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Zoning Validation: __ $~O~am.a:~ra i,ho~ ~ .~11~/~0/~/ <br />Date: ~ ' : FAXSSS-7~I8 -'-',t¥C~' <br /> , , <br /> ,IT, EYALU*TION tND/OR SEPTIC PERMII A¢~igATION <br />lOCAtION mS ,UJ.A IO <br />JobAddress J,~l q~ ~[i~1-~-~ TaxAcct. No. CrossStleet <br /> <br /> City ~ Use of Structure <br />Subdivision Lot Block No. Employees <br /> <br />Section Township Water Supply: <br />  Prlvate Well ( ) Spring <br />Lot Width Acres Irreg. Lot Comer Commuaity Well ( ) City <br /> <br />2. CONTRACTOR INFORMATION <br /> <br /> Prol~ny Owner <br /> <br /> Auth. Agent/Leasee <br /> <br />~Mailing Ad.ess <br />Mailing Address <br /> <br />~Phone No, <br /> Phone No, <br /> <br />3. FEES <br /> <br /> ** F~es include DF.Q Surcharge ($~O.OD) $ <br /> Site Evaluation, Single Family Dwelling, first lot ......................................................................................................... $320.00 <br /> Site Evaluation, Single Family Dwelling, ea addl lot ............................ ¢ ......................................................................... 235.00 <br /> Site Evaluation, Commercial, first 1000 gallons ............................................................................................................. 320.00 <br /> SiteEvaluation, Comanercial 1000- 5000gallons ....................................................................................320.00+$90/500/gal + $100/500 gallons <br /> Site Evaluation, Rural Area Variance .............................................................................................................................. 320.00 <br /> Construction Permit or Commercial Major Repair, first 1000 gallons: <br /> Standard System ................................................................................................................................. 382.00 <br /> Aerobic System .......................................... ~ ....................................................................................... 218.00 <br /> Capping Fill System ........................................................................................................................... 593.00 <br /> Cesspool ............................................................................................................................................. 382.00 <br /> Disposal Trench in Saprolite .............................................................................................................. 382.00 <br /> Evapotranspiration -Absorptlon System ............................................................................................. 218.00 <br /> Gray Water Disposal Sump ........................ ~ ...................................................................................... 190.00 <br /> Pressure Distribution System ............................................................................................................. 550.00 <br /> Redundant System ............................................................................................................................. 382.00 <br /> Sand Filter System ............................................................................................................................. 703.00 <br /> Seepage Pit ......................................................................................................................................... 312.00 <br /> Seepage Trench .................................................................................................................................. 382.00 <br /> <br /> 600 gallons - 1000 gallons ............................................................................................................... 133.00 <br /> <br />Receipt: <br /> <br /> Total: <br />Test Holes Ready: i~_.~tl..iAl~ <br />Tank Pumped: t 0 - ~ __c:~ ~___ <br />Pumping Certification AttachedO (N) <br /> <br /> <br />