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EA~X ~8-794g <br /> <br /> srI~ EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br />1. Locat'mn of installation <br /> <br />UA iON OOUNry <br /> INSPECTION <br /> <br />"~oatractor Bu.~igc~ <br /> <br />~[~Ev~{uafion~ first 1000 gal. D,' ' - 20~ $i~ ~alu~ont fi~{~ 245.00 .... <br />[. Siand~rd Szstem I~ than 1000 gal. D~i' 2a5~0 Io.oo 'L~ ~adaffi 8~m .. ~5.~ Io,oo <br /> <br /> Ora Wi}er Wa~i~)io~S~ ' ~ i20.00 I0~~] ~ B{am~ut~a 350.~ <br /> <br />~a,t Swtem , 245.09 ~0.00 :~a~e Tmch ........ 24S.~ 10,O0 <br />ee J~ ',~ ~r~neh ~45.~ 10.~ ~{~ ~w~sfing, ' 350.00 10.00 <br />~}} [~aI. DSF ] . XO0.~ .00 COa~mcfiO~ ~*~t R*n~ (Fi~'id visit) 15o~ lo.oo <br /> <br />~ ~~/:each add}[~l, nSF 25.00 .~0, Relu~tion ~o~ i ~5,00 .00 <br />~j~' ~5,00 10,~ Authofi~o~ .................. Noti~ (~i~ld VJSi0 150,00 { i~.o010-~ <br /> ........... ~500 10,00 Aulho~n No6~ (No Fi~ld Vial0 8500 <br /> <br />} A utl~o?~3,~ Notion (No Fie}d Vi~i}),,, 85.~ lO,~ <br /> <br /> ~, .D~n~pee~ou F mt tm~k ~0.~ <br /> ~9,r Tmc~ lospe~t[on~ ea. addl. track,, }~.~ ,00 <br /> <br />(Mark [fAppila~le O hisApplioallo ) <br /> <br />) 1 am a rc$i~¢red b~ilder dr ( ') the nut ho 61~.-d inpin~litatlve ' <br />)'I'h~ work will be performed by' a DEQ Licen~d Installer <br /> <br />NAME OF AEPLIIgANT (please print): <br />SIGNA~ANT: DATE: <br /> <br />MC t 5-SJ~ REV 2/93 <br /> <br /> <br />