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FOR OFFIC~ff~NLY
<br />~eceived By: .,,?
<br />Zoning
<br />Da : '7//%/-I
<br />
<br />1. Location of Installation
<br />
<br /> MARION COUNTY BUILDING INSPECTION
<br /> 220 High Street NE
<br /> Salem, OR 97301
<br />
<br /> 8:00 am - 4:30 pm Phone 558-5147
<br /> Code-A-Phone 588-7904
<br /> FAX 588-7948
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<br />SITE EVALUATION AND/OR
<br />
<br />APPLICATION
<br />
<br />MAi tON COUNTY
<br />IILDING INSPECTION
<br />
<br />~ Tax ~. No~ . O~s S~t
<br /> Sita No. , - ~ ~ ' ~ S~oture: ......
<br />
<br />Range ~ ~ Zone ~
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<br />Contractor Information
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<br />Auth, Ageut/Leasee ' ,g Maihng Address:
<br />
<br />~;;;'tractor Business Name & Number ~~.~ Mailing Address: Phone No.
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<br /> Commercial (DSF-Daily Sewage Flow)
<br /> _Si~ta,.~,v~h~50oa, first 1000gal. DSF $ 200,00 ~20,00
<br /> Site Evaluafion, ea. addl. S00 gal. DSF .... 60.00 g0.00/n
<br /> C°nstmeti°n & RePair P"e'r~2fi?" ' ' 200 00J 10.00
<br /> Standard System less than 1( ,~..,g~l. DSF .
<br /> $:oo,0o, *lS/~aeh a~.a]:.soo ga' DSF 10,00
<br /> Capping Fill 330.0( I0,0O
<br /> Di~pesal Trenches in Saprolita 200.0( 10.00
<br /> lIolding Tank 200.0 10.00
<br /> Pressure D--'-i's~'ti>{~tioh 250.0( 10,00
<br /> Redundaut System 200.0( 10.00
<br /> Seepage, Trench 200,0~ lO.O0
<br /> Steep Slope 200.0~ 10.00
<br /> Tile Dewatcr!,~g, Sysmm 280.0¢ 10,00
<br /> Plan Review
<br /> 600 gal, DSE 100I gal. DS~F 80,00 .00
<br /> (e~cept SAND FILTERS)
<br />For each additio~51,~00 gal. DSF 20.00 ,00
<br />Alterations 200,00
<br />,~.tEpair, Minor 60.00 10,00
<br />Construction Permi~ Re~!,,,w~d (Field Visitsi' ' 120.00
<br />tousling.ion Pernli[,~newal (No Field Visits) 70,00 10.00
<br />Bxisfin~tq,m Evaluation Repee . ........ 120.00 10.00
<br />Authoriz~afion Notice (Field Visit ),,, 120,00 10.00
<br />~,~A~u,~h?rization Notice (No Field Visit) 70.01 10.00
<br />Annua!,,,~valuation of Alternative System 120.00 10,00
<br />Annual Evalua~!o~of Lar~,e System 75.0~ 10.00
<br />Pumper Track In~pectlon, First truck .... 50.00 ,00
<br />Pmnper Truck Inp,qq,.e,tlqn, *a. ~dl, mtck ~,~.,00 ,00
<br />Other
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<br />(Mark ff Applicable to fltis Application)
<br />C~) '[bst Holes are Dug
<br /> ) I will call when Test Holes Dug
<br />
<br /> ) I am a registered builder or ( ) Ibc authorized rept~entafive
<br />
<br />(~.~) 'Die work wilI be performed by a DEQ Licensed InstMler
<br />( ) Udder
<br />(~) I agree to }nstall according to ti~e submitted plans and
<br /> specifications, the laws of tht~ State of Oregon and the
<br /> ordinanee,~ of Marion Connty,
<br />
<br />Residential Single Far~ly
<br />Site Evaluafion~ first lot $, 200.00 ;20.00 $
<br />Site Evaluation, ea. addl. lot 165.00 20.00
<br />Construction per a.fi, t. ..........
<br />Stan,;kard Systam 200.00 i0.00
<br />Capping Fill 330.00 10.(g)
<br />Dislx~al Trench !,.n.~,aprolite 2130.00 10.00
<br />Gray Water Disp~x~al Sump 95.00 10,00
<br />Holding T~mk 200,00 10,00
<br />Pressure Distribution 280.00 10.00
<br />Redundant 200,00 10.00
<br />Sand Filter 355,00 10.(g)
<br />Seepage Tr~'n.:~ .... 200.00 i0.00 ......
<br />Steep Slope 200.1)0 10,00
<br />Tile Dewa~ring 280.00 10.00
<br />Alteration 200.00
<br />Repair, Major (&ainfield) 95.00 10,00
<br />Repair, Minor (tank) 60,00 10,00
<br />Consau¢fion Permit Renewal (Field Visit) 120.(Y0 10,00
<br />Construction Permit Renewal (No Field Visit) 70.00 10,OO
<br />Relns~ctlon Fe~ .... 25.00 .00
<br />Aut}tofi zad o.,n.,,N,oticc (Field Visit ) _, I,~20.~,(×) 10,00
<br />Autilofizafion Notice (No field vlsi0 70.00 10.00
<br />Existing System Evaluation ...... 120,00 fi57~-
<br />Annual £valuation/A~,{~r native System 120.00 ,(X)
<br />Annual Evaluation/Temp. or Hardshi~.~H 75.0C
<br />Rural Area Variance Site l~valgafion 200.0~ 20,00
<br />
<br />To~ $ ~)
<br />
<br />NAME O~ ,~PPIC~AcANT~please print):
<br />
<br />SIGNATURE OF APPLICANT:
<br />
<br />DATE:
<br />
<br />MC ]5-74 REV 1/92
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