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Received <br /> <br />BUILDING [] MOBILE HOME [] SEPTIC <br /> <br /> pb~ne, <br /> Address' <br /> <br />~ Rel~al~': [~ ~, Chg" ~ Review ~ <br /> <br /> .... :-/ ~ ~_,~ : ~ ~. ~ - <br /> <br /> · COM <br />Sq Ft. Garage Other <br /> <br /> Valuation:: <br /> <br />Septic fnstalfation ,, <br />Site Evaluation <br /> <br />Bldg,, Fee: $ ....... <br />Mobde Home Fee,, <br /> <br />Zc~ir'~ ,Surcharge: --- <br />State SurCharge:: <br />Pla~ c~ck ~e ..... <br /> <br />DEQ Surcharge' <br />T~cal Revi~ Fee <br />Reina~ction Fee <br />Investigation F~' O ~ D ~ <br />REcErPT NO.: . <br /> <br /> <br />