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Received By: <br />Zoning Vali~dation <br /> to <br /> <br /> Sn'~; EYALUATiON .4~D/OR SEPTIC PERMIT APi, LICATioi~UILDING INSPECTION <br />1. Location of Installation ~ <br /> <br />Subdivision ~ ~hg~W~ ~t ~ Block ~ <br />Mobil~ Hom~ Eark ~ ~ <br /> <br />Contractor Information <br /> <br />Commercial (DSF - Daily ~ai~e Flow') <br />Site Evaluation, first 1000/~L DSF 245,00 2A,,~. ....... <br />Sit~ Ewlu~ion, ca. addl. 500 gal, DSF 75,00 20.00/m <br />Construction &Rcpair Pc~i~ <br />S~nda~ Sy~m lcsg than 1000 gal, DSF 245,00 10.~ .... <br />Cappin~ Fill 415,00 <br />Dgldi~g Tank 245.00 <br />~dundan/System ............. 245.00 10.00 <br />~%~¢pag¢ T~ch ........ 245,00 10,00 <br />~ ~il¢ ~wat~fiaa System ........ 350,00 10.00 <br />(For ca~,,,~itlona1500 ga DSF 25.00 ,bb" <br />Autho~ion Notice (Fiel~,~f,iQ 150.00 10.00 <br />Authodzation Notlca ~o FieM Visit) .,~'99 10,00 <br />Annual Evaluation of AIt~jve Syaem 150.00 1%90 <br /> <br />(Mark if Applicable to this Application) <br />(~ Test Holes am D~g <br /> ) I will ~all when Test Ho]ca DuS <br /> <br /> ) I ;~m performins work on a pmpcn¥ Iowa or' occupy <br /> ) I am a registered builder 0r ( ) thc authorizcd mpmsel~la~ive <br />(~ The work will be performed by a DEQ Licensed In~ller <br />( ) Od~cr <br /> <br />MC 15-SI REV 2/93 <br /> <br /> Residential ginnie Fnmilv <br /> git~ ]~valuatlonr fir~ lot ...... 245.00 20,00 <br /> Si~ Evaluaion, ca+ ~dl, lot 205.00 20,,9~ <br /> ~nstmction p~Jt <br /> C~pin~ ~ill,, 41~+00 10,00 <br /> Gray W~r Di~o~ Su~ .......... 120.00 10.00 <br />..... ~pldlnt Tank 245.00 10.00 <br />P~a~ Distdb,~lion ~50.00 I0.00 <br />Redundant 245,00 I0.00 <br />Sand Hl~r ~5.00 10,00 <br />~p~e ~nch ........... 245,00 10,00 <br />~t~ep Slope 245,00 10.00 <br />Tile ~wat~dn~ ,. 350.00 10~ <br />R~alr, Minor (~,~k) 75.00 10,00 <br />CoO~mcfion ~it ~newll (Field Visit) ....... 150,00 10,00 <br />Coa~ction Pe~it ~newnl ~o Field ~sl ) ,~5,00 10,00 <br />Relnspf$l~on Pea 25.00 ,0~ <br />A~lhofi~ilon Notice (Field Visit) , 150.00 10.00 <br />Autho~iqn Not ac (~o F ~ d V a t) SS,00 10.00 <br /> <br /> Annual ~,9~tio~Al~mative S~s~m ........ 150.00 ,00 <br /> Annual ~v~u~io~emp. or H~ship ~, 90,~ .00 <br /> R~I A~ ~ancc Si~ ~y~o~on 245.00 20,00 ..... <br /> <br />[To~al$ ~ """ I <br />Rcccipt No. <br /> <br />NAME O~AP~LICANT (pleose print): <br /> <br /> <br />