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;obAddress ~ 2-0
<br />Mobile Home P~k
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<br />2. Contractor Information
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<br />DEQ DEQ
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<br /> (~gmmemial (DSF-Da~I.y Sewage Flow) ,,,
<br /> Site Evaluation, first 1000 Sal~ DSF $ Z00.00 ~,20.00 i'~$
<br /> Site l~valuafion,, ~a. l~dI, 500 gal. DsE 60.00
<br /> consti~efiorl & Repair Permits
<br />Ste*dardSy~[er~i;ssthan lOOOgal. DS~ 200,00 10,00
<br />Standard Syatera mtxe ihaa 1000 gal, DSF:
<br />$200.00 ? $15/each addl, 5130 gal, DSF 10,00
<br />Capping Fill 330.00 10.00
<br />DJ*posal Trenel~,$ in g'~Dwllte 200.{X 10.130
<br />, orayWa~erWasteDispo.salSump ,,, 95,00 10.00
<br />~Roi,,d, ing Tank ........... 200.00 :10.00
<br />Pressure Dis~l/ufion 2gO.O0 I0,00
<br />Redundant Sys[~m 200.00 10.00
<br />Sand Filt~ 355.00 10,00
<br />se.a~ Tr~,~.¢h ....
<br />Steep Slopo 200.0( IO,O0
<br />Tile De,.wamSn8 symi~ ....... 280.00 10.'00
<br />?.lan Review
<br />6130 gal, DSF. 1001 ,;gal, DSF 80.0( ,00
<br />(ex?~p[ SAND FE,WERS)
<br />For e. aeh. additional 500 gal. DSF 20,0( ,00
<br />: AIt~afions 200.0( ~0.00
<br />Repair. Mind[ 60.0( 10.00
<br />Consttai .ctJ on Perlnit Renewal :'(Field Visi,B.) 1 ~0.0( 10,00
<br />ConsLrucfion Pen/lit,R.~.nc*wal (No Field Visits) 70,0( 10,00
<br />Existin$ S¥*tem l~valuatloo RepOrt 120.0( 10,00
<br />Authorization No,ice (Field Vi~t) 120,0~ 10.00
<br />Authorization Nc~iee (No Field Visit) ....... 70.0( 10.00
<br />Annual Evaluation of Altermaive System 120,0C 10.00
<br />~lmm} Evaluation of Lat~e System 75.0C 10.00
<br />Pumper Track Insl~ctlo~. First truck 50.~
<br />Pumper Tmek In~eetio~n,_ea~ addl, track , 35.0~ .00
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<br />(Mark il ~ ~ to this Application)
<br />( )'r, st ltoi~, =~ Dug
<br />( ) I will call when Tost Hol~ Dug
<br />{ ~am perforrvdng work oll a property I own or occupy
<br />( ) !_am~. gi~tered btdld~r tx ( ) the authorized repr~entetiv*
<br /> , ~ r~gistered builder.
<br />( ~/} Thj~f~ork will I~ p~rformcd by a DEQ Licensed Install¢r
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<br />( ~ I agree to install according to the *ubndtted r,lans and
<br /> specifications, the laws of the State of Oregon and the
<br /> txdimnte~ of Marion County.
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<br /> RosidonOal Sin~ Family
<br /> ~;it* l~valuafionI fa'st lot $ 200.00 $20.0~
<br /> Site Evaluation, ea. addl.,l? 165.~0 20.0(1
<br /> Coll~I/ucfi?q p~rnfit
<br /> SLaudard System 200.00 10,0~
<br /> Cappin~ Fill 330.00 10,0~
<br /> Disposal Trench in Sapr~lhe ~00.00 10.00
<br /> Grey Water DisP°Sal S~mp 95,00
<br /> Holding Tank ' 200.00 10,00
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<br /> l~ssure Distribution 2g0 00 10.~0
<br /> Redundant 200~0 10~00
<br /> SeePs-ge TrenCh 200.00 10,00
<br /> Steep Slopo 200.00 10,00
<br /> Tile Dewate~.n.g ..... 280-00 10200 .......
<br /> Alteration 200,00 10,00
<br /> Repelt, Majoe (dra~nfield) 95,00 10,00
<br /> Repair, MAnor (ta~k) 60,00 10,00
<br /> Cot,sttucOo, Permit Renewal (Fi~,!0 V~slt) , J 120.00 10,00
<br /> Construction Pertmt Renewal (No Fielq,Visit) 70,00 10,00 1
<br /> Relnapeetion Fee , 25-00 .00
<br />Authorization Nosi~e (Field Visit) 120,00 10,00
<br />Authori~tion NrvAce (No fiold visit? ..... 70.00 10,00
<br />..E, xlsfing System Evalua~on ....... 120.00
<br />Annual Evaluation/Alt~[nalive System 120.00 .00
<br />Annual Evalua0on/Temp, or IIardsbip M,H 75,00 .00
<br />Rural Area Vasianco Site Evaluation 200,00 20.00
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<br />flei~E,OFAPPLIC,~NT(p~easeprmt): - ,,_ / / -
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<br />MC 15-74 REV 1/92
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