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Check All Sections That Apply: <br /> EVALUATIONM SITE "• • # <br /> (PHIS IS AN EVALUATION OF THE SOIL.FOR A SEPTIC SYSTEM) <br /> ❑IMPROVEMENT PE•RMTf(Up ra 60t76FD) _ NUMBER OF g1TES .....................................S 4R5 PER SITE. <br /> ❑ DIDIVIDUALLOT (] SUBDIVISION• ❑ RECOMBINATION• ❑EX1S'TING SYSTIDrI ❑EXPANSION <br /> ❑SITE REVISIT TO REISSUE OR MODIFY A VALID IMPROVEMENT PERMTT(wlth no incream flow) ............................S 175 PER SITE. <br /> EACH SITE EVALUATION CONSLWS OF TIP TO 1 ACRES EVALUATED. <br /> PROJECTS GREATER THAN S BEDROOMS AND WON-RESIDENTIAL PROJECTS(>W Erd)REQUIRE AIIIOPIT MAL FEES <br /> PLEASE SIX HEALTH DEPARTMENT FOR SPECIFIC INFIMMATION, <br /> PROJECTS GREATER THAN 5 BEDROOMS,NON-RESIDENTIAL PROJECTS(>iW Wd)AND SUBDIVISIONS REQUIRE THAT THE APPLICANT <br /> PROVIDE A BACiatOR AND OPERATOR ON SITE TO DIG Prig. <br /> "FOR SUBDIVISIONS&RE-COMOFNAT1ONS.A CONCEPT PLAN APPROVAL OR A PLAT PREPARED BY A SURVIVOR VOR MUST BE SC67K1'I'TED W1TH <br /> THE APPLICATION, <br /> CONSTRUCTION AUTHORIZATION SECTION <br /> C, (A CONSTRUCTION AUTHORIZATION IS NEEDED TO OBTAIN A BUILDING PERMIT AND INSTALL AA ASEPTIC SYSTEM) <br /> $CONSTRUCTION AUTHORIZATION FOR NEW CONSTRUCTION OR EXPANSION ...................... .. 360(Up to 600 GPD) <br /> ❑SITE REVISIT TO REISSUE OR MODIFY A VALID CONSTRUCTION AUTHORIZATION ...................... 75(Up to 600 GPD) <br /> . CHANGES TO THE SITTE PLAN,FLOOR PLAN,OR APPLICATION REQUIRE ANEW APPLICATION AND ADDITIONAL FEES. <br /> • SYSTEMS WITH A DESIGN FLOW OVER 666 GALLONS PER DAY WILL REQUIRE ADDITIONAL FEES <br /> ' SYSTEM TYPE MUST BE REOUESTED FOR CONSTRUCTION AUTHORIZATION <br /> WELL PERMIT SCCTION <br /> ❑ NEW ❑RUPL-ACEMfN 1*• ❑IRRIGATION" <br /> C7 MONTTORLNG WELL(PER WELL FIELD) ❑GEOTHEFUNIAL WELL(PER WELL FIELD)....... . $595 <br /> Well permit fee indades initial water samples for wafer supply well!. <br /> If the well will serve more than one purpose(example'drinking water supply AND geothermol),Indicate io on page I under"Describe your project" <br /> ❑PERMIT RENEWAL,ALTERATION.OR SITE REVISIT .. ............ ..... . .............5175 <br /> ❑WELL REPAIR PERMIT(LONER INSTALLATION,DEEPEICKG OF EXISTING WELL..HYDRO-FRAC'nJMG)...--.NO FEE <br /> ❑WELL ABANDONMENT .............................................................,...... ...-....... ..-.............................NO FEE <br /> CHECK THE BOX AND SHOW ON THE SITE PLAN IF ANY OF Tilt FOLLOWING ARE ON OR ADJACENT TO THIS PROPERTY- <br /> ❑EXISTING SEPTIC SYSTEMS OR SEWER LINES ❑CHEMICAL OR PETROLEUM STORAGE TANKS <br /> MOBILE •ME PARK AUTHORIZATION SECTION <br /> ❑@XisnNG SEPTIC SYSTEM/WEIL AUTHORIZATION NSPECTlON WITH NO INCREASE IN WASTE FLOW S 175 <br /> ❑MOBILE HOME SPACE RECONNECTION INSPECTION-PER SPACE........................................................ $1 05 <br /> ❑IN-OFF]CE REVIEW FOR AUTHORTZATION.............................................................................................. $35 <br /> ORIGINAL OWNER SYSTEM IS: ❑IN USE er D VACANT does idatal <br /> APPLICATION e: OCPD CONFIRMED: <br /> DATE RECEIVED: REVIEWED BY: AtttBttlttidTti <br /> NOTM <br /> S:IENVIRONfIENTAL HEALTH SFRVICESIONSTTE PROGRAMWORMSTermit Application_luly 1,2017 <br /> 273 <br />