[ON C, OUN .TY BUILDING INSPECTION
<br /> ,~ 220 High St~et NB ' ~ - ~.:-
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<br /> S:O0 mm. - 4:30 pm ~one 598-5147 ~ -..,
<br />i ~de-A-Phong 588-7904 '
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<br /> F~ 588-7948
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<br />1. Location of Installation
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<br />....... ~0tEma.~mEIoyees ..........
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<br />_~[~Contractor Information
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<br />Property Owner Iv/aillng Address: ]?hone No.
<br />Auth, Agen~/Leas~ Mailing Address: Pholao No,
<br />Cot~t~rBusiaessH~me&~umber~ . ~ ~/ ~ '~/~ iii A SSS: (" PAo~No.~ ~ ' ~
<br />D~LteensgdConlmc/or~No. ~ ,~[ MalliagAdd~ss: ~ PhongNo,
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<br /> Commercial {DSF - l~'a'iiv Sewaf~e Flowl ' ....... $
<br /> $~ ~l~v,~; ~,. ~at soo ~i,' ~sv ...... ~.oo 2o.oo/~"
<br /> ~nstmcti~,~,Re~ait Pe~ita
<br /> S~ndard Sy~em less than 1000 ~al,~,,DS~ 2~5,00 10.00
<br /> S~nd~ Sys~m mom th~ 1000 ~1, PSF:
<br /> ....... ~45,00 + $15 each addl- 500 ga DSF 10,~
<br /> ~ill 415.00 10.00
<br /> Disposal Tgnohes in ~p,~li~ '~4L00 10,00
<br /> Seepage T~h ..... 245,00 10.00
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<br /> ....... (Pot c~h ~dltional 500 gal. ~, 2~,00 ..... ' ' ,00
<br />AJte~6~ns ..... 245,00 10,00
<br />_~9nstmctioa Po~'t Rea*wa!,,{Fteld Visit) .... 150.~ 10,00
<br />~i~tte~ gys~m BvaJuatioa ~poa 1~0.00 10,00
<br />Authorization Notloe (~i~,la Visit) 150.90 10,00
<br /> Authod~tion Notioe ~o Fteld M,(slt) g5.~ , 10,00
<br /> Annual 8valuat(,oa of Alternative Sys~m. 1~0,00 I~0
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<br />(Mark ifApplicable to this Application) ) Test Holes are Dug
<br /> ) I will call when Test Holes Dug
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<br /> ) I am performing work on a property I own or occupy
<br /> ) I am a registered builder 0r( ) the authorized repmsentallve
<br />(~'~ Thc work will be pcrf~rmed by a DEQ Licensed lnsteller
<br />( ) Other
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<br />~Residential Sin~,le Family. ...... $
<br />Site Evaluationt first lot 245~00 20,00 ......
<br />Sits F, valuation~ es,. addl. lot ...... 205,00 20,00
<br />Construc?m permit ....
<br />Standard Syste~ 245.:Q0 I0.00 2,~7,~
<br />Capping Fill 415.00 10,00
<br />Disoogal Tmncl~"in ~apmI¢¢ 245.00 10.00 ....
<br />Gray Wat~t Disppsal Sump 120,00 10,00
<br />Holdlng Tank ...... 245,00 10.00
<br />....I'resmre D $tfibut on ..... 350.00 , ,10,00
<br />Redundant ..... 245.00 10,00,
<br /> S~nd Filter ,,, 445.00 I0.00,
<br />~epage Trench 245,00 10.00
<br />__~eep Slope ...... 245.00 ,, 10,00
<br />Tile D~wat~,~inl~ 350.00 10,0p
<br />Alteration ...... 245.0!) ....10.00
<br />,,Re. pair~ M~ior (dra nile d), , 11~D0 10.00
<br />Repair, Mino~ (tank) 75.00 10,00
<br /> Con,)motion Permit Pdtnewal (]?iq 51Q' ~ ) 150,00 10.00
<br /> Constmctign perm t Renews {-No F e,d V s 1) 85.00 1.0.00
<br /> Reinspeetion,,Fee 25,00 ,,,,00
<br /> Auth0ri~tio,n Nottee (Ficld Visit) .... 150,00 ~0,00
<br /> Authorization N.o, ticc (No F e d V s t) 85,00 10.,00
<br /> F~xistin g Sy~tc,m l~valuat on 150.00 ,,10'00
<br /> Annual Evalu afiondAltera alive sys~,m 150.00 ,00
<br /> Annual Evaluatioaff~mp. or Hardship. MH 90.00 ,00
<br /> Rural At~a Va~anqe Site Eva!un, ion 245.00 ~0.00
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<br /> 7
<br />NAME OF APPLICANT (please print):
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<br />SIGNA~RE OF APPLICANT: DATE:
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<br />MC 15-SI REV 2/93
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