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MARION COUNTY BUILDING INSPECTION <br /> <br />IFOR OFFICE USE ONLY 220 I-Iig~ Street NE <br /> Received By: -- - Salem, OR 97301 <br /> Zoning Validation: ' 8:00 gill - dj:30 pill Phone 588-5147 <br /> <br /> FAX 588-7948 <br />[Date; Coda-A-Phone 588-7904 <br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br /> <br />Location o[ Installataon , <br />~ 8i~e No. Use ~ S,m~emre: <br /> ~t~mc.~i/le, ~ ~7~a ~ ~ /]Bl<k No. Em loyee~: <br /> ~ ~eg, 1~' C~er c~m~ wen <br /> <br />Contractor Information <br /> <br />Mailing Ad&ess; Phone NO- <br /> <br />Mailin~ Addwss: Phone No, <br />Mailing Address: [ Phone No. <br /> <br />DEQ Licensed C0nttaeto~ AZ No. ouq <br /> <br /> S!~e Evaluation,,~. addL l~i 165,0~ 20,00 <br /> <br />Com~nercial (DSF-Daily Sew~e Flow) <br />S~ EvaluationI fi¢c.t 1000 gal. DSF .... $ 2(×).00 :29.00 $ <br />Sit~ Evaluation. ~. addl.~5~ gak DSF ~.~ 20.~m <br />Smndi:~d ~ stem les~ fl~an i~ ga DS <br />Stand~d System more has ll~ gal, <br />$2~.~ + $15/ead~ addl. 5~ gal D~F 10.~ <br />Tq2 Dewatetiflg' ~ em 280.~ 10,~ <br />6~0 gal~ DSE I~1 gql. D~F 80,~ <br />(except SAND FILTERS) <br />For each addMonal 5~ gal, DSF <br />Altetafion~ 2~.~ 10.~ <br />Exlsfin~ S~$$om Evaluation ~c~ <br />Auq??i~fion Nmic¢ (Fio~d VisR) 1~0.~ 10.~ <br />An nual ,~,~aluation of Altor~v~ Syst¢m 120.~ I0,~: <br /> <br />Construction permit..... l <br />Standard Systent 200,(JO: 10.00 <br />Call, ping Fill 3~0100 lollg) <br />Diaposal Trench in Saprolite.... 2~'~ ] 0 l~ <br />~r~ray Water,,Dispo.qal Suni? 95.00 lO,t×) <br />l-lo!~ling 'fank 200.00 I0.00 <br /> <br /> l~dundalat ....... 200.00 10,00 <br /> Sa~d Filter 355,00 10,00 <br /> <br /> Steep Slope '~ 200.00 16~00 <br /> Tile Dewatefing ,, '"- 280,00 1 <br /> Alteration ' ' 200,00 10.00 .... <br /> R~pair. M~jor (drai~$ld) ..... 95.00 10'.O0 <br /> Repair. Minor (tank) 60.00 10,00 <br />couswaoti0n Permit Renewal (Field Visit) 'i20.00 10,00 <br />~Construction Pm-mit Renewal (No,Field Visit) '" 7~',00 .... 10.OO <br /> <br /> Roinspeetion Fee 25.00 <br />Authorization Nc<ice CField ¥isi0 120.00 I0.0~ <br />A0thorBrafion NOAco (No field visit) 70,00 10,0~ <br />Existing Syst~in Evaluation 120.0(I,,~"-YO'00 <br />Annual Evaiuatlop/Altcrnative SystCra 120.00 .00 <br />~ A~nual Eva ia onfremp, or Hardship MI-i 75.00 <br />Rural Area Varianc~ Sit~ Evaluaton 200.00 20~00' <br /> <br />Receipt No ..... <br /> <br />(M, axk~lkpplicable to this Application) <br /> will call when 'iYst Flole~ Dug <br /> <br />) I am perl~tnling work on a ixolx~ay I own or occupy <br />) I ant a registered builder or ( ) the authorized representative <br /> of a registered bulkier <br />) Thc work will be performed by a DEQ Licensed Installer <br />) O~her <br />) I agree to install according to the submitted plans and <br /> <br />N AM~/QF/~ ~L~/~//~ (please prinO: <br />Sy~N~I:URE O~gl;! LICANT. <br /> <br />Mt: 15-74 REV 1/92 <br /> <br /> <br />